On 24 July 2013, an Airbus Industrie A320 aircraft, registered VH-FNP (FNP) was being operated on a scheduled passenger flight from Perth to Newman, Western Australia.
Prior to reaching the top-of –descent point, the crew conducted a full approach briefing. This included the decision to use Flap Full for the visual approach.
Newman had a lot of aircraft movements both into and out of the airport that day. The pilot in command (pilot monitoring) focussed on maintaining separation for FNP, while the first officer (pilot flying) maintained the aircraft on the approach.
The crew reported the aircraft was on the correct glidepath and at the correct approach speed. This is confirmed by the flight data recorder (FDR) information.
By 500 ft above ground level (AGL) the landing gear had been extended and Flap 3 selected. As the visual approach had been programmed into the flight management guidance system, the crew expected to receive the automatically generated 500 ft AGL call.
At about 231 ft radio height the crew received a ground proximity warning system (GPWS) warning “TOO LOW FLAP”. Full flap was selected at about 185 ft and the aircraft landed shortly after.
Virgin Australia Regional Airlines (VARA) have initiated two safety actions in regard to the requirement to maintain track during go-around procedures and further training for the crew.
A United States Navy/National Aeronautics and Space Administration research report Cockpit Interruptions and Distractions: A Line Observation Study targets some of the actions that pilots take, when forced to make decisions, outside their well-practiced sequences.
On 8 September 2013, the pilot and passenger of a De Havilland DH‑82A aircraft, registered VH‑BJE (BJE), were conducting a local scenic flight from the Redcliffe aeroplane landing area (ALA).
At about 1615 Eastern Standard Time, the pilot broadcast a taxi call on the common traffic advisory frequency (CTAF) and commenced taxiing via the eastern-most taxiway toward runway 07. The pilot then reported broadcasting a call advising that he was entering and backtracking runway 07. The aircraft was backtracked on the grass on the southern side of the sealed runway.
At the same time, the pilot of a Piper PA‑36 aircraft, registered VH‑SEN (SEN), broadcast a taxi call on the CTAF and taxied from the eastern taxiway behind BJE, then turned onto the sealed taxiway to runway 07. When SEN arrived at the intersection between the western taxiway and runway 07, the pilot reported that he broadcast his intention to line up after an aircraft on final had landed.
The pilot of BJE taxied off the flight strip, outside the gable markers, to allow the aircraft on final to land and vacate the runway. He then reported broadcasting a lining up and rolling call and lined up on the grass to the right of the sealed runway.
At about the same time, the pilot of SEN also broadcast a call advising he was entering, lining up and rolling on runway 07. The pilot of BJE heard the pilot of SEN broadcast the call. He looked back and observed SEN lined up on the sealed runway. He immediately broadcast a call requesting the pilot of SEN delay his take-off as BJE was within the confines of the flight strip. The pilot of SEN had also observed BJE about 100 m ahead on the grass, to the right, and reported that he rejected the take-off and made a call to BJE requesting his intentions. The pilot of BJE then commenced a turn towards the gable markers.
Shortly after, SEN recommenced the take-off. When SEN passed BJE, the pilot of BJE reported that his aircraft was still within the flight strip and estimated that the aircraft came within 10-15 m of each other.
On 6 September 2013, at about 1220 Eastern Standard Time, a Piper PA-28R-200 aircraft, registered VH-MMU, was completing a private flight from White Cliffs, New South Wales, to Birdsville, Queensland. On board the aircraft were the pilot and a passenger.
As it was during the annual Birdsville horse race meeting, the pilot joined the circuit at Birdsville in accordance with the promulgated Airservices Australia Aeronautical Information Publication Supplement (AIP SUP).
The wind was fluctuating during the aircraft’s arrival, at times indicating 010 ° T at 10 kt, but close to landing it was 040 ° T at 10-15 kt. As there were restrictions on the use of runway 03, the pilot elected to fit in with traffic and use runway 32.
The approach to runway 32 placed the aircraft over raised ground and a high fence, where much of the crowd were situated. To remain at a safe altitude above the crowd, the passenger, a more experienced pilot, suggested that the pilot keep the aircraft at least 50 ft above the runway threshold, and flare soon after.
The pilot attempted to comply with this suggestion and prepared for the landing flare, but the passenger advised him that they were too high, and not to reduce the engine power until the aircraft was in a safer landing configuration. The pilot lowered the aircraft’s nose slightly and initiated the flare. The aircraft landed firmly on the main landing gear, then bounced once or twice.
