What happened

On 7 September 2013, an Airbus A320, registered VH-VFJ, was on descent into Auckland, New Zealand via a Required Navigation Performance (RNP) approach to runway 23L. During the later stages of their descent, the crew managed the aircraft speed to meet an Air Traffic Control request and according to applicable company speed restrictions.

The auto-flight system sequenced to final approach mode passing about 4,200 ft, but exited final approach mode when the crew subsequently levelled the aircraft approaching 3,000 ft. The crew levelled the aircraft to reduce speed to comply with a company speed restriction of 210 kt maximum below 3,000 ft. Having slowed sufficiently, subsequent manipulation of the auto-flight system resulted in the inadvertent engagement of open climb mode, which resulted in an increase in engine thrust and aircraft acceleration.

Attempting to avoid exceeding the limiting speed applicable to the existing aircraft configuration, the captain retarded the thrust levers to the idle stop, inadvertently disconnecting the auto-thrust system. The crew resumed the approach, unaware that the auto-thrust system was disconnected, and therefore no longer controlling aircraft speed. As the aircraft continued to decelerate, soon after the final stage of flap was selected for landing, the Flight Management Guidance System generated a low energy warning. As the crew was responding to the low-energy warning, alpha-floor auto-thrust mode engaged. The crew accelerated the aircraft to approach speed using manual thrust control, and was able to continue the approach for an uneventful landing.

The operator’s investigation into the incident found that, among other things, there may be some commonly held misunderstandings with respect to some aspects of instrument approach procedures, particularly their application to RNP approaches. The operator planned to communicate relevant procedural information to flight crew, with appropriate explanatory information, and communicate with flight crew regarding procedural requirements associated with auto-flight system mode awareness and speed monitoring. The operator also planned to include more guidance in appropriate documentation dealing with transfer of aircraft control between flight crew.

This incident highlights the need for robust and clear instrument approach and auto-flight system management procedures. It also highlights the need for consistent attention to aircraft auto-flight modes and energy state.

Aviation Short Investigations Bulletin - Issue 35

Safety summary

What happened

In the early evening of 23 September 2013, the student pilot of a Cessna Aircraft Company 182R aircraft, registered VH‑AUT, was conducting solo night circuit consolidation training at Hamilton Airport, Victoria. On the fourth circuit the pilot made a radio call indicating he was aborting the landing. Witnesses observed the aircraft climb, then turn to the right and descend, followed by a collision with terrain. The aircraft was destroyed by the impact and post‑impact fire and the pilot was fatally injured.

What the ATSB found

The ATSB found that following an aborted landing during circuit training in dark night conditions, the solo student pilot lost control of the aircraft, resulting in a collision with terrain. There was insufficient evidence to determine the reason for the loss of control.

The student pilot’s post-mortem examination identified a cardiac condition capable of causing incapacitation and their medical history included another condition that, if having effect at the time, had the potential to have contributed to the development of the accident. The Civil Aviation Safety Authority (CASA) was unaware of either condition.

In addition, the aircraft’s flaps were found to have been in the fully-extended position at impact, which was not consistent with either the operator’s or manufacturer’s procedures for a go-around. The ATSB was unable to determine when the flaps were extended and to what extent the misconfiguration influenced the accident.

Safety message

This accident highlights the importance of the shared responsibility by holders of aviation medical certificates, examining physicians and CASA to report, assess and manage medical and other conditions as they might affect the issue/renewal of those certificates. A full understanding by CASA of an aviation medical certificate applicant’s current and prior medical conditions, and use of medications, informs the consideration and development of appropriate risk controls to ensure continued safe flight. This can include the applicant continuing in, or recommencing their participation in the industry.

What happened

On 15 September 2013, the pilot of a Robinson R44 helicopter, registered VH-NUZ, was flying passengers on a private scenic flight over the Montgomery Reef and Buccaneer Archipelago area of Western Australia. The pilot had completed several take-offs and landings at that site already on the day.

After a routine landing at the reef, the pilot shut down the engine. The passengers had disembarked and were standing about 20 to 30 m away.

