What happened

On 5 June 2014, the pilot of a Beechcraft 200 aircraft, registered VH-NMW, conducted a private flight from Narrabri to Sydney Airport, New South Wales, with two passengers on board.

During the cruise, the pilot entered the arrival and approach into the flight management computer. The pilot was advised by air traffic control (ATC) to expect an instrument landing system (ILS) approach to runway 16 Left (16 L).  

The pilot was cleared by air traffic control (ATC) to descend to 3,000 ft and while on descent, was given radar vectors to intercept the localiser for runway 16 L. The pilot selected approach (‘APP’) mode on the flight guidance panel (FGP) and confirmed that the aircraft had intercepted the localiser. About 2 minutes later, the aircraft was cleared for the instrument landing system (ILS) approach on 16 L however the pilot did not observe that at this stage, the aircraft was below the glideslope.

The pilot was then temporarily distracted by explaining the multi-function display to the passenger seated in the front right seat. The controller queried whether the aircraft was on the glideslope and the pilot realised that the aircraft was below the glideslope. The aircraft then maintained the current altitude until intercepting the glideslope. Prior to intercepting the glideslope, ATC advised the pilot that the aircraft was at 1,500 ft and below the lowest safe altitude. As the aircraft was established on the localiser and about 8 NM from the runway, the applicable minimum altitude was 1,700 ft AMSL.

This incident highlights the importance of continuously monitoring aircraft and approach parameters and the impact distractions can have on maintaining a stable approach profile.

Aviation Short Investigations Bulletin - Issue 33

Safety summary

What happened

At 2245 on 5 June 2014, the crew on Pacific National (PN) coal service ER64 reported that flames were emanating from the top of the fourth locomotive, 8221, on their train. At the time, ER64 was near Awaba in New South Wales enroute to unload at the Eraring power station. The crew stopped the train and assessed the extent of the fire while also calling for fire brigade assistance. The fire was declared extinguished at 0139 on 6 June 2014. It caused substantial damage to the locomotive.

There were no reported injuries as a result of the incident.

What the ATSB found

The ATSB found that the fire was most likely caused when the clevis clamping one of the fuel sight glasses to the fuel filter assembly disengaged, allowing fuel under pressure to spray throughout the engine bay and ignite probably on either the hot exhaust manifold or from within the main generator. The sight glass assembly disengaged because its clevis had compressed, bending inwards, and allowing sufficient lateral movement for it to release from the clevis bolts in the sight glass aperture. The procedures for locomotive inspection and maintenance were not effective at identifying and addressing continuing fuel leakage problems on this type of fuel filter assembly.

What's been done as a result

Pacific National informed the ATSB that an immediate inspection of all locomotives fitted with the sight glass arrangement was conducted to ensure clevis assemblies conform to original equipment manufacturer specifications and requirements. It also informed the ATSB that an amendment was made to current maintenance procedures increasing the inspection requirements for the sight glass assembly including the clevis and clevis bolts.

Safety message

This incident illustrates the importance for locomotive maintainers to maintain vigilance and ensure adherence to current maintenance procedures when conducting maintenance on locomotive fuel systems to minimise the risk of fuel leakage and consequent potential for fire.

What happened

On 12 June 2014, a Piper PA-46 aircraft, registered VH-TSV, departed Dubbo, New South Wales for a private flight to the Sunshine Coast, Queensland with a pilot and one passenger on board. About an hour after departing Dubbo, when about 26 NM south of Narrabri, at about 13,500 ft AMSL, the pilot observed the engine manifold pressure gauge indicating 25 inches Hg manifold pressure, when the throttle position selected would normally have produced about 28 inches Hg. The pilot elected to descend to 10,000 ft, where the gauge still indicated only about 25 inches Hg. He turned the aircraft towards Narrabri in an attempt to fly clear of the Pilliga State Forest.

