Safety summary

What happened

At about 2000 on 29 October 2013, the general cargo ship Bosphorus grounded at Lytton Rocks Reach in the Brisbane River after the ship’s helmsman unintentionally put the helm the wrong way.

By the time that the Brisbane Marine Pilot on board the ship realised that the helm had gone the wrong way, it was too late to prevent the ship from grounding in the narrow section of the river. There were no reported injuries, damage or pollution as a result of the grounding.

What the ATSB found

The ATSB’s investigation found that the application of incorrect helm was not identified by the ship’s crew and that the ship’s safety management system documentation provided no guidance in relation to the allocation of function based roles and responsibilities to members of the bridge team during pilotage. 

The investigation also found that the navigational watch was handed over at a critical point of the pilotage and the risks associated with this change were not considered. Furthermore, neither the ship’s safety management system nor the Brisbane Marine Pilots’ passage plan detailed any guidance or instructions relating to handing over the watch or helmsman during high risk areas of the pilotage.

What's been done as a result

Brisbane Marine Pilots has amended their safety management system procedures to address all of the contributing factors specific to pilotage issues detailed in this report. Their risk management team has amended the passage plan specifically related to watch hand overs and changing of the helmsman.

Safety message

While functional roles and responsibilities should always be clearly assigned to each bridge team member, the pilot, the master and the officer of the watch should all check the rudder angle indicator before and after each helm order.

What happened

On 27 October 2013, the pilot of a Rockwell 114 aircraft, registered VH-AYH, departed Camden Airport, New South Wales in visual meteorological conditions on a flight to the designated training area located near Camden. The pilot was the only person on board.

About 5 minutes after departure the pilot became concerned about the level of smoke from a bush fire in the area effecting visibility. The pilot elected to return to Camden and to conduct circuits.

Due to the reducing visibility from the smoke the pilot conducted low level circuits and continued to monitor the visibility during the circuits. The first touch-and-go was conducted without incident. The pilot configured the aircraft for a second touch-and-go on runway 06. As the aircraft touched down at about 0745 Eastern Summer Time (ESuT) the pilot reported hearing a scraping sound and noticed that the landing gear was not selected down. The aircraft came to rest about a third of the way down the runway. The pilot was not injured.

The pilot indicated he did not remember hearing the aircraft’s landing gear warning horn at any stage during the landing.

This accident highlights the impact distractions can have on aircraft operations and the need to develop systems for managing distractions.

Aviation Short Investigations Bulletin - Issue 30

Safety summary

What happened

At about 1415 Eastern Daylight Time on 25 October 2013, an amateur-built Lancair Legacy aircraft, registered VH-ICZ, with the pilot and one passenger on-board, took off from Shepparton Airport, Victoria, for a flight to Yarrawonga, Victoria. Witnesses reported that the take-off and initial climb appeared normal, however shortly after, the aircraft’s pitch angle increased, after which it entered a descending right turn. The turn and descent continued until the aircraft collided with terrain alongside the airport boundary, fatally injuring the occupants and destroying the aircraft.

What the ATSB found

The ATSB found that shortly after take-off, and for reasons which could not be determined, the aircraft entered a steep climb, likely entered an aerodynamic stall, and began a descending right turn that continued until the aircraft collided with terrain.

The ATSB’s investigation was limited by the degree of damage to the aircraft and the presence of burnt carbon fibre. However, there was no evidence of any pre-existing mechanical fault with the aircraft and engine that could have contributed to the accident. A number of other possible contributing factors were considered and could not be completely discounted; those included sudden pilot incapacitation, aircraft handling, or the aircraft’s weight and balance being outside the design limits.

The aerodynamic characteristics of the aircraft design were such that it could enter a partial or completely stalled condition with little warning. The aircraft was not required to be (and was not) fitted with an angle-of-attack indicator or stall warning device.

