On 13 April 2016, a Pilatus Britten Norman Turbine Islander (BN-2T) twin-turboprop aircraft, registered P2-SBC, departed from Tekin, West Sepik Province for Kiunga, in Western Province, Papua New Guinea (PNG). A pilot and 11 passengers were onboard the aircraft. While on approach to land, the aircraft impacted heavily into terrain, approximately 1,200m west of the runway. The aircraft was destroyed and there were no survivors.
The Accident Investigation Commission (AIC) of Papua New Guinea conducted an investigation into the accident in accordance with their obligations as the State of Occurrence under Annex 13 to the Convention on International Civil Aviation. The AIC requested technical assistance from the Australian Transport Safety Bureau (ATSB) to examine items recovered from the aircraft, including cockpit instruments and personal electronic devices. In providing this support, the ATSB commenced an external investigation under the Transport Safety Investigation Act 2003.
The ATSB has completed its examination of the recovered items. The results of the instrument examination along with a copy of the recovered data from the electronic devices was provided to the AIC.
The AIC has released the final investigation report into this accident, which is available at www.aic.gov.pg. Specific enquiries related to this accident should be addressed to the AIC by email at infor@aic.gov.pg, or in writing to:
Chief Executive Officer Accident Investigation Commission PO Box 1709 Boroko, NCD Papua New Guinea
On the morning of 6 August 2016, the flight crew of an Airnorth Embraer EMB-120 aircraft, registered VH-ANQ (ANQ) (Figure 1), prepared to conduct flight TL414 from Darwin to Groote Eylandt, Northern Territory. On board were three crew and 30 passengers. The first officer for the flight was undergoing training to become a captain. This involved undertaking all tasks normally performed by the captain including the completion of the aircraft trim sheet.[1]
At about 0530 Central Standard Time (CST), the flight crew arrived at ANQ. They discovered that the refueller was running late and the aircraft servicing had not been completed. The aircraft load information also arrived about 10 minutes late. In an attempt to depart on time, the first officer (acting as the captain) completed the trim sheet more quickly than usual and did not conduct their usual double check to confirm that it was completed correctly. The completed trim sheet indicated 3° nose-up trim[2] should be used for the take-off. The first officer did not pass the completed trim sheet to the captain (acting as the first officer) to sight as is required by the company standard operating procedure.
At about 0555, the crew started the take-off roll. As the aircraft rotated,[3] the captain (the pilot flying) noted the aircraft felt out of trim, so adjusted the trim and completed a normal rotation. After the initial climb, the captain asked to review the trim sheet. The captain found that the first officer did not include 584 kg of baggage and freight in the take-off trim setting calculation. The captain and first officer recalculated the aircraft trim and found the correct trim setting for the take-off should have been 0.8° nose-up. The crew rechecked the trim sheet which showed the aircraft was within all weight and balance limitations.
The flight proceeded to Groote Eylandt without further incident.
Figure 1: Embraer 120, VH-ANQ
Source: Simon Coates
First officer comment
The first officer of ANQ provided the following comment:
Due to the late arrival of the loading paperwork and the passengers sitting in the aircraft longer than was usual, they felt pressured to complete the trim sheet quickly and pass it to the customer service officer who was standing behind them.
Captain comment
The captain of ANQ provided the following comments:
As the first officer was approaching the end of their training, the captain felt comfortable with the first officer’s ability to complete the trim sheet without error.
The company operating procedure required both flight crew to sight the trim sheet. However, this did not normally occur in operations.
The pre-flight delays had compounded to give the first officer 10 minutes to complete the pre-flight paperwork instead of the usual 20 minutes. As part of the training, the captain wanted to observe how the first officer managed the pre-flight delays and did not assist unless requested.
The day prior to the incident, the captain reported raising concerns regarding the pressure being placed on first officers training to become captains to complete the trim sheet in under two minutes. They felt that the focus during training should be on completing the trim sheets correctly before the speed naturally increases. It is better to take extra time to complete the trim sheet correctly and double check. If the time had been taken to double check, the error may have been identified.
The captain felt company communications to flight crew had a large focus on flights departing on time. This placed pressure on the flight crew to rush their pre-flight preparations.
The captain found the manual trim sheets used for EMB-120 operations laborious and presented a high risk of error.
Safety action
Whether or not the ATSB identifies safety issues in the course of an investigation, relevant organisations may proactively initiate safety action in order to reduce their safety risk. The ATSB has been advised of the following proactive safety action in response to this occurrence.
Operator
As a result of this occurrence, the aircraft operator has advised the ATSB that they are taking the following safety actions:
Change to procedure
The company standard operating procedure ‘Completion of the Trim Sheet’ has changed from both flight crew being required to sight the trim sheet to include a requirement for both flight crew members to cross check the trim sheet and take-off/landing data card for correctness.
Safety message
The NASA Aviation Safety Reporting System Hurry-Up Study examined 125 incident records that involved time related problems. The study found that in 63% of incidents the error took place in the pre-flight phase. The report suggested using the following strategies to reduce the frequency of time-related errors:
Maintain an awareness of the potential for the ‘Hurry-Up Syndrome’ in pre-flight and taxi-out operational phases.