Despite the pilot’s efforts, the aircraft veered to left of the runway and the left wheel subsequently struck a graded mound. The aircraft stopped abruptly. The pilot and his passenger sustained minor injuries, and the aircraft was substantially damaged.
It is important to be aware that the presence of others may influence your decision-making process. Their apparent ability does not mean that others can achieve the same outcome. To be competent, pilots must know, and fly within, their own personal limitations on that particular occasion.
On 30 August 2013, a Boeing 737 aircraft, registered ZK-NGI, was involved in a cabin depressurisation incident near Auckland, New Zealand.
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 13-008 / AO‑2013-008.
TAIC requested assistance from the Australian Transport Safety Bureau (ATSB) in the download of the aircraft’s cockpit voice recorder (CVR). 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 CVR was hand-carried to the ATSB’s facilities in Canberra by a TAIC officer and was downloaded on 5 September 2013. The downloaded audio and a replay report were provided to TAIC.
TAIC is responsible for releasing the final investigation report regarding this incident.
Transport Accident Investigation Commission of NZ www.taic.org.nz
______________
Released in accordance with section 25 of the Transport Safety Investigation Act 2003.
On 3 September 2013, at about 1531 Central Standard Time, a Cessna 441 aircraft, registered VH‑SMO, departed Adelaide on a charter flight to the Honeymoon aeroplane landing area (ALA), South Australia.
While en route, the pilot determined that the wind conditions were favourable for a straight‑in‑approach to runway 01 at Honeymoon.
During the descent, the pilot selected the first stage of flap. The pilot reported that normally he would lower the landing gear and confirm that it had been extended, but on this occasion, he could not recall performing this action.
The pilot then selected the second stage of flap and established the aircraft on a 5 NM final to runway 01. When about 500 ft above ground level (AGL), the pilot commenced his pre-landing checklist. After selecting full flap, the first item on the checklist, the pilot looked at the windsock to confirm the wind and observed 4-5 emus on the right side of the airstrip. He watched them run away from the airstrip and then continued the approach, but inadvertently omitted to complete the remaining checklist items, which included confirming the landing gear had been extended. The aircraft subsequently landed with the landing gear retracted.
This incident highlights the impact distractions can have of aircraft operations, particularly during a critical phase of flight.
On 30 August 2013, a loss of separation assurance occurred between an Airbus A320, registered VH‑VNQ (VNQ), and a Boeing 737, registered VH‑VZB (VZB), 50 km SSE of Hay airport, NSW. VNQ was conducting a passenger flight from Melbourne, Victoria to Cairns, Queensland under the instrument flight rules (IFR). VZB was also conducting an IFR passenger flight in the opposite direction, from Cairns to Melbourne.
Both aircraft were operating in Class A airspace, under the control of an Airservices air traffic controller. The required separation standard in the portion of Class A airspace covered by radar surveillance was 5 NM laterally or 1,000 ft vertically. The majority of air routes in the airspace over which the controller had jurisdiction were one-way routes – aircraft could only operate in the direction marked on the aeronautical charts, but the Melbourne to Cairns route was a two-way route (T139). The airspace also contained a number of east/west routes that crossed T139.
Flight crews were required to plan flights in accordance with levels based on the magnetic heading of the planned track. Within controlled airspace, air traffic control (ATC) may assign and pilots may request a level that does not conform to this requirement. The crew of VNQ had planned to operate at FL360, and the crew of VZB had planned to operate at FL360 to a position inland and abeam Emerald, Queensland, and then at FL370 to Melbourne. However, the change of level planned by VZB had not been initiated, resulting in both aircraft converging at the same flight level.
The controller reported that their focus was on monitoring VNQ’s climb through the levels of a number of aircraft on crossing air routes and only became aware of the aircraft converging at the same level when the Short Term Conflict Alert (STCA) activated. The controller applied compromised separation techniques so that, while there was a loss of separation assurance, radar separation was not infringed.
As a result of this occurrence, Airservices will review the Melbourne to Cairns air route with regard to creating one-way routes, and more generally review similar routes nationally. In addition, Airservices has issued a directive reminding controllers of their responsibilities regarding the application of non-standard levels and subsequent return to standard levels.
In this incident, the timely activation of the STCA and the controller correctly utilising compromised separation techniques ensured that the separation standards were not infringed.
At about 1009 on 31 August 2013, passenger train 7MA8, known as ‘The Overland’, was travelling from Melbourne to Adelaide when it collided with a Holden Rodeo dual cab utility on the Mahers Road level crossing at Inverleigh, Victoria.