The ATSB’s investigation found a number of instances where the regulatory requirements relating to the maintenance and operation of the aircraft had not been appropriately complied with. While the ATSB found no evidence that those non-conformances had brought about, or directly contributed to the accident, they did individually and collectively increase the risks associated with the aircraft’s operation.

Safety messages

Although amateur-built aircraft operated in the Experimental category are not required to be fitted with a stall warning device, owner-pilots should consider the benefits of such devices as a further defence against the inadvertent approach to, or entry into an aerodynamic stall.

While amateur-built experimental aircraft are not required to comply with the full range of safety regulations that are applicable to commercially-manufactured aircraft, the regulations that do apply are fundamentally important and have been introduced to control and reduce (as much as possible) the risks associated with the operation of this category of aircraft.

The ATSB research report AR-2007-043(2) makes numerous conclusions on the higher accident and fatality rates associated with amateur built aircraft operations. Pilots and passengers need to remain cognisant of the increased risks when flying in this category of aircraft.

What happened

On 15 October 2013, the pilot of a Robinson R44 helicopter, registered VH-TZE, was conducting gravity survey work, north of Daly Waters, Northern Territory. On board were the pilot and a geophysical field technician. The survey consisted of landing about every 4 km along a planned grid to collect data. 

At about 1630 Central Standard Time (CST), the pilot conducted a routine landing at a designated grid point. The technician disembarked with his equipment to carry out a reading, about 5 m away from the helicopter. 

A short time later, the pilot saw the technician waving his arms in an attempt to gain his attention. The pilot looked toward the rear of the helicopter and saw a fire underneath, which was spreading into the engine bay. The pilot exited the helicopter and notified the landholders via phone so they could construct fire breaks to contain the ensuing grass fire. The occupants were uninjured; however, the helicopter was destroyed by the fire.                 

The Australian Transport Safety Bureau (ATSB) has been notified of 13 occurrences since 2000 where a helicopter has been destroyed by grass fire, with many reports highlighting the speed with which the grass ignited and the fire spread beyond control.

Robinson R22 and R44 helicopters have exhaust systems that are low to the ground. The Pilot Operating Handbook for both types has a note in Section 10, Safety Tips stating:

‘Do not land in tall dry grass. The exhaust is low to the ground and very hot; a grass fire may be ignited.’

Pre-flight briefings highlighting the dangers of landing on grass, especially in areas of high temperatures and low humidity, can reinforce the importance of carefully choosing a landing site.

Aviation Short Investigations Bulletin - Issue 29

What happened

On 20 October 2013, the pilot of a Beech 95 B55 aircraft, registered VH TLP, was conducting a local private flight from St. Helens aerodrome, Tasmania.

The pilot commenced the take-off on runway 26 and, as the aircraft became airborne at about 50-60 ft above ground level (AGL), the pilot reported hearing a bang and the door opened. The pilot continued the climb to 1,000 ft AGL in preparation to return for landing. The pilot could not recall retracting the landing gear after take-off.

When on the downwind leg of the circuit, the pilot attempted to close the door, but was unable to reach it. On turning base, the pilot selected 10 degrees of flap. On final, he selected full flap and reduced the throttle setting to idle for landing.

As the aircraft touched down, the pilot realised that the landing gear was still retracted. The aircraft slid along the runway and came to rest about 600 m from the runway end.

This accident highlights the impact distractions can have on aircraft operations.

Aviation Short Investigation Bulletin - Issue 25

What happened

On 22 October 2013, at about 0850 Eastern Daylight-savings Time (EDT), a flight instructor and student pilot of a Schweizer 269C helicopter, registered VH-HYD (HYD), taxied to the southern helipad to conduct circuits at Moorabbin Airport, Victoria. 

Runway 17 Left (17L) was the designated runway in use at the time. The helicopter circuit area was the ‘Eastern Grass’, defined as the area extending from 20 m east of, and parallel to, runway 17L to the perimeter fence.

