What happened

On 14 November 2014, at about 1230 Eastern Daylight-saving Time (EDT), a de Havilland Canada DHC-1 (Chipmunk) aircraft, registered VHRVY (RVY), departed from Luskintyre Airfield, New South Wales, for a post-maintenance flight with the pilot and one passenger on board. The flight plan was to conduct the flight near the airfield and at a safe altitude. The aircraft had a history of ongoing problems with both the engine revolutions per minute (RPM) governing system as well as the rear vertical speed indicator (VSI). The passenger who was seated in the rear seat was to monitor and report any engine RPM fluctuations and observe the VSI indication.

After about 10 minutes of straight and level flight, as well as climbs and descents, with no fluctuations in the engine RPM, the pilot commenced some gentle aerobatics. These aerobatics were to ensure the selected engine speed was maintained through a range of flight attitudes and airspeeds. As everything appeared to be functioning correctly, the pilot then progressed to some more advanced aerobatic manoeuvres.

As the aircraft was exiting the bottom of a modified loop manoeuvre, at around 140 kt indicated airspeed (IAS), the engine began to over speed without warning.^[1] The pilot reduced the engine power and commenced trouble shooting the problem.

At the time, RVY was about 1 km north of Luskintyre Airfield (Figure 1), heading east at about 3,000 ft above ground level (AGL). The westerly wind was reported to be gusting at around 2030 kt. The pilot joined downwind for a landing on runway 30, noting the groundspeed was around 150-160 kt. While on downwind, the pilot advanced the throttle lever and noted that at about 1/3 lever movement the engine speed was at about 3,000 RPM (maximum continuous RPM at sea level pressure altitude is 2,700). Despite the engine speed, the aircraft was not able to maintain altitude. In an attempt to ‘get back’ to the airfield the pilot turned from a slightly extended downwind onto a ‘base leg’. As the aircraft turned, the engine stopped producing power. The pilot unsuccessfully attempted to restart the engine.

When RVY turned onto a final approach, the aircraft was still descending. At about 500 ft AGL, the pilot determined that they would not make the runway, so he elected to land in a paddock about 500 m east of the airfield (Figure 1). During this manoeuvre, the right wing stalled and dropped slightly. To recover, the pilot lowered the nose of the aircraft to gain more airspeed. The pilot reported that due to the high outside air temperature and gusting wind, the conditions were quite turbulent near the ground. The pilot flared the aircraft in preparation for landing and noted airframe buffeting, with little to no response from the elevator. The aircraft landed heavily, travelling through an electric fence before the aircraft stopped on a drive way just short of the selected landing area (Figure 1).

The pilot exited the aircraft quickly as the right wing fuel tank had ruptured during the landing and fuel had spilt onto the ground. The pilot tried to assist the passenger, but due to the pilot’s injuries he was unable to provide any physical assistance. After a short time, the passenger exited the aircraft. The pilot and passenger sustained serious injuries and the aircraft was substantially damaged (Figure 2).

Figure 1: Accident location

Source: Google™ earth, annotated by the ATSB

Figure 2: VH-RVY

Source: New South Wales Police Force

Aircraft information

The aircraft was manufactured in the United Kingdom in 1951 and was first registered in Australia in 1954. The aircraft had been modified by the previous owner, between 1978 to 1983, where the de Havilland Engine Company Gipsy Major engine and fixed pitch propeller instillation was replaced with a Lycoming IO-360A1B6 engine, constant speed propeller, propeller governor and an accumulator installation.

Pilot comment

The pilot worked for the maintenance organisation and had flown the aircraft after its last maintenance in 2013. The pilot indicated that at the annual maintenance inspection in 2013, small fluctuations in the selected engine RPM had been reported. Both the propeller and propeller governor were sent to be overhauled and reinstalled on the aircraft, however there continued to be slight RPM fluctuations. After the annual inspection conducted just prior to the accident, it was found that there was about a 100 engine RPM fluctuation, during gentle climbing and descending. The propeller governor and accumulator were again sent to be overhauled. The components were returned serviceable with no defects found. The pilot reported that during the overhaul some adjustments were made to the internal operating pressures of the propeller governor. The components were reinstalled on RVY and ground tested with no defects found.