As the aircraft descended through about 8,000 ft, the oil pressure gauge indicated decreasing pressure. When passing about 6,500 ft, the oil pressure gauge indicated zero and the pilot heard two loud bangs. The pilot established the aircraft in a glide, secured the engine and completed the emergency checklist. He broadcast a ‘Mayday’ call and looked for a clear area below in which to conduct a forced landing but only identified heavily treed areas. The pilot extended the landing gear and selected 10° of flap and, when at about 1,000 ft, shut the fuel off, deployed the emergency beacon then switched off the electrical system.

As the aircraft entered the tree tops, the pilot flared to stall the aircraft. The pilot was seriously injured, and the aircraft sustained substantial damage. A post-accident inspection of the engine found a hole in the right side of the crankcase, indicating an internal mechanical failure.

Aviation Short Investigations Bulletin - Issue 34

What happened

On 9 June 2014, an Airbus A330, registered VH-XFB, took off from Perth, Western Australia, bound for Sydney, New South Wales. As engine power was applied at the commencement of take-off, cabin crew members at the rear of the cabin noticed a burning odour. The crew ultimately traced the source of the fumes to a vent in the rear cabin bulkhead. Some cabin crew members were adversely affected by the fumes and were unable to complete their normal in-flight duties.

Following the flight, engineering staff found that a portion of insulation blanket fitted to the rear pressure bulkhead of the aircraft had collapsed into contact with the Auxiliary Power Unit (APU) bleed air duct, where the duct passes through the rear pressure bulkhead. The blanket wrapping material was damaged and heat affected, exposing the inner glass wool material, which was also heat affected. The engineering investigation determined that the insulation blanket in contact with the bleed air duct was the likely source of the fumes, and that the blanket had not been correctly refitted following maintenance by a previous operator of the aircraft. The operator also found a similar problem on another company A330 aircraft.

As an interim measure, the operator prohibited use of the APU on both aircraft until the insulation blanket adjacent to the APU bleed air ducting was repaired and appropriately restrained in accordance with an Engineering Order. The Engineering Order also required a visual inspection of the rear pressure bulkhead structure immediately around the bleed air duct. The second part of the Engineering Order directed that the insulation blanked be replaced entirely, as a permanent repair. The aircraft manufacturer also made a number of recommendations in response to information supplied by the operator.

Fumes can originate from a wide range of sources. While some fumes may appear subtle and innocuous, they may be the first indication of a serious problem. This incident serves to highlight the importance of treating all fumes with suspicion, and implementing a cautious and conservative response, consistent with published guidance.

Aviation Short Investigations Bulletin - Issue 38

History of the flight

The aircraft had departed Bankstown for a dual instrument flight rules (IFR) training flight, including aerial work at Goulburn followed by two practice instrument landing system (ILS) approaches at Canberra, before returning to Bankstown.

After completion of the second ILS approach, the pilot was instructed to carry out a missed approach and climb to 7,000 ft.

As the aircraft was levelling in instrument meteorological conditions (IMC), the instructor noticed that engine Manifold Absolute Pressure (MAP) had reduced from 30 inches to 25 inches. He asked the pilot if he had adjusted the power and the pilot replied in the negative. At 1127 EST, the instructor advised Canberra Approach (APP) that the aircraft had experienced a loss of power. He reported that the aircraft was able to maintain 7,000 ft and confirmed that he wished to return to Canberra for landing. Air Traffic Control then instructed the pilot to turn the aircraft onto a southerly heading.

Between 10 and 15 seconds later, the aircraft occupants heard a loud thump that shook the aircraft, and the engine RPM reduced significantly. At 1128 the pilot advised APP that the engine had failed and requested that APP provide headings to the vicinity of Lake George. APP identified the aircraft on radar at a position 17 NM to the north-east of Canberra over the western shores of Lake George. APP then passed information to the pilot about an airfield near Bungendore as a possible landing area.

At 1129, the pilot advised that assistance was still required and confirmed that the aircraft was still in IMC. APP advised the pilot to disregard the previous vectoring instructions, indicated that a landing on the Federal Highway might be possible and instructed the pilot to turn onto a heading of 020 degrees.

At 1131, the pilot advised that the aircraft was descending through 4,200 ft. At 1132, APP requested that the pilot activate his emergency locator transmitter (ELT). The pilot then advised that the aircraft was still in IMC and passing 3,500 ft. APP advised that the aircraft was passing over the northern shores of Lake George and requested the pilot to turn the aircraft right to an easterly heading to avoid high terrain in the area. No reply was received.