When pressures to ‘hurry-up’ occur, particularly in the pre-flight operational phase, it is a useful strategy for pilots to take the time to prioritise their tasks.
If a procedure is interrupted for any reason, returning to the beginning of that task and starting again will significantly reduce the opportunity for error.
Practicing positive crew resource management technique will eliminate many errors -- effective crew coordination in ’rushed’ situations will catch many potential problems.
Strict adherence to checklist discipline is a key element of pre-flight and taxi-out task execution.
Defer paperwork and non-essential tasks to low workload operational phases.
Data errors, such as the wrong figure being used as well as data being entered incorrectly, not being updated, or being excluded, happen for many different reasons. The ATSB web page Data input errors highlights that no one is immune from data input errors. However, risk can be significantly reduced through effective management and systems
The ATSB research report Take-off performance calculation and entry errors: A global perspective concluded that despite advanced aircraft systems and robust operating procedures, accidents continue to occur during the take-off phase of flight. It is imperative that the aviation industry continues to explore solutions to firstly minimise the opportunities for take-off performance parameter errors from occurring and secondly, maximise the chance that any errors that do occur are detected and/or do not lead to negative consequences.
The objective of a safety investigation is to enhance transport safety. This is done through:
identifying safety issues and facilitating safety action to address those issues
providing information about occurrences and their associated safety factors to facilitate learning within the transport industry.
It is not a function of the ATSB to apportion blame or provide a means for determining liability. At the same time, an investigation report must include factual material of sufficient weight to support the analysis and findings. At all times the ATSB endeavours to balance the use of material that could imply adverse comment with the need to properly explain what happened, and why, in a fair and unbiased manner. The ATSB does not investigate for the purpose of taking administrative, regulatory or criminal action.
Terminology
An explanation of terminology used in ATSB investigation reports is available here. This includes terms such as occurrence, contributing factor, other factor that increased risk, and safety issue.
Publishing information
Released in accordance with section 25 of the Transport Safety Investigation Act 2003
Ownership of intellectual property rights in this publication
Unless otherwise noted, copyright (and any other intellectual property rights, if any) in this report publication is owned by the Commonwealth of Australia.
Creative Commons licence
With the exception of the Coat of Arms, ATSB logo, and photos and graphics in which a third party holds copyright, this publication is licensed under a Creative Commons Attribution 3.0 Australia licence.
Creative Commons Attribution 3.0 Australia Licence is a standard form licence agreement that allows you to copy, distribute, transmit and adapt this publication provided that you attribute the work.
The ATSB’s preference is that you attribute this publication (and any material sourced from it) using the following wording: Source: Australian Transport Safety Bureau
Copyright in material obtained from other agencies, private individuals or organisations, belongs to those agencies, individuals or organisations. Where you wish to use their material, you will need to contact them directly.
On 7 April 2016, a GippsAero GA8-TC 320 Airvan (GA8) aircraft, registered P2-MFM, was being flown from Kiunga to Yehibi, Papua New Guinea. Shortly after touch-down and around 140m into the landing roll, the wheel and axle assembly from the left main landing gear leg separated from the aircraft. The pilot was able to bring the aircraft to a controlled stop.
Subsequent inspection of the right landing gear leg from P2-MFM found that it was cracked in the welded region of the axle assembly. Inspections of other aircraft in the operator's GA8 fleet, identified that numerous main landing gear legs were cracked in the same location.
The Civil Aviation Safety Authority (CASA) commenced an airworthiness investigation into the circumstances surrounding this issue. CASA requested technical assistance from the Australian Transport Safety Bureau (ATSB) to conduct a detailed metallurgical examination of the main landing gear axles from P2-MFM. To facilitate this assistance, the ATSB initiated an external investigation under the provisions of the Transport Safety Investigation Act 2003.
The ATSB has completed its examinations. Fatigue cracking and fracture was associated with marginal weld penetration between the landing gear parts and was influenced by the manufacturer's original welding processes. The manufacturer revised the assembly drawing in 2009, including enhancements to the welding procedure, such that the latest axle design is likely to have improved fatigue endurance. The ATSB was not aware of any instances of cracking of axles manufactured to the latest revision.
On 7 June 2016, the manufacturer released service bulletin SB-GA8-2016-169 (Issue 1) that recommended inspections of the axle area be conducted at service intervals not exceeding 110 hours.
A report detailing the ATSB's examination and findings was provided to CASA, the aircraft operator and the aircraft manufacturer, on 6 October 2016. Enquiries relating to the investigation should be directed to CASA on 131 757.
Figure 1: GA8 main landing gear, wheel and brake assembly showing the location of cracking and fracture on the axle assembly.
On 8 August 2016, at about 0700 Central Standard Time (CST), a Beech 58 aircraft, registered VH-UZO (UZO), departed Gove Airport, Northern Territory, for a flight to Elcho Island Airport, Northern Territory. On board were a pilot and four passengers.
During the initial climb, the pilot selected the landing gear up and noted the landing gear motor stopped after a shorter time interval than expected. At this time, the passengers reported hearing a crunching sound. The pilot observed that the landing gear unsafe light remained illuminated after the landing gear motor stopped.