The pilot believed that coming out of the modified loop manoeuvre the propeller had gone into full fine pitch, resulting in the engine entering an “overspeed” condition.

The pilot reported that apart from the strong gusty winds, the temperature was about 39°C.

Owner investigation

An investigation was conducted on behalf of the owner that found the following:

• After the accident, the engine, propeller, propeller governor and accumulator were removed from the aircraft and were inspected and tested to identify any defects.
• The engine was functionally tested on an engine test truck and no defects were found.
• The propeller was inspected at a propeller overhaul facility and did not find any evidence of damage or failure within the propeller that would explain an uncommanded movement to fine pitch.
• The propeller governor was functionally tested at an aircraft component overhaul facility and no defects were identified.
• The accumulator was functionally tested at an aircraft component overhaul facility and no defects were identified. The engineering order that approved the installation of the accumulator was reported to specify an accumulator air charge pressure of about 250 PSI. The overhaul facility test equipment was only capable of testing the accumulator to about 100 PSI.

The investigation determined that there was no conclusive reason why the engine suffered an overspeed and ceased to operate. It was suggested that the overspeed may have been a result of lack of oil pressure to the propeller when the engine of RVY was inverted, during the aerobatic manoeuvre resulting in the propeller moving to fine pitch.

Safety message

Engine failure in flight

This accident is a timely reminder to pilots to consider the effect an in-flight engine failure at different altitudes and in the given conditions can have on the options available to manage that failure and to identify a suitable forced landing area. The combination of two people on board and the high temperature would have adversely affected the aircraft’s performance on the day.

The ATSB booklet Avoidable Accidents No. 3 - Managing partial power loss after take-off in single-engine aircraft contains information that is also relevant to a complete engine power loss.

The booklet highlights the importance of:

• pre-flight decision making and planning for emergencies and abnormal situations for the particular aerodrome including a thorough pre-flight self-brief covering the different emergency scenarios.
• taking positive action and maintaining aircraft control either when turning back to the aerodrome or conducting a forced landing until on the ground, while being aware of flare energy and aircraft stall speeds.

Aviation Short Investigations Bulletin - Issue 42

About this report Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, a limited-scope, fact-gathering investigation was conducted in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions. Publishing information  Released in accordance with section 25 of the Transport Safety Investigation Act 2003 Published by: Australian Transport Safety Bureau © Commonwealth of Australia 2015 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.

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1. An engine overspeed is a condition in which an engine is allowed or forced to rotate beyond its design limit.

 

The operator had received approval to carry out certain low level operations, including power line inspections, during nominated periods of emergency. The approval was subject to a number of conditions, which included requirements that such flights be authorised by the State Emergency Services and that only persons essential to the operation be carried. As suitably qualified commercial pilots were not normally available, two private pilot members of the aero club who had more than 1000 hours flying experience had been specifically approved to conduct these flights. Before receiving this approval, the pilots had been required to complete specialised low flying training and testing. The procedure used in conducting power line inspection flights was to fly at approximately 200 feet above ground level, maintaining about 90 knots airspeed with one or two stages of flap lowered and with the aircraft tracking left of the line to assist inspection by the observer in the right seat.

The aircraft struck the spur line with its propeller and nose gear. The line did not break and the aircraft was pitched vertically to the ground.

Examination of the wreckage found no evidence of mechanical defect or malfunction which might have contributed to the accident.

What happened

On 11 November 2014, at about 1130 Eastern Standard Time (EST), a Cessna 210 aircraft, registered VH-JGA (JGA), departed from Cairns Airport, Queensland, for a scenic flight over Green Island and Arlington Reef with the pilot and four passengers on board.

After about half an hour of local flying, the pilot returned JGA to Cairns Airport. During the approach, at about 1,000 ft above ground level, the pilot selected the landing gear down, however, the green landing gear down indicator light did not illuminate. The pilot observed via an inspection mirror that the left main landing gear was just out of the landing gear recess and not in the down and locked position. The nose landing gear and right main landing gear appeared to be in the down position. The pilot advised the Cairns Tower air traffic controller that JGA would conduct a missed approach and requested a clearance to hold over the sea to determine the reason for the malfunction.