Another aircraft, VH-DUP, was in the Goulburn area at this time and the pilot offered to relay a message to VH-SMA. APP requested the pilot of VH-DUP to listen out on 121.5 MHz to determine if an ELT had been activated. The pilot of VH-DUP advised that he was unable to make contact with VH-SMA and confirmed an ELT signal on 121.5 MHz.

The time of the accident was 1133. A rear-seat occupant, who was also a qualified pilot, later stated that he estimated that the aircraft broke through the cloud base below 300 ft above ground level (AGL).

An army helicopter was dispatched from Canberra at approximately 1155 and proceeded to the area of the last known position of VH-SMA. A second helicopter carrying a medical team was dispatched to the area at 1230.

Wreckage examination

Wreckage was distributed along a 49 m trail aligned approximately east. The aircraft had entered the timbered area on this track and had partially broken up as it descended through the trees. As the aircraft penetrated the timber, it struck and severed tree branches and trunks over 150 mm in diameter, starting 49.3 m and ending 28.5 m from the main wreckage, before coming to rest on a south-westerly heading against the trunk of a large tree approximately 1 m in diameter.

The main wreckage consisted of the fuselage, the fin, the right horizontal tailplane and most of both wings. The left horizontal tailplane had been torn off during the impact sequence. The empennage showed evidence of oil streaking, indicative of engine oil loss in flight. The fuselage had been almost completely destroyed by post-impact fire.

The engine and propeller remained attached to the fuselage. Inspection of the propeller indicated that the engine was not producing power at impact. The engine was basically intact and unaffected by fire. Both magnetos had separated from the engine. There were two holes in the top of the crankcase aligned with cylinders number 2 and 3. When the engine was turned over for examination, approximately 1 L of oil flowed out of the holes in the crankcase.

Significant factors

1. The engine failed due to a loss of effective lubrication. The reason for the loss could not be established beyond doubt.
2. The engine failure occurred in weather conditions that did not permit the pilot to carry out a visual forced landing onto favourable terrain.
3. The approach controller was unable to vector the aircraft to an obstruction-free landing site due to equipment and time limitations.

What happened

On 21 May 2014, a Grob G115, registered VH-BBJ (BBJ) and a Grob G115, registered VH-ZIM (ZIM) were both conducting dual flight training, in the northern training area, near Merredin aeroplane landing area (ALA), Western Australia.

The student pilot of ZIM was conducting a pre license general flying progress test. After completion of the training area component of the test, in the northern training area, the student pilot navigated to the inbound reporting point near Burracoppin, at an altitude of about 3,500 feet above mean sea level (AMSL). During the flight, the student became disorientated and tracked toward the town of Merredin, instead of Merredin ALA. The student was not able to locate Merredin ALA and the instructor provided assistance by pointing out land features. 

At about the same time, the instructor of BBJ had just completed basic instrument flying with the student in the northern training area. The student tracked to the south-east, toward Burracoppin at 3,500 feet AMSL. The aircraft remained clear of the inbound track from Burracoppin to Merredin ALA. The instructor broadcast their intentions on the common traffic advisory frequency (CTAF).

As ZIM turned to navigate toward Merredin ALA, the instructor observed BBJ, which appeared to take up almost the entire windscreen. The instructor took over control of the aircraft, and took evasive action, pushing the control column forward and descending. At about the same time, the instructor of BBJ observed ZIM straight ahead, at or just below the horizon coming towards them. The instructor also took over control of the aircraft, to take evasive action, pulling the control column rearward and climbing.

Both aircraft returned to Merredin without further incident. The pilots of both aircraft were uninjured and neither aircraft was damaged.

The serious incident highlights that it is difficult for pilots to spot another aircraft through visual observation alone.

Aviation Short Investigations Bulletin - Issue 38

What happened

On 6 June 2014, a Grob G-115CD aircraft, registered VH-ZYM departed Merredin for Jandakot, Western Australia, on a dual navigation exercise.