Rather than continue the flight to Elcho Island, the pilot returned the aircraft to hold overhead Gove Airport while they attempted to ascertain the reason for the landing gear malfunction. The pilot noted that the circuit breaker for the landing gear had tripped, so reset the circuit breaker and selected the landing gear down. The landing gear unsafe light remained illuminated and the circuit breaker tripped again. The pilot then contacted the aerodrome reporting officer (ARO) and requested a visual confirmation of the position of the landing gear. The ARO reported that all landing gear appeared to be fully retracted.
Given that normal landing gear extension had been unsuccessful, the pilot elected to conduct an emergency landing gear extension. The Beech 58 emergency landing gear extension requires the pilot to engage a handle into the landing gear gearbox positioned behind the front seats. The handle is then turned counterclockwise to manually lower the landing gear. Fully extending the landing gear takes about 50 turns of the handle.
The pilot held the aircraft to the north of Gove Airport and engaged the autopilot while they conducted the emergency landing gear extension procedure. The pilot reported that no resistance was felt through the extension handle when attempting the landing gear extension, the handle felt like it was not connected. The pilot then flew back overhead Gove Airport for the ARO to again report on the position of the landing gear. The ARO reported that the landing gear remained retracted. The pilot then resumed holding, and calculated that they had sufficient fuel to continue to hold for a further two hours and 15 minutes. While holding, the pilot contacted the company chief pilot and engineer to assist with further troubleshooting the malfunction. The engineer examined the aircraft wiring diagram and another Beech 58 parked at the airport. The engineer then described several methods to isolate various parts of the electrical system to identify any problem which prevented the landing gear from extending. Over the next two hours, the pilot tried these methods along with multiple attempts of the emergency landing gear extension procedure. Despite the pilot’s attempts, the landing gear remained retracted.
At about 0930, the pilot prepared for a wheels up landing. They briefed the passengers on the use of seatbelts, bracing position, emergency exit locations and actions to be taken after the landing. The ARO arranged for the emergency services to be in attendance. The pilot discussed with the chief pilot whether to land on the runway or adjacent dirt. As the runway provided a hard, smooth surface of known condition, the pilot elected to land on the runway. The chief pilot then briefed the emergency services on the intended actions of the pilot. The pilot reviewed the wheels up landing procedure in the pilot operating handbook (POH), and elected to conduct a flaps up landing to minimise damage.
At about 0945, the aircraft approached the runway. Just before the aircraft touched down, the pilot shut the engines down in accordance with the POH wheels up landing procedure. As the aircraft slid along the runway, smoke filled the cabin and the pilot selected the fuel off. Once the aircraft came to a stop (Figure 1), the occupants immediately exited the aircraft. The pilot directed the passengers to a safe location behind the aircraft.
No persons were injured, and the aircraft was substantially damaged in the accident.
Figure 1: VH-UZO after the wheels up landing
Source: Pilot
Pilot comments
The pilot of VH-UZO provided the following comments:
To assist in troubleshooting the malfunction, multiple videos of the actions taken by the pilot and indications presented by the aircraft systems were sent to the engineer.
The passengers were engaged to assist in the attempts to lower the landing gear. The passenger in the seat next to the pilot held the POH. Other passengers also attempted to wind the emergency landing gear handle.
The passengers were directed to evacuate to the rear of the aircraft. The pilot has subsequently learned that the safer option is to direct passengers to the side of the aircraft and upwind, away from fuel vapours.
Engineering report
A post-accident examination of the landing gear system found that the gear box shaft bearing had fractured. This bearing secures and aligns the shaft worm drive, which attaches both the emergency handle mechanism and the electric motor to the gear box. Failure of the bearing allowed the shaft worm drive to disconnect from the gearing. The drive became jammed, causing further damage to the gear box. Damage to the gear box prevented normal operation and caused the electric motor to overload and trip the circuit breaker. The bearing failure also prevented the emergency handle from connecting to the gear box.
Safety message
Even though the operation was conducted single-pilot, this accident provides a good example of effective crew resource management techniques. The pilot quickly established that the available fuel endurance allowed ample time to carefully consider the circumstances and attempt to resolve the issue. They engaged company personnel, using multiple means, to provide as much information as possible and attempt to identify a solution to the malfunction and sought the assistance of the ARO to inspect the aircraft and to alert emergency services. Holding over an easily identifiable position, and using the passengers where appropriate to assist with management of the emergency, also reduced pilot workload. The pilot also prepared the passengers for the wheels up landing, this minimised the risk of injury and ensured the evacuation was controlled and orderly.
The objective of a safety investigation is to enhance transport safety. This is done through:
identifying safety issues and facilitating safety action to address those issues
providing information about occurrences and their associated safety factors to facilitate learning within the transport industry.
It is not a function of the ATSB to apportion blame or provide a means for determining liability. At the same time, an investigation report must include factual material of sufficient weight to support the analysis and findings. At all times the ATSB endeavours to balance the use of material that could imply adverse comment with the need to properly explain what happened, and why, in a fair and unbiased manner. The ATSB does not investigate for the purpose of taking administrative, regulatory or criminal action.
Terminology
An explanation of terminology used in ATSB investigation reports is available here. This includes terms such as occurrence, contributing factor, other factor that increased risk, and safety issue.
