On 17 July 2014 a Malaysia Airlines Boeing 777-200, registered 9M-MRD and operating as flight MH17, en route from Amsterdam in the Netherlands to Kuala Lumpur, Malaysia, disappeared from air traffic services radar overhead the Ukraine. Aircraft wreckage was subsequently identified over a large area to the south and west of the village of Hrabove, eastern Ukraine. There were no survivors.

Responsibility for the conduct of the investigation into that accident was delegated to the Dutch Safety Board (DSB) by the Ukrainian Government on 23 July 2014.

Subsequently, in July 2014 the DSB commenced a separate investigation into the operation of flight MH17 through eastern Ukrainian airspace. This second investigation was titled Decision-making regarding safety of flight routes.

Together with the investigation agencies of a number of other countries, on 18 September 2014 the ATSB received a request from the DSB for assistance in the conduct of its safety of flight routes investigation. The DSB request sought to provide a global context to its own investigation findings. The ATSB agreed to the DSB request and, in order to protect the information gathered as part of this process, initiated an external investigation under the Transport Safety Investigation Act 2003 on 7 October 2014.

The report on the ATSB’s investigation of the safety of flight-route decision-making in the Australian context was provided to the DSB on 21 November 2014 for inclusion in their final safety of flight routes investigation report. It is understood that this report is to be published early in the final quarter of 2015.

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

Dutch Safety Board
PO Box 95404 25 09 CK
The Hague

Tel: +31 70 333 70 00

General enquiries email: info@onderzoeksraad.nl

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

On 20 September 2014, a de Havilland Canada DHC-6-300 aircraft, registered P2-KSF, collided with terrain 12 km north-east of Jacksons International Airport, Port Moresby, Papua New Guinea. Four of the 9 occupants were fatally injured.

An investigation into the circumstances of the accident was conducted by the PNG Accident Investigation Commission (AIC). The AIC requested assistance from the Australian Transport Safety Bureau (ATSB) with the download and analysis of information from various components including a cockpit voice recorder (CVR), forward-looking cockpit video camera and an enhanced ground proximity warning system (EGPWS) computer. To facilitate this support and to provide the appropriate protections for the CVR information, the ATSB appointed an accredited representative in accordance with paragraph 5.23 of ICAO Annex 13 and commenced an investigation under the Australian Transport Safety Investigation Act 2003.

The PNG AIC published its final investigation report (AIC 14-1005) on 3 August 2015.

The report is available from the AIC website: www.aic.gov.pg.

Safety summary

What happened

On 6 October 2014, Cape Splendor’s boatswain (bosun) descended to the lower platform of the ship’s accommodation ladder during his lunch break. He intended to fish from this location and asked a seaman to assist. At 1250, the bosun lost his balance and fell into the sea.

The seaman immediately returned to the ship’s deck and threw a lifebuoy toward the bosun, before raising the alarm. The ship’s crew deployed its rescue boat within 10 minutes, and an extensive air and sea search continued for 3 days. However, the bosun was not found.

What the ATSB found

The ATSB found that the bosun and the seaman were not wearing any flotation devices or fall prevention equipment. The bosun had seen fish below the accommodation ladder that was in the shade, and he probably saw it as a good opportunity to fish without considering the risks involved. The lack of a lifejacket, wet clothing, and possible entanglement with fishing gear, sea conditions, and the current would have adversely affected the bosun’s ability to stay afloat and swim.

The ATSB investigation also identified that the ship’s safety management system procedures for working over the ship’s side were not effectively implemented. Hence, the ship’s crew routinely did not take all the required safety precautions when working over the side. It was also found that the crew had differing attitudes to taking safety precautions during work and recreation times as the safety culture on board was not well developed.

What's been done as a result

Cape Splendor’s managers conducted a fleet-wide review of procedures and training to ensure ship crews comply with procedures and permits to work, with particular emphasis on working aloft and/or over the side. A number of fleet-wide memoranda describing the accident were issued to promulgate lessons learned, encourage compliance with policies and procedures, and reiterate the importance of taking safety precautions during both work and during leisure periods.

The ship’s managers have prohibited fishing from ships’ accommodation ladders and warning signs have been posted. Man overboard recovery procedures were reviewed and the accident was highlighted in training programmes.

The ATSB has issued a safety advisory notice (SAN) to shipmasters, owners, and operators to promote the importance of an effective safety culture on board ships. The SAN reinforces the importance of safety awareness at all times, during both work and recreational activities.

Safety message

Any task or activity that involves a person being on a ship’s accommodation ladder or other locations over the side of the ship can result in serious or fatal injury. Therefore, precautions to prevent a person from falling overboard, and to improve survivability in case one does fall into the water, are critical. It is important to ensure that these precautions are always taken, regardless of whether the person is engaged in work, recreational or other activities.

On 23 September 2014, a Pilatus PC-12 aircraft, registered VH-HIG, was arriving at Coober Pedy, South Australia after a flight from Amata, South Australia. The pilot and one passenger were on board the aircraft. Approaching Coober Pedy, the pilot observed a line of storm activity, virga and blowing dust in the vicinity of the aerodrome.

