What happened

At about 0700 WST on 4 February, 2014 a student pilot departed Merredin Aerodrome, Western Australia for his first solo flight to the training area. He was flying a Grob G-115 aircraft, registered VH-BFW (BFW).

The wind was a light easterly when he departed to the north from runway 10.  When the training area practice sequences were completed, he returned to the aerodrome by overflying the airfield at 3500 ft, prior to joining the circuit. He noted the windsock now indicated a left crosswind, but as there was already an aircraft landing on runway 10, he elected to continue and join for this runway.

After completing crosswind, downwind and base legs of the circuit he configured the aircraft for the final approach and landing, including selecting full flap. As he commenced the round out, he realised the aircraft was about 15-20 ft above the ground and too high to continue with the landing, so commenced a go around. He applied full power and a small amount of rudder, but mindful of a previous instruction not to move the elevator forward while close to the ground, did not make any other changes to the aircraft configuration.

The application of power caused the nose of the aircraft to rise. It then encountered a gust of wind, which pushed the nose even higher, with a resultant loss of airspeed. The stall warning started to sound and the aircraft began to sink. The student attempted to recover the aircraft from the stall, but shortly after, the left wing struck the ground. The aircraft bounced back into the air and struck the ground again. The student was not injured but the aircraft was substantially damaged.

As a result of this accident, and to maximise safety at the flying school, management have split the Safety and Quality Manager position into two distinct positions. This will allow each incumbent to work separately, to maximise safety at the flying school. Management have also briefed all flight instructors on the importance of using correct phraseology when briefing and teaching students; as well as the importance of their role to ensure a safe environment for the students.

Aviation Short Investigations Bulletin - Issue 30

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 6 January 2014 at 1808 Coordinated Universal Time (UTC), a GippsAero GA8 Airvan aircraft, registered F-ORPH, was destroyed when it collided with terrain shortly after take off from Félix Eboué Airport, Cayenne, French Guiana. The pilot had returned for maintenance due to an engine problem during an initial take off attempt. The collision occurred after the pilot declared a MAYDAY two minutes after a second take off. One occupant was seriously injured while the other suffered minor injuries.

As the accident occurred in an overseas department of France, the Bureau d'Enquêtes et d'Analyses pour la sécurité de l'aviation civile (BEA) of France is responsible for investigating this accident. In accordance with international convention, the BEA notified the Australian Transport Safety Bureau (ATSB) as Australia is the State of Manufacture of the aircraft. In accordance with clause 5.18 of Annex 13 to the Convention on International Civil Aviation, the ATSB appointed an accredited representative to liaise with the BEA and initiated an investigation under the Australian Transport Safety Investigation Act 2003.

Given the time since the accident took place and that the BEA has not requested any assistance from Australia, the ATSB has decided to discontinue its investigation.

On 26 January 2014, a Boeing 737-300F aircraft, registration ZK-TLC, was conducting freight operations from Brisbane, Qld. to Honiara, Solomon Islands. During the landing on runway 24 at Honiara International Airport, the right main landing gear collapsed, causing substantial damage to the landing gear assembly and the adjacent inboard wing surfaces. The three crew members were uninjured.

The Civil Aviation Authority of the Solomon Islands (CAASI) is responsible for investigating this accident. As part of that investigation, CAASI requested technical assistance from the Australian Transport Safety Bureau (ATSB) in the download and presentation of data and audio from the aircraft's flight data and cockpit voice recorders.

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 the investigation, and initiated an external investigation under the provisions of the Australian Transport Safety Investigation Act 2003, providing appropriate protection for the recorded information.

Both flight recorders were received at the ATSB's Canberra laboratories on 5 February 2014, accompanied by a representative of the New Zealand Transport Accident Investigation Commission (TAIC) - representing the State of Registry of the aircraft under Annex 13 protocols.  ATSB specialists successfully downloaded the cockpit voice recorder (CVR) and Flight Data Recorder (FDR), using the manufacturers' standard procedures.