At about 0914, the pilot of a Piper PA 31 aircraft, registered VH-IBI (IBI), requested a clearance for an IFR flight to Barnbougle Dunes, Tasmania and commenced taxiing for runway 17L. At about 0917, the pilot of an aircraft taxiing for circuits reported ready at the holding point for runway 17L.

To facilitate re-sequencing of the aircraft, the controller opted to change the departure runway for IBI from runway 17L to runway 13L. At this time, the helicopter, HYD, was on the runway 31 Right threshold at the far end of runway 13L, however the controller did not see the helicopter when conducting a scan of the runway prior to clearing IBI for take-off.

At about 0918, the controller cleared IBI for take-off from runway 13L. The pilot of IBI sighted the helicopter ahead, on the runway centreline, when about two-thirds of the way along the runway. As the aircraft had already exceeded the minimum rotate speed, the pilot continued the take-off, increased the aircraft’s angle of climb, and IBI passed about 100-200 ft above HYD.

As a result of this investigation, Airservices Australia has committed to review procedures at Moorabbin Airport.

 Aviation Short Investigation Bulletin - Issue 28

What happened

On 23 September 2013, the pilot of a De Havilland DH-82 Tiger Moth aircraft, registered VH-RAY, taxied at Sandy Beach aeroplane landing area (ALA), New South Wales to conduct circuits in visual meteorological conditions. The pilot was the only person on board.

The pilot taxied to the end of the runway and applied the brakes to conduct engine run up checks. The pilot released the brakes and lined up on the runway heading and then applied full power for take-off. The aircraft accelerated down the runway. As the airspeed increased the tail rose to the take-off position, at about 200 meters down the runway and at about 30 knots indicated air speed the nose of the aircraft dropped very rapidly, and the aircraft flipped onto its back.

The aircraft was inspected by the maintenance organisation and it was determined that the left main landing gear brake drum had evidence of corrosion, and the brake operating rod was found stiff to operate. When the brakes were applied and released the left brake did not release fully. After the brake was cleaned and lubricated the brake operated normally. The maintenance organisation suspects that the left brake was partially engaged on take-off. The maintenance organisation determined that the aircraft was last flown on 12 February 2013 and the aircraft was normally stored in a high corrosion environment.

This accident is a timely reminder of the work that the Civil Aviation Safety Authority (CASA) is conducting on the safety of ageing aircraft in Australia.

Aviation Short Investigation Bulletin - Issue 28

What happened

On 21 October 2013, an Air Tractor AT-502B aircraft, registered VH-FLH, was conducting rice sowing operations north-east of Deniliquin, New South Wales. At about 1145 Eastern Daylight-savings Time (EDT), the pilot was conducting his fourth landing for the day onto the property airstrip located about 11 NM north-east of Deniliquin Airport.

The pilot reported that the approach was normal, at an airspeed of about 58-60 kt, with a predominately south-west wind of about 5-8 kt. The wind fluctuated between the west and south, but remained light.

During the landing, the main wheels touched down first, followed by the tail, which was locked into place. Shortly after, the aircraft suddenly veered right about 45°. The pilot considered a go around, but was concerned that the aircraft would not clear the boundary fence running along the side of the runway. Consequently, he elected to continue the landing and selected reverse thrust, applied left brake, left rudder and left aileron in an attempt to re-align the aircraft with the runway.

The wheels began to grab and the left undercarriage leg detached causing the aircraft to swing facing about 90 ° from the runway.

The pilot was not injured, but the aircraft was substantially damaged. An investigation could not determine what led to the loss of ground control, however a wind gust may have been a contributing factor.

Aviation Short Investigation Bulletin Issue - 27

Safety summary

What happened

On 24 October 2013, the pilot of a modified PZL Mielec M18A Dromader, registered VH-TZJ, was conducting a firebombing mission about 37 km west of Ulladulla, New South Wales. On approach to the target point, the left wing separated. The aircraft immediately rolled left and descended, impacting terrain. The aircraft was destroyed, and the pilot was fatally injured.