While holding over the sea, in the vicinity of Cairns Airport, at about 1,000 ft, the pilot conducted a landing gear emergency extension, but the left main landing gear still did not lock in the down position. The pilot contacted the operator and maintenance organisation via a mobile phone and conducted extensive troubleshooting, but was unable to get the left main landing gear to lock in the down position.

JGA was then returned to Cairns Airport and the pilot conducted a low level pass over the runway so that the landing gear could be observed. The nose landing gear and right main landing gear were observed to be in the down position, while the left main landing gear was observed to be out of the landing gear recess and only extended to about a 45 degree angle. The pilot elected to hold over the sea and reduce the amount of fuel on board, before conducting a landing. The pilot consulted with the operator and the maintenance organisation and decided to land on the grass area, abeam runway 33, with the landing gear retracted.

The pilot of JGA conducted two practice approaches to assess the aircraft configuration and landing area before beginning the approach for a wheels-up landing. The pilot extended the flaps to help slow the aircraft and, after turning onto a long final, briefed the passengers for the landing and instructed them to take up the brace position. Just prior to touchdown, the pilot turned off the master switch and moved the engine mixture control to the cut-off position. At about 1416, the aircraft landed on the fuselage underside on the grass area abeam runway 33 and came to a stop. The pilot and four passengers were uninjured and the aircraft was substantially damaged (Figure 1).

Figure 1: Damage to JGA

Source: Aircraft operator

Pilot comment

The pilot had flown the aircraft on a previous flight that day and had not noticed anything unusual. The pilot commented that there was sufficient fuel on board the aircraft so that there was time to investigate the malfunction and to plan and prepare for the landing.

When conducting the emergency extension, the nose and right main gear went straight to the down and locked position before the emergency extension hand pump was used. The hand pump had no effect on moving the left main landing gear.

Operator comment

The operator conducted an investigation into the accident and determined that the housing of the left main landing gear had fractured (Figure 2), resulting in the gear not extending to the down and locked position. The operator reported that they conducted a visual inspection of the left and right main landing gear actuators for cracks and checked the tightness of the actuator mounting bolts at the periodic (100 hourly or 12-month) maintenance inspections with the actuator in-situ. The last inspection was conducted about 50 hours prior to the accident, with no defects found.

JGA was manufactured in 1981 and, at the time of the accident, the aircraft had about 12,882 hours total time in service. The aircraft was maintained under the Civil Aviation Safety Authority (CASA) maintenance schedule (Civil Aviation Regulations 1988 (CAR) Schedule 5). The left main landing gear was a non-lifed component and had been on the aircraft since new. There was no record that the actuator had been overhauled.

Figure 2: JGA left main landing gear actuator showing the fractured housing

Source: Aircraft operator

Cessna service manual

The Cessna 210 aircraft service manual contained a Supplemental Inspection Document (SID) 32-10-01 (temporary Revision Number 10 dated 1 August 2011) with a compliance date by 31 December 2013 that directly related to the removal and detailed inspection of the main landing gear retraction system. The inspection was to be carried out initially every 3,000 hours total time in service or 10 years whichever occurred first and repeated every 500 hours or 5 years whichever occurred first (JGA was manufactured in 1981 and had about 12,882 hours total time in service). The SID also required verification that Cessna Service Bulletin SEB01-2 Main Landing Gear Actuator Inspection has been accomplished. The Cessna 200 series SIDs were introduced in August 2011 and the CASA current compliance dates have been extended until 30 June 2015 for aerial work and charter operations and 31 December 2015 for private operations to allow for sufficient time for full compliance.

Cessna Service Bulletin SEB01-2 Main Landing Gear Actuator Inspection revision 2 dated 4 June 2007, required the inspection of the main landing gear actuators for the presence of cracks. Indicating that non-compliance with the service bulletin could result in failure of the main landing gear actuator. The service bulletin required the removal and disassembly of the main landing gear actuators and a fluorescent penetrant inspection of the actuator body to be carried out using black light and a magnifying glass to detect any cracks (Figure 3). The inspection was to be carried out initially every 3,000 hours total time in service within the next 100 hours operation and subsequent inspections every 500 hours total time in service thereafter.