Publishing information
Released in accordance with section 25 of the Transport Safety Investigation Act 2003
Ownership of intellectual property rights in this publication
Unless otherwise noted, copyright (and any other intellectual property rights, if any) in this report publication is owned by the Commonwealth of Australia.
Creative Commons licence
With the exception of the Coat of Arms, ATSB logo, and photos and graphics in which a third party holds copyright, this publication is licensed under a Creative Commons Attribution 3.0 Australia licence.
Creative Commons Attribution 3.0 Australia Licence is a standard form licence agreement that allows you to copy, distribute, transmit and adapt this publication provided that you attribute the work.
The ATSB’s preference is that you attribute this publication (and any material sourced from it) using the following wording: Source: Australian Transport Safety Bureau
Copyright in material obtained from other agencies, private individuals or organisations, belongs to those agencies, individuals or organisations. Where you wish to use their material, you will need to contact them directly.
On the morning of 27 July 2016, V/Line passenger train 8309 departed Melbourne for Shepparton, Victoria. The train consisted of a locomotive hauling four passenger cars and was crewed by a driver and conductor. There were 22 passengers on board when the train approached the regional town of Toolamba, south of Shepparton.
At about 1147 the train had passed Toolamba, and approached the Pogue Road level crossing travelling north at about 100 km/h. At about the same time, a utility vehicle was travelling east along Pogue Road and was approaching the level crossing. The crossing was controlled by a Stop sign (Figure 1) that required road users to stop near the crossing and look for trains.
Figure 1: Pogue Road level crossing viewed from the direction of the car’s approach
Source: Chief Investigator, Transport Safety (Vic)
The driver of the car travelled this route almost daily and was familiar with the crossing. On this day, he had driven into town earlier that morning and was returning home. On the approach to the crossing, the driver’s view towards the train was obscured by an orchard and road side trees to the south-west of the crossing (Figure 2).
Figure 2: Pogue Road approach to the level crossing. The view to a train approaching from the right was obscured by road-side vegetation and an orchard.
Source: Chief Investigator, Transport Safety (Vic)
When the train came into view, the driver applied the vehicle’s brakes, leaving skid marks on the gravel road about 40 m in length. However, the vehicle could not be stopped before the crossing and collided with the first passenger carriage behind the locomotive. The impact was to the underframe area of the carriage and dislodged a diesel fuel tank from the train. The passenger compartment remained intact and there were no reported passenger injuries. The road vehicle was severely damaged (Figure 3) and its driver suffered bruising injuries.
Figure 3: Damaged road vehicle and the fuel tank from the impacted rail car.
Source: V/Line Pty Ltd
The train driver had sounded the train horn as the train approached the whistle board that was located 400 m from the crossing, and again a short distance before the crossing. He reported that he did not see the road vehicle. The impact of the car on the train alerted the driver to the collision and he made an emergency brake application.
ATSB comment
Road vehicle driver
The driver was very familiar with the crossing and had used it many times without seeing a train, probably reducing his expectation. This factor and possibly other distractions led to the driver approaching the crossing with a reduced level of vigilance.
Level crossing
Pogue Road is a single-lane gravel road with a speed limit of 100 km/h. It intersected the 100 km/h train line to Shepparton at near right angles. The crossing was controlled by Stop signs (passive control) that required road users to come to a stop and check for trains before proceeding. The signage at the crossing and the advanced warning signage on the approach was in good condition and generally consistent with the Australian Standard for railway crossing signage[1], with minor variations not material to this incident. There have been no previous near-miss or collision incidents reported at this level crossing.
The road-side vegetation and orchard meant that the view to the track was obscured on the approach to the crossing. The provision of Stop sign traffic control measures is consistent with this configuration, as this required road users to stop in a position that would allow them to sight trains.
Passive control measures at level crossings
A range of studies have found that providing active warnings reduces crash rates by 48 to 88 per cent[2]. The same paper recommends further research into low-cost warning devices for passive crossings[3]. On passenger lines, the risk associated with collision extends to rail passengers.
Safety message
Road users are reminded to be vigilant when approaching a passive rail level crossing and check for trains in both directions before crossing.
Rail operators should continue to consider options for reducing the risk of collision at crossings with passive (only) control devices, particularly on passenger line corridors.
Purpose of safety investigations
The objective of a safety investigation is to enhance transport safety. This is done through:
identifying safety issues and facilitating safety action to address those issues
providing information about occurrences and their associated safety factors to facilitate learning within the transport industry.
It is not a function of the ATSB to apportion blame or provide a means for determining liability. At the same time, an investigation report must include factual material of sufficient weight to support the analysis and findings. At all times the ATSB endeavours to balance the use of material that could imply adverse comment with the need to properly explain what happened, and why, in a fair and unbiased manner. The ATSB does not investigate for the purpose of taking administrative, regulatory or criminal action.
Terminology
An explanation of terminology used in ATSB investigation reports is available here. This includes terms such as occurrence, contributing factor, other factor that increased risk, and safety issue.
Publishing information
Released in accordance with section 25 of the Transport Safety Investigation Act 2003
Ownership of intellectual property rights in this publication
Unless otherwise noted, copyright (and any other intellectual property rights, if any) in this report publication is owned by the Commonwealth of Australia.