After arriving at Jandakot, and having a lunch break, another instructor briefed the student on circuit procedures at Jandakot. A third instructor then conducted a session of circuits with the student. The student then taxied back to the apron where the instructor egressed. The student then conducted 3-4 solo circuits prior to returning to the southern apron for parking.

As the aircraft arrived at the company parking area, the student saw the fuel truck operator refuelling an aircraft on the left side of the taxiway. He assessed that there was sufficient room to taxi past the vehicle, and entered the taxiway with the vehicle on his left.

Shortly after, the aircraft’s left wing struck the vehicle and it then swung rapidly around facing the diesel fuel tank. The student applied the brakes, and the aircraft propeller stopped within centimetres of the tank.

The fuel vehicle operator had seen the aircraft taxi in and had hit the emergency stop button as the aircraft struck the vehicle.

The student was not injured, however the aircraft and fuel truck sustained minor damage.

As a Safety Action the flying college have temporarily ceased to use the taxiways into the parking lines. Operational staff have been briefed and trained on safe aircraft manoeuvring in this area.

Also, as agreed with the fuel company, all new students will participate in a Fuel Hazards training course conducted by the fuel company. Students will have to complete all relevant training modules before commencing flying training.

The fuel company are considering the use of cone markers around the vehicle during refuelling operations.

A collaborative Safety Action between the flying college, the refuelling company and the airport operator have changed refuelling and taxying procedures on the southern apron.

Aviation Short Investigation Bulletin - Issue 35

What happened

On 2 June 2014, at about 1200 Central Standard Time (CST), the approach controller at Darwin Airport, Northern Territory was processing the arrival of a Qantas Boeing 737 aircraft, registered VH-XZA (XZA), and an Airnorth Fairchild SA227, registered VH-ANW (ANW). When about 34 NM south-east of Darwin on a standard arrival route, XZA was cleared by the approach controller to descend to 3,000 ft for an approach to runway 11.

About 3 minutes later, when about 34 NM SE of Darwin, ANW was cleared by the approach controller to descend to 3,000 ft. This resulted in a loss of separation assurance as both aircraft were at a similar distance, tracking for runway 11, assigned the same altitude, with no assurance that vertical or radar separation would be maintained.

The approach controller then handed over to another approach controller, explained that both aircraft were on descent to 3,000 ft, and advised the incoming controller to monitor the situation.

When ANW was about 19 NM from the airfield, the controller instructed the pilot to turn left onto a heading of 360° and about 20 seconds later advised the pilot of ANW that relevant traffic was a Qantas 737, about 6 NM ahead, and to report sighting that aircraft.

The controller then received a ‘predicted conflict alert’ (PCA) on their situation data display. The pilot of ANW then reported having the 737 in sight and the controller instructed the pilot of ANW to follow the 737 and cleared ANW for a visual approach to runway 11.

When the PCA sounded, about 1,300 ft of vertical separation and 4.5 NM laterally existed between the two aircraft. As the radar separation standard of 3 NM laterally and 1,000 ft vertically applied at the time, a loss of separation between the aircraft did not occur.

This incident highlights the importance of having tactical separation assurance in place at all times.

Aviation Short Investigations Bulletin - Issue 34

What happened

At about 0900 Eastern Standard Time (EST), a Beech BE76 aircraft, registered VH-SRO (SRO), departed Archerfield Airport, Queensland, for a local flight to the training area south of the airport, with an instructor and a pilot in command under supervision (ICUS) on board. At about 0920, the student pilot of a Cessna 172 aircraft, registered VH-EEM (EEM), departed Archerfield for a solo local area flight. The student’s planned route was to track south-east outbound from Archerfield at 1,000 ft above mean sea level (AMSL), and when overhead the Logan Motorway, climb to 2,500 ft AMSL and track towards Logan Village. There the aircraft climbed to 3,000 ft AMSL and the student practiced turns before tracking towards Jimboomba.