The pilot positioned for a landing on runway 32, but discontinued the first landing attempt after losing visual contact with the runway due to blowing dust. As the aircraft descended through about 100 ft above ground level during the second landing attempt, the pilot encountered strong wind shear and the aircraft sink rate increased significantly. Almost simultaneously, the aircraft was engulfed in blowing dust which denied the pilot external visual reference. The pilot contemplated another go-around, but noting the very high sink rate, the intensity of the turbulence and the proximity of the aircraft to the ground, he assessed that he could not execute a go-around safely.

The aircraft touched down short of the runway threshold and to the right of the runway centreline, on a firm surface that was once part of the runway strip. The aircraft passed through a wire aerodrome perimeter fence, and came to a stop after a ground roll of around 150 m. The pilot was unable to see outside the aircraft until it had almost come to a stop, and apart from buffeting and intense wind noise, he did not feel anything unusual during the ground roll. The pilot taxied to the terminal area to refuel the aircraft, unaware at that point that the aircraft had passed through the perimeter fence during the landing roll.

After refuelling, the flight continued to Adelaide where an engineering inspection revealed damage in the area where the nose landing gear meets the aircraft structure, and scoring damage to the underside of the left wing and flap.

Virga extending from convective cloud, blowing dust and dust devils are visual indications that may provide a warning of hazardous wind shear in the area. Pilots are encouraged to monitor the environment for any signs of hazardous weather, and remain particularly mindful of the significant dangers associated with wind shear.

Aviation Short Investigations Bulletin - Issue 39

On 26 September 2014 at about 0450 Eastern Standard Time, the pilot of a Kavanagh Balloon, registered VH-CNX, conducted pre-flight preparations for a charter flight with 22 passengers. Due to the forecast winds, the pilot elected to depart from Beaudesert, with a planned landing site in Cedar Grove, Queensland.

The pilot conducted a safety briefing including demonstration of the landing position. The passengers then assumed their landing positions and the pilot was satisfied they understood the correct position to adopt. After completing the pre-flight checks, the balloon lifted off at about 0550. After about a 20-minute flight, the pilot commenced the descent to the landing site.

During the approach, the pilot observed a light ground fog and was heading directly into the sun, making the landing site difficult to see. The pilot attempted to obtain an accurate rate of descent from the altimeter, but it was reading erratically. The pilot instructed the passengers to adopt the landing position, but not all of them complied. He repeated his instructions to the passengers, the altimeter continued to read erratically and facing directly into the sun made visual assessment of the approach difficult.

The balloon landed hard and bounced once before landing about 3 m further along the ground. Two passengers sustained serious injuries, and seven had minor injuries. The balloon was undamaged.

In this incident, the combination of moderate wind speed, the position of the sun, equipment issues and non-compliance to instructions by passengers, contributed to increase the pilot workload at a critical phase of flight.

Aviaiton Short Investigations Bulletin - Issue 37

On 7 October 2014, the pilot of a Bell 206B3 helicopter registered VH-CLR, departed Cairns, Queensland with one passenger on-board to conduct a charter flight to Mount Cook, about 9 km south-east of Cooktown Airport, Queensland.

To assess the landing area at Mount Cook, the pilot made 3-4 practice approaches and a practice landing prior to continuing to Cooktown to pick up the remaining passengers. The landing area was a rocky ledge jutting out from the south-eastern side near the top of Mount Cook.

The pilot conducted two flights to drop off a total of five passengers. He reported that the wind during these two flights was about 10 knots from the south-east. When he returned to pick up the first load of passengers, the wind had increased to about 14-15 knots.

During the approach to land, the pilot reported that he felt the helicopter was stable and appeared unaffected by the increased wind. As the helicopter prepared to touch down, both the ground co-ordinator and a passenger moved closer to it. Just prior to touching down on the right skid, the pilot felt the helicopter momentarily lift, most likely from a gust of wind, and drift to the right. The helicopter rolled rapidly onto its right side and slid a short distance forward, prior to coming to rest.

The helicopter fell onto the ground controller and nearby passenger. The ground controller sustained serious injuries. The pilot and passenger received minor injuries and the helicopter was substantially damaged.

The roll onto the right side by the helicopter is consistent with the phenomenon known as dynamic rollover. When a helicopter rests on one skid, the aircraft may begin rolling, and under certain circumstances it cannot be controlled.

The operator has advised the ATSB that they have taken several Safety Actions since the occurrence. These are detailed in the report.

Aviation Short Investigations Bulletin - Issue 38

On 23 September 2014, at about 1500 Central Standard Time, a Robinson R44 helicopter, registered VH-HLB, departed Bulman camp, Northern Territory, to conduct gravity survey operations. On board were a pilot and a geophysical field technician. The operation involved flying to specified locations 2 km apart and selecting a suitable landing site within 400 m of the location.

At about 1630, after completing landings at about 30 sites, the helicopter arrived overhead a specified location. The pilot identified a potential landing site, overflew it to more closely assess the site and then entered an out-of-ground-effect hover just above treetop height to determine whether the selected site was suitable for landing. The pilot decided the site was unsuitable as trees prevented sufficient clearance for the main and tail rotors.

