Safety summary

What happened

On 18 October 2013, the pilot of an Ayres Corporation S2R Thrush, registered VH-JAY, was conducting aerial agricultural spraying activities on a property near Hyden, Western Australia. At about 1330, following the completion of a number of spray runs and a break for lunch, the pilot departed to complete further spraying. Following the failure of the aircraft to return, a search was initiated. The aircraft wreckage was found a short time later about 1,700 m from the departure airstrip. The aircraft was destroyed, and the pilot was fatally injured.

What the ATSB found

The ATSB found that the aircraft departed controlled flight from which the pilot was unable to recover, leading to the collision with terrain. On the basis of the available evidence, it was not possible to determine the reasons for the loss of control.

The ATSB identified two aspects of the aircraft’s operation which had the potential to adversely affect safety. These were the use of an unapproved fuel mix and operation of the aircraft above its published maximum take-off weight.

Safety message

Operators and pilots are reminded of the dangers of operating aircraft engines on an unapproved fuel mix as this increases the likelihood of engine damage which could affect the safety of operations. Pilots and operators are also reminded of the need to adhere to an aircraft’s maximum take-off weight to ensure the on-going safety of the aircraft and operations.

On 19 October 2013, an ATR-42-320F cargo aircraft (registered P2-PXY) with three persons on-board was substantially damaged following a high-speed rejected takeoff and subsequent runway overrun at Madang Airport, Papua New Guinea.

An investigation of the occurrence is being undertaken by the Accident Investigation Commission (AIC) of Papua New Guinea, in accordance with Papua New Guinea's obligations as the State of Occurrence under Annex 13 to the Convention on International Civil Aviation.

The aircraft was fitted with a cockpit voice recorder (CVR) and a separate flight data recorder (FDR). The AIC requested assistance from the Australian Transport Safety Bureau (ATSB) in the download and analysis of information from both recorders. In accordance with paragraph 5.23 of Annex 13, the ATSB appointed an Accredited Representative to assist the AIC and commenced an investigation under the Australian Transport Safety Investigation Act 2003.

After removal from the aircraft, the recorders were transported by an AIC officer to the ATSB’s technical facilities in Canberra, Australia, and were received on 22 October 2013.

The CVR and FDR were successfully downloaded and it was confirmed that both recorders had recorded the accident sequence. The recorders were returned to the AIC on 23 October 2013 together with a copy of the downloaded CVR audio files, FDR plots and data listings.

The PNG AIC is responsible for the final investigation report into this accident. Any enquiries regarding the AIC investigation should be directed to:

PNG Accident Investigation Commission

Telephone: +675 323 2911

Fax: +675 323 2139

Website: www.aic.gov.pg/

Address:
Accident Investigation Commission
PO Box 1709
Boroko
National Capital District
Papua New Guinea

______________

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

What happened

On 15 October 2013, at about 0410 Eastern Daylight-savings Time (EDT), the flight plan for a Qantas Airways Airbus A330 aircraft, registered VH-QPD, was automatically generated and released by the dispatcher at about 0420. The flight was scheduled to depart Sydney, New South Wales at 0600 on a passenger service to Perth, Western Australia. At about 0430, the captain of QF 565 downloaded the weather package and flight plan onto his iPad.

At about 0440, the company meteorologist advised the dispatcher that a new terminal aerodrome forecast (TAF) had been issued for Perth, which required QF 565 to have an alternate destination due to forecast fog and the dispatcher produced a new flight plan for the flight.

The crew arrived at the airport before 0500. The FO downloaded the flight plan and weather (briefing package) at about 0504. The flight plan downloaded by the FO was the original flight plan, despite dispatch having released the new plan prior to this time.

The crew reviewed the information and noted that there were no weather requirements for Perth and that they both had the same flight plan. The captain noted that their initial cruising altitude was flight level (FL) 320. The crew completed the briefing and requested 32.1 tonnes of fuel be uploaded and the flight departed at about 0600. When at the top of climb, the captain retrieved the deck log and noticed that the initial flight level on the log was different to the initial planned level and a departure fuel of 45 tonnes on the log and realised that they were using the original, incorrect, flight plan data. Due to improving weather at the Perth, the flight was able to continue to the destination.

As a result of this occurrence, the aircraft operator has highlighted the occurrence to the dispatch team and issued an Internal Notice to Airmen (INTAM) to the flight crews to ensure they are in receipt of the latest flight plan data before flight.

This incident highlights the importance of ensuring vital information is relayed to crews in a timely manner.

Aviation Short Investigation Bulletin - Issue 26

What happened

On 23 September 2013, the crew of a Boeing 777-3ZGER aircraft operated by Virgin Australia, registered VH-VPE (VPE) conducted a scheduled passenger flight from Brisbane, Australia to Los Angeles, United States. At about 0305 Coordinated Universal Time in the cruise at flight level (FL) 310 and flying in clear air the aircraft encountered abrupt severe turbulence.  The flight crew turned on the seat belt sign, reduced the speed of the aircraft and requested from air traffic control a descent to a block altitude from FL310 to FL 290.