At about 1530 Western Standard Time the pilot, who was the sole occupant, then started the helicopter’s engine and completed the pre-flight checks. When the pilot raised the collective to bring the helicopter into a hover, it suddenly rotated three times while airborne. The pilot could not regain control and elected to land immediately, however the helicopter landed heavily. The pilot shutdown the engine and exited the helicopter.

The direction that the helicopter rotated could not be ascertained by the pilot or witnesses. The pilot and bystanders were not injured but the helicopter sustained substantial damage as a result of the hard landing.

Based on the information provided, the Australian Transport Safety Bureau (ATSB) was unable to determine what led to the loss of control.

During the investigation, the ATSB was made aware that instances of ‘sudden and violent yawing in forward flight’ had occurred on other ‘low time’ R44 helicopters, being attributed to a ‘sticky inlet valve’, with no recurrence after maintenance rectification.

There were no Service Difficulty Reports (SDR) regarding this issue in the Civil Aviation Safety Authority’s SDR database, making it difficult to pursue this line of enquiry.

The ATSB encourages reporting of occurrences to the ATSB and defects to CASA to allow for continued improvements to aviation safety.

Aviaiton Short Investigations Bulletin - Issue 37

What happened

On 1 September 2013 the pilot of a Cessna 210 aircraft, registered VH-JMG (JMG), conducted a private flight from Port Macquarie to Bankstown, New South Wales.

The pilot regularly flew this route and was very familiar with the airspace. On this day, he was feeling unwell, so departed earlier than usual, at about 1510 Eastern Standard Time.

The flight went as planned, with the aircraft arriving at the cruise level of 8, 500 ft around Taree. The pilot requested and was issued a clearance to enter Class C controlled airspace at Williamtown.

The pilot put the aircraft on autopilot, and listened to music through the radio, whilst monitoring the aircraft.

Soon after, there was no further communication with JMG until the pilot called close to Bankstown.

The pilot had fallen asleep and re-entered Class C controlled airspace prior to waking up again. He conducted a spiral descent down to the Lane of Entry near Brooklyn Bridge. The flight then continued as planned with a safe arrival and landing at Bankstown.

This report highlights the need for all pilots to carefully consider their fitness to fly. This includes assessing fatigue and illness. The following publications provide additional information on pilot incapacitation and the ‘IMSAFE’ checklist:

• Pilot Incapacitation: Analysis of Medical Conditions Affecting Pilots Involved in Accidents and Incidents – 1 January 1975 to 31 March 2006
• Federal Aviation Administration Risk Management Handbook

Aviation Sort Investigation Bulletin - Issue 25

Safety summary

What happened

At about 1200 on 15 September 2013, the pilot-owner of a Cessna 206, registered VH-WAV, landed on a public road to repair a truck at a work camp. At about 1516, during take-off from a different, curved road, the aircraft’s left wing struck a tree at a height of about 30 ft. The wingtip and aileron separated before the aircraft impacted terrain, fatally injuring the pilot and passenger. The aircraft was destroyed.

What the ATSB found

The distance available from where the pilot increased power for take-off was much shorter than the distance advised in the aircraft’s pilot operating handbook under the prevailing conditions.

There was no apparent reason for the pilot to attempt a take-off from that location when a more suitable location was nearby. It is most likely that the pilot misjudged the distance available, the prevailing conditions and their effect on the aircraft’s performance, or had a false recollection of the relative layout of the two roads and thought that there was more take-off room available beyond the curve. However, it is also possible that the pilot’s judgement of the available distance, or his decision-making capability, was affected by a serious medical condition and/or prescribed medications that had not been reported to the Civil Aviation Safety Authority (CASA) until after the pilot’s previous medical certificate had expired.

In addition, the ATSB found that the pilot’s seat had broken from its mounts, probably as the result of heavy, unsecured cargo striking it during the accident sequence. This could have had a detrimental effect on the survivability of the accident.

Safety message

The accident highlights the importance of carefully considering all relevant factors that could affect the suitability of a particular landing and take-off area. These include: aircraft weight and engine power; wind direction, speed and gusts; ambient air pressure and temperature; surface slope, material, and condition; other physical characteristics of the area such as its length and width; and the height and location of surrounding obstacles.