Figure 3: Cessna Service Bulletin SEB01-2 Fracture located in JGA main main landing gear actuator inspection area landing gear actuator

Source: Cessna Aircraft operator

Aircraft maintenance

The aircraft operator reported that all Service Letters and Service Bulletins are reviewed by the maintenance organisation and implemented based on experience and at their request.

Information provided to the operator by the aircraft maintenance organisation was that the actuator fractured in what appeared to be one clean break and not a crack that slowly progressed, and that type of crack could occur in a sudden overload situation during the take-off when the landing gear is selected up and the wheels contact the ground. The maintenance organisation also recommended that the Service Bulletin requirements be carried out on aircraft that have exceeded 5,000 airframe hours.

ATSB comment

ATSB investigation AO-2011-115

The ATSB investigation AO-2011-115 Flight control system event involving Cessna 210N, VHJHF, 48 km West of Bourke Airport, NSW, 12 September 2011 found that reported elevator control input difficulties resulted directly from the fracture of the aircraft’s two horizontal stabiliser rear attachment brackets. The nature of the failures was typical of the damage sustained by aircraft as they age and move beyond the manufacturer's originally intended design life.

The investigation found at the time, that some aircraft registration holders believed that their aircraft was exempt from the manufacturer’s supplemental inspections, such as the Cessna SIDs when their aircraft was maintained using the CASA maintenance schedule (Civil Aviation Regulations 1988 (CAR) Schedule 5). While the CASA maintenance schedule did not make any specific reference to the incorporation of the manufacturer’s supplemental inspections, it was a CAR requirement that all aircraft be maintained in accordance with approved maintenance data that, by definition, included those inspections.

The ATSB investigation report AO-2011-115 is available at the ATSB website.

CASA Airworthiness Bulletin (AWB) 02-048

CASA issued Airworthiness Bulletin (AWB) 02-048 Compliance with Cessna Supplemental Inspection Documents (SIDs) on 7 April 2014 to clarify the requirement to comply with Cessna SIDs. The AWB comprised Aviation Ruling 01/2014, which stated that compliance with the Cessna SIDs was mandatory, irrespective of the category of operation or the elected maintenance schedule for the aircraft, be it:

• CAR 42A Manufacturer’s Maintenance Schedule,
• CAR 42B CASA Maintenance Schedule (Schedule 5), or
• CAR 42C Approved System of Maintenance.

The AWB also stated that:

Significantly, the SIDs were developed on the assumption that the aircraft had been maintained using the Manufacturer’s Maintenance Schedule, or equivalent (including the incorporation of all applicable Service Bulletins), and do not necessarily take into account modifications or repairs made to the aircraft since manufacture. Therefore, all relevant Service Bulletins need to be incorporated to be in compliance with the SIDs inspections.

Since the accident involving JGA, CASA released Issue 2 to AWB 02-048, dated 10 April 2015, to clarify that those service bulletins listed in the SIDs are required to be incorporated and confirmed that, where specified in the SIDs, on-going inspections are also required to be complied with.

The AWB further stated that:

Therefore, all Service Bulletins that directly relate to the structural integrity of the aircraft need to be incorporated to be in compliance with the SIDs inspections. Please note that some Service Letters and other information referred to in the SIDs requirements were originally discretionary in nature. These documents are now considered mandatory if referred to as part of the SIDs inspections requirements in relation to [principal structural elements (PSEs)] PSEs.

Further information can be found in AWB 02-048, which is available at www.CASA.gov.au.

US Federal Aviation Administration (FAA) Service Difficulty Reporting (SDR) database

A search of the US Federal Aviation Administration (FAA) Service Difficulty Reporting (SDR) database found about 65 entries dated from 1995 to 2014 of reported crack or cracks in the main landing gear actuator/s, in the same crack location as specified in the service bulletin or in that area and with the same part number as JGA’s actuator or one of the actuator part numbers listed in the service bulletin. Five entries had originated from Australia. About 20 reports resulted in an inflight incident and eight mentioned landing with the landing gear in the up position or without both main landing gear in the down position.