At the same time, the cabin crew had begun the meal service and the seat belt signs were turned off. Cabin crew members reported being thrown around the cabin by the turbulence with two of the 12 cabin crew hitting their heads on the aircraft cabin ceiling. Food and catering equipment were spread over seats, passengers and the aisles with the rear section of the aircraft affected the most. All passengers were seated at the time with their seat belts on. One passenger reported a sore neck and another passenger reported a burn injury as a result of a spilt hot meal. There were no reported injuries to the four flight crew.

This incident is a timely reminder for passengers to keep their seatbelt fastened when seated, pay attention to the safety demonstration and any instructions given by the cabin crew and read the safety information card in the seat pocket.

Aviation Short Investigation Bulletin - Issue 28

What happened

On 15 October 2013, the pilot of an Air Tractor AT‑502 aircraft, registered VH‑CJY, was preparing to conduct aerial spraying operations about 33 km west of Temora, New South Wales. 

The owner of the property had provided the pilot with a map of the area to be sprayed, which included power lines. There was a road and a row of trees to the south of the paddock, with double power lines (as marked on the map) about 130 m north of the treeline. The pilot planned to fly over the trees and under the power lines on each leg, before turning to commence the next run.

At about 1730 Eastern Daylight-saving Time, when to the south of the paddock at about 15-20 ft above ground level (AGL), after turning to commence the next run, the pilot saw a cross arm indicating the presence of a wire attached to a derelict homestead. He decided not to climb the aircraft as it would have collided with the larger double power lines. The pilot then heard a bang, with the aircraft’s propeller spinner contacting the wire.

The pilot flew the aircraft under the double power lines and climbed to about 150 ft AGL. The engine was vibrating, but continued to produce power. The engine then steadily lost power. The pilot secured the engine and conducted a forced landing in a paddock. During the landing, the aircraft ground-looped and the left wing contacted the ground. The aircraft was substantially damaged, and the pilot received nil injuries.

The pilot did not see the wire at any stage, nor was it marked on the map provided to the pilot by the property owner.

Aviation Short Investigation Bulletin - Issue 24

What happened

On the evening of 8 October 2013 a Dornier DO228 aircraft, registered VH-VJN (VJN) was taxiing to the company hangar at Brisbane Airport, Queensland after the completion of a charter flight.

As the flight crew turned right onto the Hotel 2 South taxiway, two vehicles were travelling along the designated movement area along Hotel 2 South from the opposite direction.

This incident did not involve an on-site investigation by the ATSB and the investigation includes differing recounts of the event from the flight crew and the driver of the second vehicle.

Aircraft movements at Brisbane Airport have increased from 123,000 in 2004 to 222,000 in 2013. At the time of the incident there were about 1,700 vehicles approved to access the taxiway hotel system.

The ATSB published a research paper on ground operation occurrences at Australian Airports over a 10 year period. Of the 282 ground occurrences reported to the ATSB between 1 January 1998 and 31 December 2008, about 37 per cent of those incidents occurring as the aircraft approached a gate, were attributed to near collisions with vehicles. This report is available at: www.atsb.gov.au/publications/2009/ar2009042.aspx.

Aviation Short Investigation Bulletin Issue - 27

What happened

On 11 October 2013, the student pilot of a G-115C2 Grob aircraft, registered VH-ZIV, departed the Merredin aeroplane landing area (ALA) on his first solo flight to the designated training area located near Lake Brown, Western Australia.

After about 1.4 hours the student elected to return to Merredin, tracking via Burracoppin Township. The student was unable to sight Merredin (ALA) and broadcast on the universal communications (UNICOM) frequency indicating that he was unsure of his position. The UNICOM operator gave him directions to locate Merredin.

The student located Merredin and joined the circuit for runway 28. When on short final he determined that he was too high and initiated a go-around. The student commenced a second circuit to runway 28. When on short final, the student reported there was a crosswind with slight windshear, and the glare from the sun was making it increasingly difficult to see the runway. The aircraft touched down heavily and bounced. The student reported that the sun glare made it very difficult to judge the height of the aircraft and he believed that the aircraft had not bounced very high. At about 1700 Western Standard Time the aircraft touched down again on the nose landing gear, which subsequently collapsed. The aircraft slid along the runway and came to a stop. The student pilot was uninjured and the aircraft sustained substantial damage.

The aircraft operator conducted an internal investigation and determined the student’s last meal was at 0600, which consisted of a sandwich and the operator’s flight risk assessment tool (FRAT) for the accident flight was incomplete. If all values for the flight had been entered, the total risk value for the flight would have been in the red area stating ‘No dispatch’.

The student indicated he had about 6 hours sleep the night before the accident as he was finishing his ground school homework and preparing for the next day.

This accident highlights the importance of pilots also assessing their own wellbeing, to determine if they are physically and mentally prepared, and if the operating conditions are suitable for the conduct of the flight. The effect of sun-glare when relying on visual cues is an important consideration for all pilots.