Though no link with the accident was established, flying without a valid medical certificate, or omitting to report a diagnosed condition or treatment to a Designated Aviation Medical Examiner or to CASA, can lead to such an impairment being undetected or its effect underestimated.

Unrestrained cargo poses a significant risk to the survivability of aircraft occupants. Pilots should take care to ensure that all cargo is adequately restrained to prevent movement during flight and improve survivability in the event of an accident.

On 30 March 2012, a Europa XS amateur-built aircraft collided with terrain shortly after takeoff from Caboolture Airfield, Queensland. The pilot, who was the sole occupant, was fatally injured. 

The Australian Transport Safety Bureau (ATSB) did not investigate the accident, which was investigated by the Queensland Police Service (QPS) on behalf of the Queensland Coroner. On 20 June 2013, the Queensland Coroner requested ATSB assistance with the review of the coroner’s investigation and advice of any potential additional lines of enquiry or other expert review before the matter proceeded to inquest.

To facilitate this support, the ATSB initiated an external investigation under the provisions of the Transport Safety Investigation Act 2003. A report on the results of the ATSB’s review of the coroner’s investigation was provided to the Queensland Coroner on 6 September 2013.

Any enquiries as to the planning for, or conduct of the Coroner’s Inquest into this accident should be directed to the Queensland Coroner’s Office at:

Queensland Courts
Office of the State Coroner
Brisbane Magistrates Court
363 George Street
Brisbane QUEENSLAND 4000 

Telephone: (07) 3239 6193
Facsimile: (07) 3239 0176
Email: state.coroner@justice.qld.gov.au
Web: www.courts.qld.gov.au

______________

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

What happened

On 13 September 2013, the flight instructor and student pilot of a Robinson R22 helicopter, registered VH-ONT, were preparing for a dual training flight from Armidale, New South Wales.

Prior to take-off, the instructor explained the purpose of the fuel mixture control guard, the use of the carburettor heat, and took the student through the start-up checklist.

At about 1515 Eastern Standard Time, the helicopter departed, with the instructor operating the controls. During the climb, at about 300 ft above ground level (AGL), the instructor handed control of the helicopter over to the student. When maintaining 1,200 ft AGL, the instructor discussed with the student on how to enter a descent. After confirming that they would reduce the engine power, the instructor asked the student to pull the carburettor heat on.

The instructor looked outside to check for traffic and the engine then stopped. The instructor immediately initiated an autorotation and lowered the collective. He observed that the fuel mixture control was in the idle cut-off position. The student had removed the fuel mixture control guard, inadvertently pulled the fuel mixture control instead of the carburettor heat control and then replaced the guard. The instructor asked the student to push the fuel mixture control back in and he broadcast a ‘MAYDAY’ call.

The instructor selected a paddock and focused on the autorotation. Prior to the landing flare, the low rotor revolutions per minute (RRPM) horn sounded. The helicopter landed and ran on the ground on its skids, before rolling onto its side due to the slope of the paddock. Both occupants sustained minor injuries and the helicopter was substantially damaged.

This accident highlights the benefit of pilots positively identifying the control to be manipulated, prior to performing the action.

Aviation Short Investigation Bulletin - Issue 24

What happened

On 12 September 2013, at about 0956 Eastern Standard Time, a Cessna 185 aircraft, registered VH-OZA (OZA), departed Moruya, New South Wales for a parachute drop overhead the airport.

At about 1013, the crew of a Regional Express Saab 340B aircraft, registered VH-ZLJ (ZLJ), broadcast a call advising they were taxiing for runway 36 at Moruya, for a scheduled passenger service to Merimbula. In response, the pilot of OZA broadcast a call advising of his intention to conduct a parachute drop overhead.

At about 1018, the crew of ZLJ broadcast that they had entered, and were rolling on runway 36, and intended to conduct a right turn after take‑off, with a departure track of 178° (True).

Soon after, the parachute drop was completed. 

At about 1021, the crew of ZLJ asked the pilot of OZA to confirm that the drop had been completed. At that time, ZLJ was climbing through 3,500 ft and tracking to overhead the airport. The crew then questioned the altitude, time and position the parachutists had been dropped. The pilot of OZA advised that they had been dropped about 0.4 NM to the west of the airport, about 30 seconds previously.