The sole occupant of the utility was seriously injured and transferred to Royal Melbourne Hospital. The locomotive crew suffered from shock, but none of the train’s 103 passengers were injured.
What the ATSB found
The ATSB’s investigation found that the driver of the utility was travelling along a maintenance access track adjacent to the railway before he turned into Mahers Road. As a result, he was provided with no warning of the approaching train.
The investigation also found that, at some time in the past, the railway property boundary fence had been removed, thereby providing local vehicle access along the railway maintenance track. As a result, over time and with regular use, the false perception that the maintenance track was part of Gallagher Road was created and reinforced.
Since the maintenance access track was not a public road, neither the ARTC nor the Golden Plains Shire had identified a need to provide traffic control.
What's been done as a result
The Australian Rail Track Corporation and the Golden Plains Shire have advised that they will work together to permanently isolate the rail corridor from Gallagher Road.
Safety message
This incident highlights the need for road and rail authorities to work together in maintaining the integrity of fences and structures used to exclude public access to the railway corridor.
The occurrence also highlights the need for drivers of motor vehicles to be vigilant at railway level crossings.
On 1 September 2013, a Robinson R22 helicopter, registered VH-HVW, departed a stock camp located about 40 NM (70 km) south-west of Lake Nash Station, Northern Territory. Shortly after take-off, the helicopter was observed commencing a steep climbing left turn to depart overhead the camp. As the helicopter turned into a downwind position, the wind appeared to affect the controllability of the aircraft. It appeared that the pilot attempted to respond to the situation, however, there was insufficient altitude to recover. The helicopter contacted the ground and flipped over a number of times before coming to rest. The pilot sustained serious injuries and the helicopter was destroyed.
Wind direction and velocity are important considerations for helicopter pilots. It is crucial that pilots maintain an awareness of the wind and be aware of the consequential effects on helicopter performance. This will assist pilots with responding promptly and appropriately to a situation and preventing a loss of control.
At about 1050 Eastern Standard Time on 31 August 2013, the crew of a Bell Helicopter Co. 412EP helicopter, registered VH-VAS, were tasked to pick up a patient who was reported to have sustained injuries during a fall in the hills around Macs Cove, near Mansfield, Victoria. Due to the confined winch area and the possible fouling hazard associated with nearby trees, the crew elected to conduct a double-lift extraction with the patient in a rescue strop, accompanied by a paramedic. As the paramedic and patient reached the helicopter’s skid‑landing gear, the patient became increasingly unresponsive and began slipping from the rescue strop. The paramedic and winch operator attempted to restrain the patient however, despite their efforts, the patient slipped out of the rescue strop and fell to the ground, sustaining fatal injuries.
What the ATSB found
The ATSB found that, due to the compressive nature of the rescue strop around the patient's chest, combined with the patient’s weight and pre-existing medical conditions, the patient probably lost consciousness during the winch operation. While the rescue strop was serviceable at the time, it was not suitable for the patient and contributed to them falling from the strop following their loss of consciousness.
The ATSB also identified that the operator and Air Ambulance Victoria had limited documented guidance to assist rescue personnel select the most appropriate winching rescue equipment.
What's been done as a result
Concurrent with the release of its preliminary investigation report on 10 October 2013, the ATSB issued a safety advisory notice to helicopter winch operators, noting the circumstances of this accident. The notice advised operators to consider the risk to patients, or other persons being winched, of slipping out of a rescue/retrieval strop and the implications for their operations.
Following this accident, the operator and Air Ambulance Victoria introduced a seat-type harness for patient recovery via winch and issued guidance to their crews on the order of priority of use for rescue equipment during over land winch operations. The Civil Aviation Safety Authority also issued an Airworthiness Bulletin clarifying the use and application of rescue/retrieval strops. In addition, various helicopter emergency medical service providers have improved information sharing to communicate operational knowledge and lessons learnt.
Safety message
The ATSB advises helicopter emergency medical service and other operators carrying out winching operations to note the circumstances of this accident and consider the implications for their operations of the risk of patients or other persons being winched slipping out of a rescue/retrieval strop. In this context the size, weight and medical condition of the person(s) being winched may indicate that other recovery options offer reduced risk.