Although most reports indicated that the crack or cracks were located in the same area specified in the service bulletin, about 15 indicted they originated from one or more of the actuator attachment bolt holes. About 13 cracks had been located while carrying out the requirements of the service bulletin and the same number again were located while conducting a fleet inspection of the actuator. Several mentioned that this is an ongoing issue and suggested that the actuator be redesigned. One report mentioned a loose actuator attachment bolt, while two mentioned that the bolts were correctly torqued.

Although some entries lacked details, about seven specifically mentioned they were found during a scheduled inspection. One mentioned that the actuator had failed 25 hours after a 100 hourly inspection, which specifically checked the actuators externally for cracks. About three entries reported that the actuator had failed subsequently from conducting the requirements of the service bulletin. One reporter indicated that an inspection should be conducted on the actuator any time that the landing gear contacts the ground in other than the fully extended or fully retracted position.

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:

Maintenance action

The operator’s Cessna 210 aircraft fleet will undergo further examination to see if there is any evidence of other potential failures within the fleet.

Safety message

This accident highlights the importance of comprehensive, periodic maintenance inspections and the role of supplemental inspections in maintaining ageing aircraft. As aircraft age, the original maintenance schedules may not be sufficient to ensure the aircraft’s ongoing safety. It is important to review the aircraft’s maintenance schedule to ensure it is appropriate for the aircraft and that it adequately provides for the continuing airworthiness of the aircraft.

In 2007, the ATSB released research report B20050205 - How Old is Too Old? The impact of ageing aircraft on aviation safety. The report found that some aircraft manufacturers have recognised that the original maintenance schedules may not be sufficient to ensure the aircraft’s (ongoing) safety and have developed supplementary inspection programs (such as the Cessna SIDs); other aircraft do not have the same level of airworthiness support. The report concluded that adequate maintenance of ageing aircraft requires the participation and ongoing cooperation of aircraft manufacturers, regulatory authorities, owners, operators and maintainers.

In addition, further information is detailed in CASA’s Ageing Aircraft Management Plan (AAMP).

CASA Flight safety Australia June 2014 Doing it right is available at: www.flightsafetyaustralia.com/2014/06/

CASA Flight Safety Australia December 2014 SIDS program finds dangerous defects.

Aviation Short Investigations Bulletin - Issue 41

About this report Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, a limited-scope, fact-gathering investigation was conducted in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions. Publishing information  Released in accordance with section 25 of the Transport Safety Investigation Act 2003 Published by: Australian Transport Safety Bureau © Commonwealth of Australia 2015 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 October 2014, a Robinson R44 helicopter, registration ZK-HBQ, collided with terrain in the Kahurangi National Park, near Nelson, New Zealand.

The New Zealand Transport Accident Investigation Commission (TAIC) is conducting an investigation into the circumstances of the accident. As part of its investigation, TAIC requested technical assistance from the Australian Transport Safety Bureau (ATSB) in the recovery of data from a damaged GPS unit recovered from the wreckage. To protect the information supplied by TAIC to the ATSB and the ATSB's investigative work to assist TAIC, the ATSB initiated an investigation under the Transport Safety Investigation Act 2003.

The ATSB successfully recovered data from the GPS unit and has provided the data to TAIC to assist with their investigation.

Enquiries relating to the accident investigation should be directed to TAIC at: www.taic.org.nz

 

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Released in accordance with section 25 of the Transport Safety Investigation Act 2003.

What happened

On 31 October 2014, the pilot of a de Havilland DHC-2 aircraft, registered VH-AWD (AWD), conducted a scenic charter flight from Hayman Island Water Landing Area, Queensland. The pilot of AWD broadcast on the common traffic advisory frequency (CTAF) when passing Pinnacle Point. The broadcast from AWD was heard by the pilot of a Gippsland Aeronautics GA-8 aircraft, registered VH-NOQ (NOQ), which had departed from Shute Harbour Airport for a scenic charter flight. Although he heard the broadcast, the pilot of NOQ did not know where Pinnacle Point was as it was not labelled on the visual terminal chart (VTC).

The pilot of NOQ broadcast on the CTAF after passing Tongue Point and heading south along Whitehaven Beach. The pilot of AWD heard a broadcast on the CTAF, possibly that of the pilot of NOQ at Tongue Point, but did not hear the contents of the broadcast. As he missed the broadcast, the pilot of AWD then broadcast his position and intentions, and did not receive a response.