After completing training exercises at 3,000 ft AMSL in the vicinity of Beaudesert, SRO commenced tracking north towards Park Ridge to return to Archerfield. At about 0940 EST, 6 km south of Park Ridge and 3,000 ft AMSL, the instructor sighted EEM on a converging heading in his 1 o’clock position, and immediately took control of the aircraft from the pilot ICUS. He conducted a descent and estimated that EEM passed about 50 ft above SRO and about 100 m away horizontally. The student pilot of EEM observed SRO pass below and to the right.

Radar data provided to the ATSB by Airservices Australia indicated that EEM passed about 100 ft over SRO, with aircraft altitudes unverified.

This incident highlights the importance of communication and the limitations of unalerted see-and-avoid principles.

Aviation Short Investigations Bulletin - Issue 33

Prior to departing for Atherton the pilot had submitted a flight plan, indicating that the expected flight time was 3 hours 7 minutes. The weather forecasts were satisfactory for flight under visual flight rules, but there were areas of reduced visibility because of smoke associated with bush fires on the latter part of the route. The pilot elected fo fly on the direct track from Mount Isa to Atherton, although the terrain over this route is relatively featureless, making visual navigation difficult.

The aircraft departed Mount Isa at 1500 hours EST, giving an expected arrival time at Atherton (about 740km to the northeast) of 1807 hours. At 1727, the pilot amended his arrival time to 1830 hours, but gave no indication of the reason for this delay. At 1810 he advised Cairns Flight Service Unit (FSU) that he intended descending from the cruising altitude of 9500 feet to "about 6000" because of smoke haze. At 1817 hours he advised that he was approximately 20 miles from Atherton and expressed doubts about being able to land there because of extremely thick smoke. In response to queries from the FSU he indicated that the radio navigation aid fitted to the aircraft was not operating properly; and that he had undergone some training, but was not qualified, for night cross-country operations.

The published end of daylight at Atherton was 1836 hours, however the smoke in the area would have effectively brought this time forward. The aerodrome was not equipped with any runway lighting, and Cairns FSU relayed a suggestion to the pilot from the Townsville Senior Operations Controller (SOC) that the aircraft proceed to Cairns (50km north north east of Atherton), the nearest aerodrome with runway lighting and an aerodrome beacon. The pilot accepted the suggestion and proceeded on a heading calculated by the SOC.

Efforts by the SOC to determine the position of the aircraft were hampered because the pilot apparently had not maintained an in-flight record of positions, times and headings flown. However, at 1834 hours the pilot reported that he was passing between two towns, and advised three minutes later that he thought the towns could have been Atherton and Mareeba. Unfortunately, neither he nor the SOC appeared to consider the desirability of diverting the aircraft and circling over one of the towns in order to positively establish the position of the aircraft. Had the towns been Atherton and Mareeba the pilot should have been able to sight the lights of Cairns in less than 10 minutes, however no alteration to the assigned heading was given until 1859, at which time the pilot was told to orbit.

Discussion took place between the FSU operator and the SOC on the possibility that the aircraft had crossed the coast and was over the sea. The SOC instituted the Distress Phase of Search and Rescue procedures at 1900 hours and at 1905 he gave instructions for the pilot to take up a westerly heading. Shortly afterwards the pilot established communications with Cairns Tower.

During the following 90 minutes the SOC relayed numerous messages to the aircraft through Cairns Tower; other aircraft conducted an airborne search and the Cairns meteorological station radar was activated in efforts to locate the aircraft. At 1945 hours the pilot confirmed that the aircraft was over water and the aircraft apparently remained over water for the remainder of the flight. The engine subsequently failed from fuel exhaustion and the pilot advised he was descending over a "fairly smooth sea".

The final transmission from the aircraft was made shortly before 2037 hours, at which time it was passing through 400 feet. An intensive search was commenced the following morning and continued for several days, however no trace of the aircraft or its occupants has been found.

Significant Factors:
1. Adverse weather conditions (smoke), increasing difficulties with visual navigation.
2. Radio navigation equipment not functioning correctly.
3. The pilot did not maintain an accurate navigation log.
4. The pilot became uncertain of his position.
5. Inadequate navigation assistance was provided to the pilot by the responsible operational control facility.