Preliminary report
Report release date: 10/10/2013
The occurrence
At about 1050 Eastern Standard Time1 on 31 August 2013, the crew of a Bell 412EP helicopter, registered VH-VAS, was tasked to pick up a male patient who was reported to have fallen in the hills around Macs Cove, near Lake Eildon, Victoria (Vic.). The helicopter was contracted by Air Ambulance Victoria to provide emergency medical service (EMS) operations. The crew consisted of a pilot, aircrewman and a flight paramedic. The crew were informed that, due to the difficult terrain and the size of the patient, a winch extraction would likely be required.
The crew departed Essendon Airport, Vic. for the scene at 1105 (Figure 1). The weather was fine with light north-west winds.
Figure 1: Accident location and flight route
Source: Google earth
At about 1145 the helicopter arrived overhead the ground party and patient who were located in a heavily-wooded area in steep terrain about 1-1.5 km from the nearest road (Figure 2). The trees in the surrounding area were up to 60 ft high and the crew noted numerous dead branches that could create a hazard for winching operations.
Figure 2: Accident scene looking south-west
Source: Victorian Police
The crew located a suitable area into which to winch the paramedic to assess the patient’s condition. They discussed likely retrieval options and decided that a stretcher winch would be too dangerous due to the steep terrain, surrounding vegetation and the possibility of fouling. Due to the small winch area and the possible fouling hazard, the crew elected for a double-lift extraction with the patient in a rescue/retrieval strop (strop) (Figure 3).
Figure 3: Example of a double-lift with rescue/retrieval strop
Source: ATSB
The paramedic and aircrewman were unable to get the winch portable radio to work, so they decided that the paramedic would use hand signals to indicate whether a winch extraction would be required. The aircrewman winched the paramedic into the site at 1203. The pilot then flew the helicopter to land at Macs Cove, about 1 NM (2 km) to the south-west, and waited about 20 minutes before returning to the scene. This allowed the paramedic time to assess the patient.
At 1224, the helicopter departed Macs Cove to return to the scene. On arrival the crew noted that some trees had been cleared to create a larger winching area and that the patient had been moved to this area. After about 5 minutes the paramedic signalled to the crew that he was ready to winch and the crew positioned the helicopter over the winching area in an approximately 80 ft hover, about 20 ft above the tree canopy.
Initially the winching procedure appeared to proceed normally. The aircrewman reported that the paramedic appeared to have his arms and legs wrapped around the patient, as is the normal procedure. When the paramedic and patient were approximately 30–40 ft above the ground, the aircrewman noticed that they had moved towards the edge of the winch area and close to the upper branches of the trees. The paramedic stated that he came in contact with the branches and had to use both hands to fend off as he came through the tree canopy. The helicopter was moved back and right about 5 ft and the winch continued.
The aircrewman reported that once the paramedic and patient were clear of the canopy, at about 15 ft below the aircraft, he noticed that the patient was moving or wriggling. The aircrewman stopped the winch for a control check, and shortly after resuming the winch noticed that the patient’s arms were not in the usual position in the strop and that the paramedic appeared to be shouting at the patient. The aircrewman elected to continue winching in, and informed the pilot that the patient was slipping.
As the paramedic and patient reached the height of the helicopter’s right skid-landing gear, the paramedic was facing the helicopter and the patient was facing outwards. The paramedic reported attempting to pin the patient against the skid in an attempt to stop him slipping. The aircrewman continued winching until the paramedic’s head was level with the middle of the door opening. At this stage the aircrewman informed the pilot that he could see the patient slipping further. He dropped the winch pendant and reached down, grabbing the patient’s shoulder in an attempt to stop his fall. The aircrewman stated that by this stage the patient appeared to be unresponsive and limp.
Despite the crew’s efforts, the patient slipped out of the strop and fell to the ground, sustaining fatal injuries. Preliminary investigations indicate that the aircraft, winch and rescue equipment were serviceable at the time of the accident, and that the crew were qualified to carry out the task.
Further investigation
The investigation is continuing and will include examination of:
the rescue/retrieval strop design and its potential limitations with respect to the weight and physical dimensions of a patient
potential medical issues associated with patients being winched in rescue strops
the operator’s rescue procedures and protocols
certification procedures for helicopter winching rescue equipment.
Safety action
Although no organisational or systemic issues have been identified at this stage of the investigation, the following proactive safety action has been advised by Air Ambulance Victoria and the operator of the helicopter. In addition, the Australian Transport Safety Bureau (ATSB) has released a Safety Advisory Notice (SAN) advising operators of rescue and other winch-fitted helicopters of the potential hazards associated with the use of the rescue/retrieval strop.