As the pilot attempted to depart the area, the helicopter started to sink and the pilot observed the rotor revolutions per minute (RRPM) decaying. He lowered the collective and rolled on throttle in an attempt to increase the RRPM. The outside air temperature gauge indicated about 40 °C and the pilot reported that increasing the throttle did not provide any detectable increase in power. The pilot then eased forward on the cyclic. The helicopter continued to descend and the main rotor blade collided with multiple tree branches. When at about 6 ft above ground level, the helicopter rotated about 180° and landed hard with the left skid touching the ground first. The helicopter sustained substantial damage and the pilot and passenger were uninjured.

This incident highlights the effect of air temperature on aircraft performance. Understanding the controllability issues at the limits of the normal operating envelope can assist pilots in recognising the symptoms of reduced aircraft performance.

Aviation Short Investigations Bulletin - Issue 37

On 26 June 2014, a Tecnam P96 Golf aircraft, recreational registration 24-4470, collided with terrain near Krondorf, Barossa Valley in South Australia.

Recreational Aviation Australia (RA-Aus) is responsible for investigating this accident. As part of its investigation, RA-Aus requested technical assistance from the Australian Transport Safety Bureau (ATSB) in the examination of physical components and recovery of data from a GPS unit being used by the pilot. To protect the information supplied by RA-Aus to the ATSB and the ATSB's investigative work to assist RA-Aus, the ATSB initiated an investigation under the Transport Safety Investigation Act 2003.

Results of a visual examination of the physical components were provided to RA-Aus on 7 August 2014.

Following examination of the GPS, a download of its data was attempted using the manufacturer's procedures. The GPS unit could not be powered and it was determined that the GPS unit had sustained circuitry damage sufficient to prevent its download by conventional means. Subsequently, the discrete device (chip) containing the track memory was identified, removed, and a raw data file downloaded using specialised techniques. Decoding of the raw information showed that there was no available data relevant to the investigation. A report detailing the download procedure was provided to RA-Aus on 19 September 2014.

On the 16 September 2014, two Robinson R22 helicopters, registered VH HQJ and VH-IAY, were conducting aerial mustering operations about 26 NM east-north-east of Broome, Western Australia. The two R22 pilots were working together, and had planned mutual separation using relevant ground features in the area of operations. The two R22 pilots were also in radio contact on a company radio, and monitoring the multicom frequency. There was lifting fog in the area at the time, with some clear patches emerging.

At about 0745 Western Standard Time, the pilot of one of the R22s observed a light aircraft in close proximity, and advised the pilot of the other R22 that was operating some distance away. That pilot immediately looked in the direction that he thought the light aircraft may have appeared, and observed a single-engine light aircraft travelling at low level in an easterly direction. He witnessed the aircraft bank sharply towards the north, perhaps in response to having sighted the other R22 which was operating almost directly beneath the flight path of the light aircraft. Following what appeared to be an evasive manoeuvre, the light aircraft resumed its easterly track, still at low level. One of the R22 pilots tried to make contact with the pilot of the light aircraft on the multicom frequency, but without response. The light aircraft continued out of sight towards the east, and the two R22s resumed their aerial mustering operation.

Without a report from the pilot of the light aircraft, the full circumstances surrounding the incident are unclear. Nonetheless, this incident demonstrates the importance of effective communications and an effective lookout, even at low level when other aircraft may be unexpected. Furthermore, pilots should avoid operating at low level in areas where other aircraft may be engaged in aerial mustering or similar operations.

Aviation Short Investigations Bulletin - Issue 39

On 20 September 2014, the pilot of a Piper PA-25 aircraft, registered VH-CPU, conducted a ferry flight from Camden to Bunyan aeroplane landing area, via Goulburn, New South Wales.

After refuelling at Goulburn aerodrome, the pilot tracked to overhead Michelago and continued south towards Bunyan. About 10 km south of Michelago, the pilot intended to overfly a private airstrip to assess its condition and suitability as a potential out-landing site for gliders operating from Bunyan.

The aircraft was heading south and as the airstrip was oriented approximately north-south, the pilot elected to overfly the runway. When about 300 m beyond the runway threshold, the aircraft struck powerlines that crossed the runway about 15 m above ground level, dislodging the windscreen and canopy. The top of the fin was severed by the powerlines. Immediately after the strike, the aircraft banked to the left before returning to level flight. The pilot assessed that the aircraft was too high to land ahead on the remaining runway and made a right turn, initially planning to land towards the north on the adjacent paddock. However, due to the rough surface of the paddock and tailwind, he conducted a short downwind leg before turning to the right, and the aircraft landed into wind on the runway.

The ability of pilots to detect powerlines depends on the physical characteristics of the powerline and the effect of weather conditions. Powerlines may not be contrasted against the surrounding environment and the wire itself can be beyond the resolving power of the eye. Pilots are advised to use additional cues to identify powerlines, such as the power poles and buildings to which the powerlines may connect.

Aviation Short Investigations Bulletin - Issue 38