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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.

The crew of the Airbus Industrie A340 responded to a traffic alert and collision avoidance system (TCAS) resolution advisory (RA) and climbed 600 ft above the cleared level of flight level (FL)190. The conflicting traffic was a formation of military McDonnell Douglas Corporation FA-18A Hornet aircraft in transit through a military airspace corridor. Traffic information was passed to the crew of the A340 by the air traffic controller. The Hornet crews were on military control frequencies. At the time of the TCAS alert, the Hornets had climbed to FL180 from FL170 to transit civil airspace via a military airspace corridor 75km north of Sydney, known as the Hunter Corridor. Civil radar data indicated that the Hornets climbed to FL183 and military radar data indicated a climb to FL182. The crews stated that they were positive that they had levelled at FL180, and that they had the A340 in sight. Analysis of the radar data indicated that, at the time of the resolution advisory, the standard vertical separation had reduced to less than 1000ft resulting in an infringement of separation standards.

The pilot-in-command of the Cessna 210 suffered a seizure which rendered him unconscious. He was subsequently unable to safely control the aircraft. The geoscience operator, who was also a rated pilot and was sitting in the right seat of the aircraft, took control of the aircraft and diverted to and landed safely at Bourke. The geoscience operator had to continually prevent the pilot-in-command's body from inadvertently fouling the flight controls during the return flight to Bourke. After the aircraft landed, the pilot regained consciousness and underwent medical treatment. Later the same day the pilot suffered another seizure and was hospitalised for a short period.

The investigation by The Netherlands authorities is continuing. The ATSB has completed its contribution to the investigation and plans to publish a copy of the final report on the ATSB website www.atsb.gov.au when it is received from The Netherlands.

The investigation by the Italian authorities is continuing. The ATSB has completed its contribution to the Italian investigation and plans to publish a copy of the final report on the ATSB website www.atsb.gov.au when it is received from the Italian authorities.

After the interim completion of agricultural spraying operations, the property owner asked the pilot to disperse one load of insecticide over a neighbour's property. The adjacent property owner had requested this work to be done. As the pilot hover-taxied an Agusta-Bell 47G-3B1 helicopter towards a water replenishing point on the neighbour's property, the cockpit bubble and one main rotor blade of the helicopter struck an unseen single strand high-tension power line partially concealed by a shed. The pilot was able to maintain control of the helicopter and landed safely. The helicopter sustained minor wire impact damage to one main rotor blade, the main rotor mast, and one tail rotor blade. The pilot and passenger escaped without injury. The water tanks were near a shed which partially concealed the wire which was at an angle of about 45 degrees to a height of 60 to 70 feet AGL. The wire also blended into the background foliage. The pilot had visited this section of the neighbour's property about 2 years ago. No wires were noted during this visit. The owner of the adjacent property had not briefed his neighbour to inform the pilot about a new wire that had been erected near the water tanks. Consequently, the pilot had not been adequately briefed by the other property owner as to the presence and location of the recently erected wire which was in close proximity to the water tanks.

The Boeing 767 was established on the ILS glide path to runway 27 in VMC. The crew noted that the visual approach angle appeared shallower than normal for the aircraft configuration and consequently had the crew flown the aircraft in accordance with the ILS indication, the aircraft would have probably landed short of the runway. The crew also noted that the Precision Approach Path Indicator indicated a significant undershoot. Several international crews have reported contradictory indications on the runway 27 ILS glide slope and Precision Approach Path Indicator (PAPI) guidance systems. The crews believe that the Den Pasar runway 27 ILS glide slope and PAPI may be unsafe for use in IMC. Consequently, Bali Air Traffic Services have issued a NOTAM stating that the runway 27 ILS glide path is unreliable and awaiting further testing.

When a Dash-8 entered the circuit on a 5 mile final for runway 36, an amateur Vans RV-6 reported downwind for runway 27. The Dash-8 crew attempted to contact the pilot of the RV-6 but were unable establish clear communications with the pilot to determine the precise position of the RV-6 and to clarify the pilot's intentions. As a pre-cautionary measure, the Dash-8 crew elected to climb to 2,000 ft to avoid the RV-6. Witnesses on the ground reported sighting the RV-6 behind and below the Dash-8 on the extended centreline of runway 36/18 as the Dash-8 began the climb. The RV-6 was not detected visually or by TCAS. The Dash-8 was re-positioned for an approach to runway 09 when the crew had received a transmission from the RV-6 pilot which indicated that he had landed on runway 36.

The pilot of a Piper Archer aircraft was conducting circuit work at Bathurst. While making a glide approach to runway 35, he applied engine power to adjust the approach, but was only able to obtain sufficient power to continue with the landing. On touch-down, with the intention of conducting a touch-and-go landing if the engine responded normally, the pilot advanced the throttle but received little response. He abandoned the take-off and cleared the runway.

The pilot reported that he conducted a complete engine power check, during which engine power and response appeared to be normal, with no indications of carburettor icing. The pilot then taxied the aircraft to the runway 35 threshold where he conducted further engine checks. All indications were normal. When the engine power was reduced below 1,000 RPM as he lined up for take-off on runway 35, the engine stopped and would not restart. Observing two individuals running towards the aircraft, the pilot shutdown the aircraft systems, and on leaving the aircraft noticed smoke emanating from the right side of the engine cowling. Soon after, flames were clearly visible. The fire was extinguished using a portable extinguisher.

Approximately 30% of the engine bay had sustained damage. Inspection of the engine found that the carburettor needle and seat assembly was not functioning correctly. Fuel leaked from the carburettor, both into the engine induction and into the engine bay. This condition was consistent with the circumstances of the power loss and the fire in the engine bay. When a company LAME initially inspected the engine at Bathurst, he activated the aircraft's fuel boost pump and fuel poured from the carburettor.

Detailed inspections of the carburettor were conducted by the operator and an independent engineering facility, but the carburettor defect and the fuel leakage could not be fully replicated. However, the independent examination of the carburettor found some indications of chemical residue or other agents that could have interfered with the functioning of the carburettor. The possibility of fuel contamination was supported by indications of a black deposit on the brass chains retaining the fuel tank caps. The black deposits on the chains and the fuel filter were later examined by a specialist facility and were found to be consistent with Ethylene Diamine.