The crew of ZLJ immediately turned the aircraft left. They continued to parallel their intended departure track overwater until about 10 NM to the south of the airport. The flight continued without further incident.

As a result of this occurrence, the operator of OZA has advised the ATSB that they have distributed a letter to all company pilots detailing the incident and highlighting the importance of not becoming complacent with procedures.

This incident highlights the impact complacency and time pressures can have on aircraft operations. It is important that pilots remain vigilant and alert, and be mindful that the even the most routine tasks must be conducted with care and concentration. Furthermore, when time pressures do occur, it is a useful strategy for pilots to take the time to re-evaluate the task and their priority.

Aviation Short Investigation Bulletin - Issue 24

Safety summary

What happened

On 7 September 2013 at about 0925, V/Line passenger train 8205 travelling to Warrnambool, Victoria collided with a northbound road vehicle (rigid truck and dog trailer combination) at the Pettavel Road level crossing in Mount Moriac, located about 20 km west of Geelong. Vehicular traffic across the Pettavel Road level crossing was controlled by warning and Stop signs (passive controls).

Five passengers, the locomotive driver and a conductor sustained minor injuries in the collision. The truck driver was not physically injured.

The collision destroyed the road vehicle trailer and caused significant damage to the locomotive and approximately 75 m of track infrastructure.

What the ATSB found

The ATSB found that the driver of the truck did not come to a stop at the railway crossing Stop sign and proceeded into the level crossing and the path of the train. It is possible that the truck driver’s attention to the driving task was compromised and he did not look for trains. It is also possible that the driver noticed the train and misjudged its speed, believing that he could get through the crossing before the arrival of the train.

When at the Stop sign south of the crossing—the direction the truck driver approached the crossing—there was adequate sighting to the east, the direction from which the train approached.

The investigation also found that location of the warning signage and the Railway Crossing Ahead sign on the approach to the level crossing was not in accordance with Australian Standard AS 1742.7-2007, Manual of uniform traffic control devices, Part 7: Railway crossings. These non-compliances with the standard were not contributory to this incident.

What's been done as a result

V/Line has made a submission to the Railway Crossing Project Delivery (RCPD) Committee1 to consider the upgrade of the Pettavel Road level crossing from passive to active warning protection devices.

Surf Coast Shire Council has relocated the signage to comply with the requirements of the Australian Standard AS 1742.7-2007, Manual of uniform traffic control devices, Part 7: Railway crossings.

Safety message

Road vehicle drivers, especially of heavy vehicles, using railway level crossings equipped with passive controls need to be vigilant, observe road-warning signs, obey road rules and look out for trains.

What happened

On 6 September 2013, at about 1545 Eastern Standard Time, the pilot of a Beech A36 aircraft, registered VH‑FFY, taxied for a private flight from the Caloundra aeroplane landing area (ALA) to Archerfield, Queensland.

The pilot reported that, during the take-off run, all engine indications were normal. When at about 200 ft above ground level (AGL), the pilot detected a burning smell and observed smoke entering the cockpit from the pilot foot-well. The engine continued to produce power. At about 300 ft AGL, as the area was heavily forested, the pilot commenced a turn back to the runway for landing.

The pilot opened the left side storm window to draw the smoke out of the cockpit and reduced power. The engine then began to run rough. The pilot elected to conduct a forced landing and selected a suitable paddock. The pilot shut down the engine and prepared the aircraft for landing.

During the landing roll, the nose landing gear separated from the aircraft due to the uneven terrain and the propeller subsequently contacted the ground. One passenger sustained minor injuries.

After the accident, the exhaust tailpipe from the turbocharger assembly was found on the runway at Caloundra. An engineering inspection revealed that the tailpipe had separated at a weld joint.

As a result of this occurrence, the turbo-normalizing system manufacturer has advised the ATSB that the requirement to complete the circumferential weld will be highlighted in the installation instructions. The tailpipe supplied will also be clearly marked as supplied tack-welded, with additional instructions showing the requirement to perform the circumferential weld prior to flight. 

Aviation Short Investigation Bulletin - Issue 24