What the ATSB found

The ATSB found that the left wing separated because it had been weakened by a fatigue crack in the left-wing lower attachment fitting. The fatigue crack originated at small corrosion pits in the attachment fitting. These pits formed stress concentrations that accelerated the initiation of fatigue cracks.

The ATSB also found that, although required to be removed by the aircraft manufacturer’s instructions, the corrosion pits were not completely removed during previous maintenance. During that maintenance, the wing fittings were inspected using an eddy current inspection method. This inspection method was not approved for that particular inspection and may not have been effective at detecting the crack.

Data from a series of previous flights indicated that the manner in which the aircraft was flown during its life probably accelerated the initiation and growth of the fatigue crack.

Finally, the ATSB also found a number of other factors which, although they did not contribute to the accident, had potential to reduce the safety of operation of PZL M18 and other aircraft. These included the incorrect calculation of the flight time of M18 aircraft and a lack of robust procedures for the approval of non-destructive inspection procedures.

What's been done as a result

The Civil Aviation Safety Authority (CASA) revised the airworthiness directive for inspection of the wing attachment fittings to ensure that they were inspected using the magnetic particle inspection method. CASA also made, or plans to make, a number of changes to their systems and procedures to address issues identified in this report.

Separately, the ATSB reminded operators of M18 aircraft of the importance of the correct application of service life factors when operating at weights above the original maximum take-off weight. In addition, PZL Mielec plans to release additional maintenance documentation clarifying the need for removal of the wings for proper inspection of the wing attachment fittings. Finally, at the request of the owner, the supplemental type certificate for operation of the modified M18 Dromader at take-off weights up to 6,600 kg has been suspended by CASA.

Safety message

This accident shows that even when flying within operational limits, the ‘harder’ and faster an aircraft is flown the more rapidly the structure will fatigue.

To help ensure that maintenance objectives are consistently met, the ATSB reminds aircraft maintenance personnel of the importance of only using properly approved maintenance instructions. This accident confirms the importance of referring directly to those maintenance instructions when conducting maintenance.

Safety summary

What happened

On 23 October 2013, the pilot of a Cessna 182Q aircraft, registered VH-KKM and operating under the visual flight rules, departed Moruya Airport, New South Wales on a private flight to Mangalore Airport, Victoria. The flight route encompassed the Alpine National Park, where the forecast and actual weather included extensive thick cloud and severe turbulence.

Shortly after passing Mount Hotham Airport, Victoria, the aircraft collided with terrain on the eastern side of Mount Blue Rag, at about 5,000 ft above mean sea level. The pilot sustained fatal injuries and the aircraft was destroyed.

What the ATSB found

The ATSB found that the visual flight rules-qualified pilot had minimal total and recent flying experience and departed Moruya with less than visual meteorological conditions forecast along the planned route. It was very likely that these conditions were encountered shortly after passing Mount Hotham Airport, while flying over the Alpine National Park. From the evidence available it was likely that the pilot encountered reduced visibility to the extent that terrain avoidance could not be assured, resulting in the aircraft colliding with terrain in controlled flight.

Safety message

This accident highlights the risks associated with operating under the visual flight rules in adverse weather, particularly when flying in a challenging environment such as in mountainous terrain.

Thorough pre-flight planning is essential for avoiding weather. It is not only important to obtain the relevant weather forecasts to develop a mental picture of the conditions that may be encountered, but also to assess this information and understand how it relates to the planned flight. In forecast marginal weather, this involves consideration of alternative options such as diverting or turning back and pilots assessing their skills and/or aircraft’s suitability for the task in the conditions.

During flight, pilots must continuously assess the weather for conditions that may adversely affect the safety of the flight and be prepared to use an alternative course of action if conditions deteriorate. This can include seeking assistance, such as that available from air traffic control.

The ATSB is concerned about the frequency of accidents – many fatal – that involve pilots flying with reduced visual cues. This has been highlighted on the ATSB website as a SafetyWatch priority, along with a number of strategies to help manage the risk and links to relevant safety resources.