NOQ tracked to the southern end of Whitehaven Beach, turned and headed north returning to Tongue Point. When just south of Tongue Point for the second time, the pilot of NOQ broadcast on the CTAF and advised that he was changing to Hamilton Island air traffic control (ATC) Tower frequency. The pilot then commenced a left turn, selected the Tower frequency and was no longer monitoring the CTAF.

At about 1354 Australian Eastern Standard Time, and 1,300 feet, when approaching Tongue Point from Dumbell Island, the pilot of AWD sighted NOQ on a reciprocal track and estimated the aircraft passed on his right about 50 m away and about 50 feet above AWD.

This incident highlights the importance of broadcasting radio calls on, and monitoring, the appropriate frequency, to alert pilots and assist in see-and-avoid practices. It serves as a reminder to keep a good lookout for other aircraft, particularly around high traffic areas and radio frequency zone boundaries.

Aviation Short Investigations Bulletin - Issue 38

On 9 April 2014, a Quest Aircraft Company Kodiak 100 registered PK-SDF collided with terrain during take off from Doyo Baru Airstrip, Jayapura, Papua Indonesia. The accident destroyed the aircraft and fatally injured the two occupants.

The National Transportation Safety Committee (NTSC) of Indonesia is responsible for investigating this accident. The aircraft was fitted with advanced cockpit instrumentation that included a flight data logging function. Although subjected to significant fire damage, the cockpit instrumentation and associated avionics were recovered by on site investigators and transported to the NTSC facilities for further examination. Examination of the instruments revealed remnants of non-volatile memory devices that were fitted to the cockpit displays.

The NTSC requested specialist assistance from the Australian Transport Safety Bureau (ATSB) to attempt the recovery of flight data from the non-volatile memory chips fitted to the cockpit instrumentation.

In accordance with clause 5.23 of Annex 13 to the Convention on International Civil Aviation (ICAO Annex 13) the ATSB appointed an Accredited Representative to assist the NTSC and initiated an investigation under the Australian Transport Safety Investigation Act 2003.

Examination of the instrument display components indicated they had suffered significant heat exposure resulting in the memory device packaging melting. The examination revealed parts of the memory device were present in the display components, however the memory chip could not be located. Consequently no accident flight data could be recovered to assist the NTSC investigation team. Preliminary results were conveyed to the Head of Aviation Sub Committee and a final report provided in November 2014.

The National Transportation Safety Committee of Indonesia is responsible for releasing a final investigation report regarding this occurrence. Contact details for the NTSC are:

National Transportation Safety Committee Office

Ministry Of Transportation Republic Of Indonesia
Transportation Building 3rd Floor
Jalan Medan Merdeka Timur No. 5
Jakarta Pusat 10110
Indonesia

Phone : +62 21 384 7601
Fax : +62 21 351 7606
Email : knkt@dephub.go.id

 

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Released in accordance with section 25 of the Transport Safety Investigation Act 2003.

What happened

On 27 October 2014, at about 1030 Eastern Daylight-savings Time (EDT), a Cessna 172 aircraft, registered VH-ZZD departed Ballarat, Victoria, for Luskintyre, New South Wales, on a private flight under the visual flight rules. The pilot refuelled at Wangaratta, Victoria, and took a break for refreshments at Temora, New South Wales. As he neared Kandos, New South Wales, the pilot elected to track directly to Luskintyre, rather than follow his planned route which took him over a number of towns further north.

The direct track between Kandos and Luskintyre was over heavily treed and undulating terrain, leaving the pilot unable to positively visually fix his position. As he continued in an easterly direction, the pilot grew increasingly concerned about the possibility of infringing controlled airspace further to the east. Rather than risk infringing controlled airspace, the pilot decided to make a precautionary landing to ascertain his position. The pilot commented that precautionary landing options were very limited, but he ultimately selected a paddock that was clear of obstacles, and while relatively short, it offered an uphill landing run to assist in stopping the aircraft.

During his approach to land on the selected paddock, with full flap selected, the pilot found himself overshooting the selected aim point. Concerned that he would not be able to land safely, the pilot elected to discontinue the approach and commenced a go-around. As the go-around proceeded however, the aircraft collided with a line of trees on rising terrain beyond the far end of the selected paddock. The aircraft was substantially damaged, and the pilot received serious injuries. The aircraft wreckage was discovered by a local resident around 2 hours after the accident, independent of other search and rescue activities.