Safety action by Air Ambulance Victoria
Following the winching accident all winching operations were suspended involving Air Ambulance Victoria emergency medical service (EMS) helicopters. This suspension remained in place until the results of an interim investigation by the helicopter operator confirmed that an equipment fault did not contribute to the accident.
In addition, Air Ambulance Victoria has, in conjunction with its EMS contractors, commenced a separate investigation that will examine the availability of suitable alternatives to the current rescue/retrieval strop.
Safety action by the operator
Immediately after the accident the operator suspended all winching operations pending initial investigations. Following its initial investigation and associated risk assessment, winch operations were recommenced.
An interim report has been published by the operator with associated safety action. This included reinforcing the need to critically assess a patient’s physical and medical state and any associated risks before committing to using the rescue/retrieval strop. An order of priority use of rescue equipment was promulgated for application in overland winch operations.
The ATSB advises helicopter emergency medical service and other operators carrying out winching operations to note the circumstances of this accident and consider the implications for their operations of the risk of patients or other persons being winched to slip out of a rescue/retrieval strop. In this context the size, weight and medical condition of the person(s) being winched may indicate that other recovery options offer reduced risk.
1. Eastern Standard Time (EST) was Coordinated Universal Time (UTC) + 10 hours.
The information contained in this web update is released in accordance with section 25 of the Transport Safety Investigation Act 2003 and is derived from the initial investigation of the occurrence. Readers are cautioned that new evidence will become available as the investigation progresses that will enhance the ATSB's understanding of the accident as outlined in this web update. As such, no analysis or findings are included in this update.
Inquest
ATSB Response to Findings
On 4 September 2015, Coroner Stella Struthridge of the Coroner’s Court of Victoria, without holding an inquest, released findings into the 2013 fatal helicopter winching accident involving a Bell Helicopter Co. 412EP. The accident was the subject of ATSB Investigation AO-2013-136.
The ATSB summary explains that a patient died during a retrieval operation for the patient after the patient had become injured in a fall. The patient slipped out of the rescue strop and fell to the ground.
The Coroner referenced the ATSB investigation and noted the ATSB findings that the use of a rescue strop, without employing an integral hypothermic strap was not suitable for the patient’s size and medical condition. The Coroner also noted the ATSB safety issue identified that there was limited guidance for rescue personnel regarding the selection of the most appropriate rescue equipment and the conditions when various types of equipment should be considered.
There were no significant differences in views between the findings of the Coroner and the findings of the ATSB with respect to the manner in which safety could be improved. This included the ATSB’s key safety message that when undertaking a winching operation the implications for the operation of the risk of patients or other persons being winched slipping out of the rescue/retrieval strop.
ATSB investigations and coronial investigations
Coronial investigations are separate to ATSB investigations. In this matter the respective authorities are largely in accord as to the factors that contributed to the development of the accident involving VH-VAS.
The ATSB's report can be downloaded by clicking on the link: Final report
On 26 August 2013, a Qantas Airways Boeing 737 aircraft, registered VH-VZA (VZA) was completing a scheduled passenger flight from Cairns, Queensland to Sydney, New South Wales.
After landing, at about 2010 Eastern Standard Time, VZA was cleared by air traffic control (ATC) to taxi to Bay 6 of the Domestic 1 (DOM 1) apron area at Sydney Airport. At about the same time, the captain observed the lights of a white security vehicle approaching from about 50 m away and about 90° to the right of the aircraft.
As the vehicle approached the intersection of the airside road and taxiway ‘Bravo 2’ the driver reported slowing to between 25 to 30 km/h. He looked to his left, but did not see the lights of VZA. Assuming the area was clear; he directed his attention to the parking bay area to the right.
The captain thought the vehicle would continue along the airside road, however, as the car continued in a northerly direction across the intersection the captain believed it was on a collision course with VZA. Realising the vehicle driver had not seen VZA the captain immediately stopped the aircraft.
The security vehicle continued toward the aircraft then came to an abrupt stop about 10 m to the right of the aircraft’s nose.
The ATSB published a research paper on ground operation occurrences at Australian airports over a 10-year period. This publication highlighted ground operations as potentially being one of the most dangerous areas of aircraft operation. Of the 282 ground occurrences reported to the ATSB between 1 January 1998 and 31 December 2008, 11 per cent happened when the aircraft was approaching the gate. About 37 per cent of the approaching the gate phase occurrences were attributed to near collisions with vehicles. These occurrences required immediate braking action by the flight crew or vehicle driver in order to avoid a collision.