Creative Commons licence
With the exception of the Coat of Arms, ATSB logo, and photos and graphics in which a third party holds copyright, this publication is licensed under a Creative Commons Attribution 3.0 Australia licence.
Creative Commons Attribution 3.0 Australia Licence is a standard form licence agreement that allows you to copy, distribute, transmit and adapt this publication provided that you attribute the work.
The ATSB’s preference is that you attribute this publication (and any material sourced from it) using the following wording: Source: Australian Transport Safety Bureau
Copyright in material obtained from other agencies, private individuals or organisations, belongs to those agencies, individuals or organisations. Where you wish to use their material, you will need to contact them directly.
On 1 August 2016, at about 0830 Western Standard Time (WST), a Cessna 172 aircraft, registered VH-WKB (WKB), departed from Cape Leveque Aircraft Landing Area (ALA), Western Australia (WA). The pilot (owner) and one passenger were on board the private flight.
Prior to departure, the pilot had checked the amount of fuel in the aircraft’s fuel tanks with a dipstick and estimated there was about 50 litres of fuel remaining. The pilot planned a one hour coastal sightseeing flight to Broome, using a five knot headwind component, at a fuel flow of 35 litres per hour.
Shortly after departure, the pilot noted the headwind component had increased from five knots to about 25 knots. About 45 minutes into the flight, the fuel gauges were indicating lower than the pilot had anticipated, so they initiated a climb to a higher altitude in an attempt to improve their flight range. About one hour and five minutes into the flight, the pilot heard the engine make a ‘bit of a cough’ and noticed the fuel gauges were indicating empty. Considering that their direct track to Broome Airport would require them to fly over water and a residential area, the pilot elected to conduct a precautionary landing.
The pilot identified a clear section of straight road ahead, broadcast a MAYDAY[1] call and landed the aircraft on the Manari road, about 30 kilometres north of Broome airport (Figure 1). The aircraft had been flying for about one hour and 10 minutes. There were no injuries and the aircraft was not damaged.
Following the landing, the pilot confirmed with Broome Air Traffic Control that they landed safely and cancelled their MAYDAY. Aviation fuel was transported by road, to where WKB had landed and it was refuelled. Two vehicles blocked a section of the road to allow WKB to depart for Broome and the aircraft landed at Broome without further incident.
Weather planning
The pilot checked the area forecast and the Broome airport aerodrome forecast (TAF)[2] before departure and elected to use the TAF wind of five knots because they planned to fly at about 500 feet. On arrival at Broome Airport, the pilot noted the wind speed on the Broome TAF had increased to 24 knots with gusts to 38 knots.
Figure 1: VH-WBK flight with key events
Source: Google earth, annotated by ATSB
Fuel consumption
In March 2015, the pilot flew the aircraft from Moorabbin Airport, Victoria, to Kununurra Airport, WA, and calculated the average fuel flow was 32 litres per hour. In June 2016, a periodic inspection was conducted, which included a calibration check of the fuel gauges and dipstick.
The day prior to the incident flight, the pilot flew the aircraft to Mitchell Plateau ALA, where it was refuelled with aviation fuel from a drum, and then onward to Cape Leveque (Figure 1). The use of fuel from a drum at Mitchell Plateau precluded an accurate fuel flow check by the pilot and there was no fuel stock available at Cape Leveque during their overnight stay.
Subsequent to the incident flight the pilot calculated the fuel flow had increased from 32 litres per hour to 37 litres per hour.
Safety message
This serious incident highlights how several factors, which on their own were not critical, combined on the day to result in a critical situation for the pilot. The fixed fuel reserve on board at the time of departure was less than the recommended 45 minutes for piston engine aircraft flights, as published in
. Shortly after departure the headwind component increased and unknown to the pilot, the fuel consumption was greater than planned.
The pilot commented that they were not in a rush and probably too relaxed in their approach to the flight. Consequently, the effect of the change in wind speed on fuel reserves was not given the priority that it required. They also highlighted the importance of aircraft owners confirming fuel consumption after a periodic inspection is conducted.
The objective of a safety investigation is to enhance transport safety. This is done through:
identifying safety issues and facilitating safety action to address those issues
providing information about occurrences and their associated safety factors to facilitate learning within the transport industry.
It is not a function of the ATSB to apportion blame or provide a means for determining liability. At the same time, an investigation report must include factual material of sufficient weight to support the analysis and findings. At all times the ATSB endeavours to balance the use of material that could imply adverse comment with the need to properly explain what happened, and why, in a fair and unbiased manner. The ATSB does not investigate for the purpose of taking administrative, regulatory or criminal action.
Terminology
An explanation of terminology used in ATSB investigation reports is available here. This includes terms such as occurrence, contributing factor, other factor that increased risk, and safety issue.
Publishing information
Released in accordance with section 25 of the Transport Safety Investigation Act 2003
Ownership of intellectual property rights in this publication
Unless otherwise noted, copyright (and any other intellectual property rights, if any) in this report publication is owned by the Commonwealth of Australia.
Creative Commons licence
With the exception of the Coat of Arms, ATSB logo, and photos and graphics in which a third party holds copyright, this publication is licensed under a Creative Commons Attribution 3.0 Australia licence.