Pilots unsure of their position or requiring navigational assistance, are encouraged to seek Flight Following services from ATC. In this case, contact with ATC may have allayed the pilot’s concerns about the prospect of infringing controlled airspace, and negated the need to consider a precautionary landing. With respect to precautionary landings, pilots are encouraged to initiate an early go-around given any doubt regarding the prospects of a safe landing.

Aviation Short Investigations Bulletin - Issue 39

On 23 June 2014, a Eurocopter Deutschland BO-105 helicopter, registration P2-NHW, was conducting village-to-village sling-load operations in mountainous terrain in Morobe Province of Papua New Guinea. While on approach to land at the remote village of Onggake, the helicopter’s number-one engine sustained a power loss that required the pilot to conduct a forced landing. There were no injuries. On-site examination of the helicopter revealed that significant internal damage had occurred to the compressor assembly from the number-one engine, a Rolls-Royce M250-C20B turboshaft.

The Papua New Guinea Accident Investigation Commission (PNG AIC) commenced an investigation into the accident and subsequently, technical support was requested from the Australian Transport Safety Bureau (ATSB) in the examination of the compressor assembly. In providing this support, the ATSB commenced an external investigation under the Transport Safety Investigation Act 2003.

The initial disassembly and examination of the compressor was conducted at the ATSB’s technical facilities in Canberra. The parts were subsequently sent to the engine manufacturer in the United States for detailed metallurgical examination. Reports from both the engine manufacturer and the ATSB were provided to the PNG-AIC to assist with the investigation.

The PNG Accident Investigation Commission is responsible for and will administer the release of the final investigation report into this accident.

Further information regarding the occurrence can be found at www.aic.gov.pg or specific enquiries should directed to infor@aic.gov.pg.

Double-click on icon above to open formatted ASOR report document. Last amended 12 Nov 2004 (post ED review to include dates). ?? ?? ?? ?? 1

TECHNICAL ANALYSIS INVESTIGATION REPORT 200404065 Recovery and Presentation of Recorded Data for the Transport Accident Investigation Commission New Zealand Hughes 369HS, ZK-HCC Accident near Fox Glacier, New Zealand 30 November 2003 Factual Information On 30 November 2003, a New Zealand registered Hughes 369HS, ZK-HCC, was operating on a standard scenic flight over the Fox Glacier, New Zealand. The intended track was over Fox Glacier, around Mount Cook and Mount Tasman, returning via the Fox Glacier to land at Fox Glacier township. After a normal climb to 9,500 ft and commencing level forward flight, the pilot noticed the power turbine speed and main rotor speed reduce. The pilot descended to 6,500 ft where power was restored. Several minutes later a second power loss occurred. The pilot then carried out an emergency landing at the base of Fox Glacier. During the emergency landing the helicopter sustained damage to a landing gear skid and rolled onto its side. The pilot and passengers vacated the helicopter with no serious injuries. A passenger had been photographing the scenic flight using a video camera. Sounds relating to the operation of the main rotor gearbox had been recorded on the video. The Transport Accident Investigation Commission (TAIC) of New Zealand was responsible for investigating this accident and requested assistance from the Australian Transport Safety Bureau (ATSB) to analyse the sounds recorded on the video camera. It was requested that the data be presented in tabular and graphical format. The Executive Director of the ATSB approved the request and the examination was conducted in accordance with the Australian Transport Safety Investigation Act 2003. A copy of the video recorded during the accident flight was forwarded to the ATSB by the TAIC aviation investigator in charge. The video was received at the Bureau on 24 February 2004 and examined by an ATSB recorder specialist. The audio signals were downloaded and analysed using the Bureau's audio software and graphical and tabular presentations of the data were prepared. Information relating to the operation of the helicopter's main rotor system was provided to the TAIC investigator in charge for consideration in preparing their report. A copy of the TAIC investigation report (03-007) may be found at: www.taic.org.nz or by contacting the Transport Accident Investigation Commission, PO Box 10-323, Wellington, New Zealand.