Copies of the recorded audio and flight data were subsequently provided to CAASI representatives, together with a selection of graphical plots representing selected parameters from the accident landing at Honiara, and two previous landings at Honiara that were also available from the FDR. The recorder units were returned to the aircraft operator on 7 February 2014.

The CAASI is responsible for releasing a final investigation report on this occurrence. The CAASI may be contacted via the Pacific Aviation Safety Office (PASO).

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

What happened

On 29 January 2014, the pilot prepared PA31 registered VH-OFF for a private flight from Aldinga ALA to Kangaroo Island, South Australia.

To check the fuel quantities, the pilot entered the cockpit, turned on the master switch, and placed the left and right fuel selectors onto the Main tank (inboard) position. The gauge for each tank showed just under half full. He then placed each fuel selector onto the auxiliary (outboard) tank position, where the gauge indicated the right and left auxiliary tanks were each about a quarter full. He did not return the selectors to the main tanks. He estimated that refuelling the main tanks would allow sufficient fuel for the flight with over an hour in reserve. He exited the aircraft while it was refuelled and continued preparing for the flight

The pilot conducted his normal memory pre take-off checks; however on this flight he did not complete his usual final check of reaching down with his right hand to confirm the position of the fuel selectors.

During the take-off, just after rotation both engines began surging, there was a loss of power, and the aircraft yawed from side to side. As there were no warning lights, he retracted the landing gear in an attempt to get the aircraft to attain a positive rate of climb, so he could trouble shoot at altitude.

At about 50 ft, the pilot realised the aircraft was not performing so he selected a suitable landing area. He focussed on maintaining a safe airspeed and landed straight ahead.

The aircraft touched down and slid before coming to rest. The pilot and passenger exited the aircraft.

One of the safety concerns of the ATSB SafetyWatch is fuel mismanagement leading to exhaustion or starvation.

Aviation Short Investigations Bulletin - Issue 29

On 7 June 2013, during a routine inspection at Auckland International Airport, New Zealand of a Jetconnect Boeing 737-800 aircraft, registered ZK-ZQG, maintenance personnel discovered damage to the horizontal stabiliser mechanism.

An investigation into the circumstances of this incident is being conducted by the Transport Accident Investigation Commission (TAIC) of New Zealand. The TAIC investigation reference is 13-007/AO-2013-007.

On 29 January 2014 the TAIC requested Australian Transport Safety Bureau (ATSB) assistance in gathering aircraft maintenance information from the Australian-based maintenance provider and certain of its personnel. In accordance with paragraph 5.23 of Annex 13 to the Convention on International Civil Aviation Aircraft Accident and Incident Investigation, the ATSB appointed an accredited representative to the TAIC investigation. To facilitate this support, the ATSB initiated an external investigation under the provisions of the Transport Safety Investigation Act 2003. The information gathered by the ATSB was provided to the TAIC on 28 March 2014.

The TAIC is responsible for, and will administer the release of the final investigation report into this incident. Any enquiries regarding the TAIC investigation should, in the first instance, be directed to:

Deputy Chief Investigator of Accidents
Transport Accident Investigation Commission
PO Box 10323, The Terrace
Wellington 6143, New Zealand.

Telephone: +64 4 473 3112
Facsimile: +64 4 499 1510

www.taic.org.nz

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

What happened

On 23 January 2014, at about 1520 EST, a Fairchild SA226 aircraft, registered VH-OGX, departed Thangool for a charter flight to Archerfield, Queensland. En-route, the pilot received the current Automatic Terminal Information Service (ATIS) for Archerfield, which indicated cloud at 800 ft and that the runway was ‘wet’.

At about 1615, the pilot commenced an instrument approach to Archerfield. Approaching the western boundary of the aerodrome, the pilot sighted the runway and circled at 900 ft above ground level before approaching to land on runway 10 Left. When lined up on final, the aircraft was to the right of the extended runway centreline and the pilot elected to conduct a go-around.