Creative Commons Attribution 3.0 Australia Licence is a standard form licence agreement that allows you to copy, distribute, transmit and adapt this publication provided that you attribute the work.
The ATSB’s preference is that you attribute this publication (and any material sourced from it) using the following wording: Source: Australian Transport Safety Bureau
Copyright in material obtained from other agencies, private individuals or organisations, belongs to those agencies, individuals or organisations. Where you wish to use their material, you will need to contact them directly.
The Myanmar Accident Investigation Bureau (MAIB) are investigating an accident involving an Embraer Regional Jet, ERJ190-100 and an Avions Tolouse Regionale, ATR 72-600.
As part of its investigation, the MAIB initially requested assistance from the Australian Transport Safety Bureau (ATSB) in the download and analysis of the flight recorder from the Embraer.
Consistent with clause 5.23 of Annex 13 to the Convention on International Civil Aviation (ICAO Annex13), the ATSB appointed an accredited representative to assist the MAIB and initiated an investigation under the Transport Safety Investigation Act 2003.
The MAIB subsequently informed the ATSB that they had sought assistance elsewhere for the flight recorder download.
The ATSB has therefore discontinued the investigation.
Any requests for information regarding the occurrence should be addressed to:
Myanmar Accident Investigation Bureau First Floor, DCA HQ Building (B) Yangon 11021, Myanmar Tel: 951 533162 Fax: 951 53016 Email: ddmaib@dca.gov.mm
Section 21 (2) of the Transport Safety Investigation Act 2003 (TSI Act) empowers the Australian Transport Safety Bureau (ATSB) to discontinue an investigation into a transport safety matter at any time. Section 21 (3) of the TSI Act requires the ATSB to publish a statement setting out the reasons for discontinuing an investigation.
On 26 July 2016, the ATSB commenced an investigation into a loss of separation between a Jetstar Airbus A320 registered VH-VFO and an Air Asia X Airbus A330 registered 9M-XXC, near Gold Coast Airport, Queensland.
The Airbus A330 was departing Gold Coast Airport for Auckland, New Zealand while the A320 was arriving from Avalon, Victoria. Both aircraft were in visual meteorological conditions and the flight crews of both aircraft had the other aircraft in sight.
At the request of air traffic control, the flight crew of the A330 reported the A320 in sight and was instructed to pass behind that aircraft and climb. As the A330 climbed, both flight crew received a Traffic alert and collision avoidance system (TCAS)[1] Resolution advisory (RA).[2]Separation reduced to about 600 ft vertically and 0.35 NM (650 m) laterally. The required separation standard was 1,000 ft and 3 NM (5.6 km).
An Airservices Australia (Airservices) internal investigation into the occurrence identified the following safety issue:
Visual-pilot separation is not applied internationally in Classes A, B and C airspace. This may result in pilots of foreign registered aircraft not being familiar with their requirements and obligations when subject to this form of separation.
In response to the identified issue, safety action was undertaken to:
Review the risks of the application of visual pilot separation as applied to foreign registered aircraft. In determining its ongoing feasibility, with these operators, ensure any identified risks are appropriately managed
That review was conducted and resulted in a recommendation to:
Remove PASS BEHIND as a stand-alone phraseology for assigning pilot visual separation. (Note: could still be used in conjunction with other phraseology e.g. MAINTAIN SEPARATION WITH (AND PASS BEHIND).
The review also recommended that the following rule changes be considered in regard to assigning visual separation:
• Changing phraseology from MAINTAIN SEPARATION WITH to MAINTAIN OWN SEPARATION WITH. (alignment with ICAO phraseology)
• Restricting the use of pilot visual separation for jet traffic to sight and follow scenarios. That is, no ‘pass behind’ for jets.
• Limiting the application of pilot visual separation for foreign registered aircraft to sight and follow situations.
Airservices subsequently advised that it intends to implement the review recommendation and also the phraseology rule change described in the first dot point of the review considerations.
The ATSB reviewed the Airservices reports, safety issues and safety actions. Based on this review, the ATSB considered it was unlikely that further investigation would identify any systemic safety issues. Consequently, the ATSB has discontinued this investigation.
On 27 July 2016, at about 0930 Eastern Standard Time (EST), the pilot of a Robinson R22 Beta helicopter, registered VH-HRL (HRL), completed mustering operations at a property about 33 km south of Blackall, Queensland. The helicopter then departed from the property on a ferry flight and tracked towards the pilot’s home about 110 km to the west-northwest. The pilot was the sole occupant of the helicopter.
At about 1002, the pilot’s GPS tracker indicated that the helicopter had stopped moving, about 41 km from its destination and on the helicopter’s direct track. The helicopter had struck a powerline and subsequently collided with terrain. At about 1030, a local landowner notified the energy provider of a power outage. Two line workers from the energy provider later departed from Blackall to determine the source of the power outage.
At about 1500, while inspecting the powerlines in the area, the line workers located the wreckage of HRL. The windshield and right skid of the helicopter had struck the single wire, which was strung east-west across a cleared area, 4.8 m above the ground. The first point of impact of the helicopter was about 31 m beyond the powerline and it then collided with the ground inverted about 18 m further away. During that impact, it appeared that the pilot’s seatbelt sheared through and the pilot was ejected from the helicopter sustaining serious injuries. The wire had been stretched about 30 m, two power poles broke off and another two were pulled out of the ground. The helicopter was destroyed (Figure 1).