Aviation Short Investigation Bulletin - Issue 28

What happened

On 7 October 2013, the pilot of a Fairchild SA227 aircraft, registered VH‑UZP (UZP), was preparing for a freight charter flight from Ballina/Byron Gateway Airport (Ballina) to Coffs Harbour, New South Wales.

At the same time, the flight instructor and pilot of a Bell 47G helicopter, registered VH‑UTF (UTF), were conducting circuit training at Ballina. After landing, the pilot broadcast on the common traffic advisory frequency (CTAF) that UTF was entering runway 06 to conduct left hand circuits. Shortly after, UTF departed and recommenced circuit training.

The pilot of UTF broadcast turning onto a left base for runway 06. Soon after, UTF landed about two-thirds of the way along the runway and came to a stop, facing east.  The instructor briefed the pilot prior to commencing a further circuit. 

The pilot of UZP broadcast a taxi call and commenced taxiing to runway 06. After hearing no further broadcasts from the pilot of UTF, the pilot of UZP broadcast on the CTAF that he was entering and backtracking runway 06. The pilot again received no response. He taxied UZP onto the runway and lined up on runway 06. The pilot broadcast a lining up and rolling call and commenced the take-off run. Just prior to rotation, he sighted UTF stopped on the runway, towards the departure end. He elected to continue the take-off and increased the climb angle to provide separation with UTF.

The instructor of UTF then attempted to contact UZP, with nil response received. He then realised that the radio volume had been turned down. UTF then vacated the runway.

Broadcasting and monitoring the CTAF and maintaining a good lookout are useful strategies to improve safety at non-towered aerodromes.

Aviation Short Investigation Bulletin - Issue 25

What happened

On 5 October 2013, a Piper PA-44 aircraft, registered VH-CZH (CZH), was enroute to Rottnest Island, from Perth, Western Australia, to conduct instrument flight rules (IFR) navigation aid (navaid) training. On board were a flight instructor and student.

There was other IFR training aircraft on the Rottnest Island common traffic advisory frequency (CTAF) when CZH arrived over the navaid to commence the practice non-directional (radio) beacon (NDB) training. Both the instructor and student made frequent broadcasts on the CTAF to advise other traffic of the aircraft’s position and their intentions. The weather was instrument meteorological conditions and conditions were deteriorating as a large cold front was moving rapidly in from the south-west.

At about 1509 Western Standard Time (WST), as CZH was inbound in the holding pattern at 2,000 ft, Perth Centre air traffic control (ATC) advised the crew that an IFR Mooney M20 aircraft, registered VH‑DJU (DJU), was inbound to Rottnest Island, and would be on descent from 3,000 ft, for instrument navaid training. The estimated time of arrival overhead the NDB would be 1518. The instructor in CZH acknowledged this traffic information.

Shortly after, the instructor and student in DJU requested a descent to 2,000 ft due to severe turbulence at their current level. This descent took DJU from controlled to uncontrolled airspace and thus a change from ATC separation responsibility, to pilot responsibility for maintaining separation in the Rottnest Island area.

When the crew in CZH had not heard from DJU on the CTAF, the instructor tried unsuccessfully to raise them on this frequency. He then contacted ATC on the Perth Centre frequency, who provided traffic information. The pilots subsequently arranged mutual separation

The ATSB SafetyWatch campaign highlights the broad safety concerns that come out of our investigation findings and from the occurrence data reported to us by industry. One of the safety concerns is safety around non-controlled aerodromes. Insufficient communication between pilots, and breakdowns in situational awareness were the most common contributors to occurrences in the vicinity of non-controlled aerodromes.

Aviation Short Investigation Bulletin - Issue 26

What happened

On the evening of 7 October 2013, the pilot of a Cessna 172 aircraft, registered VH‑NUU (NUU), commenced night circuits at Archerfield Airport, Queensland. He reported that there were also four other aircraft and a helicopter conducting night circuits at the time. The pilot reported that the aircraft in the circuit were flying a ‘modified’ due to a strong tailwind and to make allowances for a helicopter that had been conducting stop-and-go circuits.

At the same time, the pilot of a Beech F33A aircraft, registered VH‑ZBZ (ZBZ), inbound to Archerfield, was advised by air traffic control that there were four or five aircraft in the circuit area. ZBZ joined the circuit between an aircraft on downwind and another on upwind. The pilot of ZBZ reported that he had the aircraft in front of him (NUU) sighted on downwind and extended the downwind leg to maintain separation with NUU.

NUU turned onto base and about 20 seconds later, the pilot of ZBZ also broadcast that he was turning onto base. Soon after, the pilot of ZBZ broadcast that he was established on final. At that time, he had sighted an aircraft well ahead on late final and believed it was NUU. The pilot of NUU immediately broadcast that he was on final.

The pilot of ZBZ then saw NUU below his aircraft. The pilot of ZBZ conducted a go‑around and NUU continued the approach.

Airservices Australia surveillance data indicated that the vertical separation reduced to 300 ft.

Maintaining a vigilant lookout at all times and standardisation of the circuit pattern is important for safe operations in the vicinity of non-towered aerodromes.

Aviation Short Investigation Bulletin - Issue 25