The second circle was still tight, due to low cloud to the west of the runway, and the pilot reported that the aircraft was about 30 to 50 m right of the extended runway centreline when on final. It was raining heavily as the aircraft touched down close to the runway centreline and about 300 m beyond the runway threshold. The pilot reported that as the wheels touched down, the aircraft commenced sliding towards the right, possibly due to aquaplaning. The aircraft veered off the right side of the runway and onto the grass. The aircraft then slid along the runway and veered off to the left side. The left main landing gear entered the grass and the aircraft came to rest at an angle to the runway.

A runway inspection revealed standing water on the right side of the runway near the threshold. This incident highlights the importance of conducting a go-around as soon as landing conditions appear unfavourable.

Aviation Short Investigation Bulletin - Issue 28

What happened

On 29 January 2014, at about 1100 Eastern Daylight-savings Time (EDT), the student pilot of a Piper PA-28-161 aircraft, registered VH-OWO (OWO), taxied to runway 17 Left (17 L) at Moorabbin Airport, Victoria to conduct solo circuits. A Cessna 172S aircraft, registered VH-FPV (FPV), was also conducting circuits from runway 17 L, with a student pilot and instructor on board.

After completing a touch-and-go circuit, the pilot of OWO was following an aircraft on upwind. As the pilot of OWO commenced his turn onto downwind, he sighted the aircraft he had been following and realised he had turned inside it. The pilot of OWO reported that, having ‘cut off’ an aircraft in the circuit, he was conscious of staying ahead of the aircraft. As OWO turned onto final, the pilot was instructed by the controller to go around as he was then too close to an aircraft conducting a full stop landing on the runway.

On his final circuit, the pilot of OWO reported downwind for a full stop landing. He was instructed to follow a Cessna (FPV) and sighted the aircraft. After completing downwind checks, he sighted an aircraft on final, assumed it was FPV and continued to follow that aircraft.

At about 1123, FPV was established on early final, at about 400 ft AGL, when he sighted OWO in a turn about 100 ft above and just in front of FPV. He immediately took control of the aircraft from the student and descended to increase the vertical separation between the two aircraft.

As the pilot of OWO commenced the turn onto final, at about 500 ft AGL, he sighted FPV to his right about 200 ft below OWO. He levelled OWO off to maintain separation between the two aircraft. The controller instructed the pilot of OWO to go around.

When operating in Class D airspace, pilots must sight and maintain separation from other aircraft. Pilots and ATC have a dual responsibility to maintain situational awareness of other traffic.

Aviation Short Investigation Bulletin - Issue 28

What happened

On 25 January 2014, at about 1300 Eastern Daylight-savings Time, a Piper PA-28-180 aircraft, registered VH-PXB (PXB), taxied at Forbes aerodrome, New South Wales, for a private local flight with the pilot and one passenger on board.

The passenger of PXB reported that, about 10 minutes after take-off, the pilot appeared to suffer a seizure and lost consciousness. The passenger took control of the aircraft, turned the aircraft back towards Forbes aerodrome and used the radio to call for help.

The pilot of a Pawnee was back-tracking at Forbes, when he heard the passenger of PXB call for help on the CTAF.  He ascertained that the passenger was able to control the aircraft, but had not landed an aircraft previously. He assisted the passenger to conduct orbits to the north of the aerodrome and maintain about 2,000 ft AMSL.

After orbiting for about 22 minutes, the passenger advised that the pilot was conscious and had taken control of the aircraft to return to land. The pilot of the Pawnee became concerned as he observed PXB descending and heading south-west, away from the aerodrome. He communicated with the pilot and with the assistance of the passenger, PXB turned towards the aerodrome. A few minutes later, PXB landed just short of the threshold of runway 27, bounced once and veered off the runway during the landing roll.

The pilot of PXB did not recall any of the flight after the initial climb, until when the aircraft was lined up for a landing on runway 27. He reported feeling unwell prior to the flight and his doctor advised that dehydration was the most likely cause of his loss of consciousness.