The line workers called emergency services using a satellite phone, and remained with the pilot until police and paramedics arrived at about 1700.
Figure 1: Accident site showing damage to VH-HRL
Source: Queensland Police
Accident site
The helicopter struck the powerline in a clearing, mid-span between two power poles about 250 to 300 m apart. The helicopter was travelling across the direction of the powerline.
An aircraft warning marker may be installed on an overhead cable or its supporting structures to warn pilots of their presence. The powerline struck in this incident was not, and was not required to be, marked with aircraft warning markers according to the relevant Australian Standard (AS3891.1).
Based on the forward speed indicated by the distance of the wreckage from the wires, and the marks left in the ground by the helicopter main rotor blades, the helicopter engine was probably producing power at the time it struck the wire.
ATSB comment
Due to the injuries sustained in the accident, the pilot was unable to recall the event or provide any comments for the investigation.
Safety message
Low-level flight carries an increased risk of striking hazards, such as powerlines, many of which are difficult to see in flight. The ability of pilots to detect powerlines depends on many factors, including the physical characteristics of the powerline (such as the spacing of power poles and the orientation of the wire), prevailing weather and light conditions, and the nature of surrounding terrain and vegetation.
The objective of a safety investigation is to enhance transport safety. This is done through:
identifying safety issues and facilitating safety action to address those issues
providing information about occurrences and their associated safety factors to facilitate learning within the transport industry.
It is not a function of the ATSB to apportion blame or provide a means for determining liability. At the same time, an investigation report must include factual material of sufficient weight to support the analysis and findings. At all times the ATSB endeavours to balance the use of material that could imply adverse comment with the need to properly explain what happened, and why, in a fair and unbiased manner. The ATSB does not investigate for the purpose of taking administrative, regulatory or criminal action.
Terminology
An explanation of terminology used in ATSB investigation reports is available here. This includes terms such as occurrence, contributing factor, other factor that increased risk, and safety issue.
Publishing information
Released in accordance with section 25 of the Transport Safety Investigation Act 2003
Ownership of intellectual property rights in this publication
Unless otherwise noted, copyright (and any other intellectual property rights, if any) in this report publication is owned by the Commonwealth of Australia.
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With the exception of the Coat of Arms, ATSB logo, and photos and graphics in which a third party holds copyright, this publication is licensed under a Creative Commons Attribution 3.0 Australia licence.
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The ATSB’s preference is that you attribute this publication (and any material sourced from it) using the following wording: Source: Australian Transport Safety Bureau
Copyright in material obtained from other agencies, private individuals or organisations, belongs to those agencies, individuals or organisations. Where you wish to use their material, you will need to contact them directly.
On the morning of 20 March 2016, the pilot of a Cessna 182S aircraft, registered VH-PCO, conducted a private flight from Moorabbin Airport to Tooradin Airfield,[1] Victoria, with two passengers on board. The aircraft took off from runway 17 Right at Moorabbin, and the wind during the 21 NM flight was south-easterly at about 10 kt. The runway in use at Tooradin was 04 (Figure 1), and the pilot reported that the landing at the end of that flight was uneventful.
Figure 1: Tooradin Airfield
Source: Google earth, annotated by the ATSB
After landing at Tooradin, the pilot prepared to conduct a scenic flight to Wonthaggi, Wilsons Promontory and return, with three passengers on board. While on the ground at Tooradin, the pilot was concerned that the wind had increased since their arrival, therefore obtained an updated weather forecast and the actual weather at Tyabb, which was about 12 NM south-west of Tooradin. The pilot also obtained the latest weather report for Moorabbin, where the wind was from 120° at 11 kt, and runway 13 was in use.
Based on that information, the pilot assessed that it was suitable to go ahead with the planned flight, but also made the contingency plan to divert to Moorabbin if the strength of the crosswind at Tooradin was not suitable for a landing on their return.
The pilot reported that the flight was normal. At about 1320 Eastern Daylight-saving Time (EDT), the aircraft returned to Tooradin, and the pilot elected to join the circuit on a right downwind for runway 04. While on the downwind circuit leg, the pilot and the front seat passenger observed a windsock, which was located near the runway 04 threshold (near the helipad). The pilot stated that the windsock indicated that the wind was blowing straight down the runway, and elected to continue the approach.
After turning onto final approach, the pilot selected full flap (40°). When at about 300 ft above ground level, the pilot confirmed that the windsock still indicated a headwind, and continued the approach. The pilot reported that as the main wheels touched down, about 300 m beyond the runway threshold, the aircraft veered left off the runway onto the grass.
The pilot immediately commenced a go-around by applying full power and raising the aircraft’s nose in an attempt to clear aircraft parked on the grass ahead. The stall warning horn sounded, and the pilot assessed that the aircraft was not climbing and that its landing gear may collide with the parked aircraft.
The pilot therefore reduced the power to idle and the aircraft landed heavily to the north of the runway. The aircraft then struck three other aircraft that were parked on a grassed area between the runway and a sealed taxiway.