This incident highlights the importance of pilots assessing their fitness to fly prior to every flight.

Aviation Short Investigation Bulletin - Issue 28

What happened

On 19 January 2014, the pilot of a Eurocopter AS350B3, registered VH-VTX, departed Hobart, Tasmania for Camden, New South Wales, with a planned refuel stop at a Helicopter Landing Site (HLS) near Orbost, Victoria. The flight was planned under the visual flight rules (VFR) and the pilot was the only person on board.

The flight proceeded past Flinders Island then in a northerly direction over Bass Strait towards the HLS near Orbost. While over Bass Strait, however, the pilot encountered deteriorating weather including patches of low cloud and areas of reduced visibility. After unsuccessfully attempting to manoeuvre around the weather, the pilot decided to divert back to Flinders Island. Soon after turning in a southerly direction and noting an increase in wind strength from the south, the pilot became concerned that insufficient fuel was available to safely reach Flinders Island. The pilot then elected to make a precautionary landing on a nearby offshore resource platform, and landed on the platform with a remaining endurance of about 55 minutes.

In response to this incident, the operator reported that company pilots were reminded of flight planning weather considerations and that specific instructions dealing with Bass Strait crossings were being considered. The incident serves as a reminder of the need for careful planning when intending to proceed into an area where poor weather is forecast, and the importance of timely and conservative decision making when poor weather is encountered.

Importantly, irrespective of how the pilot ended up in a position where landing on an offshore resource platform seemed the only option, the pilot made a very sound decision not to continue flight into instrument meteorological conditions (IMC). Numerous accidents have resulted when flights conducted under the VFR encounter IMC.

Aviation Short Investigations Bulletin - Issue 31

Safety summary

What happened

On 30 December 2013 at 1547, train 2DA2 (travelling from Darwin to Adelaide) derailed while traversing the points into the loop line at Union Reef. Shortly beforehand, the train crew had commanded the points to reverse for entry into the loop line, however the automated points system was unable to complete the reversal movement – leaving the points in an unsafe open position.

There were no injuries sustained during the derailment, but about 100 m of track infrastructure was damaged, and the main line between Darwin and Tarcoola was blocked for about 5 days.

What the ATSB found

The ATSB found that the northern points at Union Reef had most likely failed to fully transition for the crossing loop because of ore product build up and inadequate lubrication. It had been previously recognised that this location was prone to ore product build up in the four foot and points, but the inspection and maintenance regime had not been adjusted to address this localised issue and the potential increase in risk to rail operations that it presented.

The ATSB also found that the train crew were distracted by several conflicting responsibilities at a time when they were also expected to be preparing for entrance to the crossing loop. While the driver was operating the train at a speed he considered appropriate for traversing the points, he did not expect the point enhancer to remain at red (or the points to be unsafe), and as such, he was unable to stop the train before the open points. Reduced sighting of the point indicator/enhancer due to track curvature and track side vegetation had limited the opportunity for early identification and response to the red indication, even though a repeater indicator had provided prior warning as to its unsafe status.

What's been done as a result

Following this occurrence, Genesee Wyoming Australia (GWA) reviewed the reliability, inspection and maintenance frequency of motorised self-restoring points machines. Similarly, with a view to identifying and addressing any increased risk in these locations, GWA specifically undertook to monitor the functionality and performance of track/points exposed to the accumulation of mining products.

Responding to the human element, GWA advised that a Critical Safety Zones program will be introduced to provide clarification to train crews on acceptable speeds and necessary caution required when approaching points with reduced sighting distances.

Safety message

Rail operators and train crews are reminded that distraction can have a profound impact on safety during critical phases of train operation. To combat situations where signals (often the final defence against an incident) are affected by reduced sighting distances, strengthened guidance should be given to train crews on ensuring that appropriate approach speeds are established and maintained throughout the critical areas.