The aircraft sustained substantial damage and the pilot and passengers were uninjured (Figure 2).
Figure 2: Accident site showing damage to VH-PCO
Source: Country Fire Authority Victoria
Pilot experience and comments
The pilot had a total of 168.8 hours of aeronautical experience, including 5.4 hours in the Cessna 182S.
The pilot provided the following comments:
Prior to the flight, the pilot assessed the wind using the windsock to the north of the field and the torn windsock near the shipwreck. On final approach, the pilot referenced the windsock near the runway 04 threshold (near the helipad).
In hindsight, they should have retracted the flaps to 20° for the go-around.
There was no indication of a crosswind during the approach.
Weather observations
There was no automatic weather station at Tooradin. The nearest weather data recorded by the Bureau of Meteorology was at Moorabbin and Frankston, and the ATSB obtained the 1-minute weather data for those locations. The runway at Tooradin was situated adjacent to Western Port Bay, and the runway direction in use was 04. The pilot and an instructor at Tooradin reported that the wind at Tooradin was generally not the same as that experienced at Moorabbin.
Around the time of the accident, the wind at Frankston was varying in direction from 096° to 143°, from 6 to 10 kt, gusting to 15 kt. An instructor at Tooradin reported that throughout the day, the wind was about 7 to 9 kt, some of which was crosswind, as it was blowing at about a 45° angle to the runway.
The instructor also reported that the main windsock for the airfield was to the north of the field, and there were two windsocks on the southern side of the strip – one located near the helipad and the other, which was torn but still indicating accurately, adjacent to the shipwreck (Figure 1).
Safety action
Whether or not the ATSB identifies safety issues in the course of an investigation, relevant organisations may proactively initiate safety action in order to reduce their safety risk. The ATSB has been advised of the following safety action in response to this occurrence.
Aircraft operator
Although the accident flight was a private flight, the aircraft operator, as a training organisation, has advised the ATSB that as a result of this occurrence, they are taking the following safety actions:
Improving the delivery of training in crosswind circuits and go-arounds
The aircraft operator is reviewing
what grade instructors are authorised to conduct training in crosswind conditions
which aerodrome the lessons are delivered at
the minimum crosswind component for the lessons
where it is delivered within the training syllabus
the contents of training notes and sequence briefing
how they allocate testing officer to ensure there is no student input.
The operator has also asked flight testing officers to emphasise crosswind and go-around techniques.
Presentation to company pilots
The operator has arranged for a senior airline captain to deliver a presentation to company pilots on stabilised approaches, selection of the touchdown zone, and appropriate responses to non-normal situations.
Carriage of airsick bags
Aircraft folders will be equipped with airsick bags, to reduce the effect a sick passenger may have on a pilot’s workload.
Review of Emergency Response Plan
While the operator assessed that their emergency response plan was effective in this incident, they have identified some improvements to be implemented.
Safety message
A report prepared by the US Aircraft Owners and Pilots Assocation, Cessna 182 Skylane Safety Highlights,stated that the number of accidents for the aircraft type was inversely proportional to the number of hours a pilot had accumulated, and the majority of accidents involved pilots with less than 400 hours’ total time. Landing was the most accident-prone phase of flight. The report also stated that the maximum demonstrated crosswind component for most Cessna 182 aircraft was 15 kt – most pilots should consider that as limiting until they are highly proficient in crosswinds. The aircraft’s Pilot Operating Handbook suggested procedures for landing in crosswinds, including that they should be performed with the minimum flap setting necessary for the field length.
The Flight Safety Foundation Approach-and-landing accident reduction tool kit
The objective of a safety investigation is to enhance transport safety. This is done through:
identifying safety issues and facilitating safety action to address those issues
providing information about occurrences and their associated safety factors to facilitate learning within the transport industry.
It is not a function of the ATSB to apportion blame or provide a means for determining liability. At the same time, an investigation report must include factual material of sufficient weight to support the analysis and findings. At all times the ATSB endeavours to balance the use of material that could imply adverse comment with the need to properly explain what happened, and why, in a fair and unbiased manner. The ATSB does not investigate for the purpose of taking administrative, regulatory or criminal action.
Terminology
An explanation of terminology used in ATSB investigation reports is available here. This includes terms such as occurrence, contributing factor, other factor that increased risk, and safety issue.
Publishing information
Released in accordance with section 25 of the Transport Safety Investigation Act 2003
Ownership of intellectual property rights in this publication
Unless otherwise noted, copyright (and any other intellectual property rights, if any) in this report publication is owned by the Commonwealth of Australia.
Creative Commons licence
With the exception of the Coat of Arms, ATSB logo, and photos and graphics in which a third party holds copyright, this publication is licensed under a Creative Commons Attribution 3.0 Australia licence.
Creative Commons Attribution 3.0 Australia Licence is a standard form licence agreement that allows you to copy, distribute, transmit and adapt this publication provided that you attribute the work.
The ATSB’s preference is that you attribute this publication (and any material sourced from it) using the following wording: Source: Australian Transport Safety Bureau
Copyright in material obtained from other agencies, private individuals or organisations, belongs to those agencies, individuals or organisations. Where you wish to use their material, you will need to contact them directly.
