What happened

On 26 May 2013 at 1512 Western Standard Time, the pilot of a Piper PA‑31, registered VH-KLS (KLS), taxied for departure from runway 32 at Port Hedland for a flight to Karratha, Western Australia. The pilot made the necessary common traffic advisory frequency (CTAF) broadcast.

At about 1517, an aviation rescue and fire fighting (ARFF) vehicle that had been operating on the eastern side of the airport entered taxiway Bravo to return to the fire station on the western side. The crew made a CTAF broadcast at 1518, stating that they intended to cross runway 32 on taxiway Alpha. Hearing no response to the broadcast and seeing no aircraft on the runway, the crew crossed runway 32.

The pilot of KLS taxied onto the threshold of runway 32 and commenced the take-off roll. The pilot reported making the required CTAF broadcasts. At 1520, as KLS became airborne, the pilot observed the fire vehicle crossing the runway about 500 m ahead. As the aircraft was airborne, the pilot assessed the safest action was to continue the take-off and the aircraft passed over the intersection between runway 32 and taxiway Alpha between 300 and 400 ft above ground level. By the time KLS crossed the intersection the fire vehicle was clear of the runway.

The crew of the fire vehicle had not heard any CTAF broadcasts from KLS nor did they see the aircraft when they scanned the runway prior to crossing, possibly due to heat haze. The pilot of KLS had not heard the CTAF broadcast made by the fire vehicle.

As a result of this occurrence, the ARFF service provider has advised the ATSB that they will undertake two safety actions. They will release a national operational safety note advising ARFF operators of the efficient use of aviation radio communications when driving on an airfield. Additionally, they will undertake a comprehensive review of aviation radio coverage at Port Hedland as part of radio commissioning works. Any identified radio coverage deficiencies will be monitored by the service provider until resolution.

 Aviation Short investigation Bulletin Issue 22

Safety summary

What happened

On 15 May 2013, an ATR-GIE Avions de Transport Regional ATR72-212A (ATR72), registered VH‑FVR and operated by Virgin Australia Regional Airlines Pty Ltd (VARA), was conducting an instrument flight rules flight from Brisbane Airport to Moranbah Airport, Queensland. During the visual approach to Moranbah, the aircraft descended to a height of 440 ft above ground level as the pilot manoeuvred to avoid cloud. As the pilot levelled the aircraft, a number of terrain awareness warning system (TAWS) ground proximity warning system alerts activated. The aircraft was climbed, and the circuit was continued, with the activation of another TAWS alert prior to the aircraft landing.

What the ATSB found

The ATSB found that the captain’s rapid decision to descend limited the opportunity to discuss alternative approach options, descent limits and go around options should visibility reduce to below that required for visual flight.

The ATSB also identified significant under reporting by VARA of ATR72 TAWS-related occurrences to the ATSB.

What's been done as a result

VARA advised the ATSB of a number of safety actions following this occurrence. This includes the incorporation of the ATR fleet into the company’s cyclic recurrent check programme, the provision of safety promotion briefings to all company pilots, and the production of safety publications that alert crew to the defences that standard operating procedures and threat and error management provide.

In addition, VARA directed its flight crew to submit occurrence reports for all ground proximity warning system (TAWS) occurrences and implemented a review process to ensure that all relevant reports are passed to the ATSB. A review of the ATSB database in the period since these initiatives and the production of this investigation report showed that VARA’s reporting of TAWS occurrences was now consistent with other similar operator/operation reporting rates.

Safety message

This occurrence highlights the importance to flight crew of good communication and the inherent risk of spontaneous decision making. In addition, the advantages of following procedural information contained in operational documentation and aeronautical publications, such as the Aeronautical Information Publication Australia, is evident.

On 5 May 2013, a Eurocopter AS365N2 helicopter, registered 9M-DBH, was involved in an accident while taxying to park at RMAF Sempang, Malaysia.

An investigation into the circumstances of the accident is being conducted by the Office of the Chief Inspector of Air Accidents, Ministry of Transport, Malaysia. The investigation is being conducted in accordance with Malaysia’s obligations as the State of Occurrence under Annex 13 to the Convention on International Civil Aviation (ICAO Annex 13) and the Malaysian Civil Aviation Regulations 1996.

The Office of the Chief Inspector of Air Accidents requested assistance from the Australian Transport Safety Bureau (ATSB) in the analysis of signals recorded on the helicopter’s cockpit voice recorder (CVR). To facilitate this support and 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.

Download of the CVR was undertaken by the Singapore Air Accident Investigation Bureau (AAIB) and three 30-minute tracks of digital audio information were provided to the ATSB via secure file transfer. Spectral analysis of the audio was undertaken and the observations of interest compiled into a report that was provided to the Office of the Chief Inspector of Air Accidents in September 2013.

The Malaysian Office of the Chief Inspector of Air Accidents is responsible for releasing a final investigation report regarding this occurrence. 

Contact details for the office are:

Pejabat Ketua Inspektor Kemalangan Udara
(Office Of The Chief Inspector Of Air Accident)
Kementerian Pengangkutan Malaysia
Aras 2, Precinct 4
Pusat Pentadbiran Kerajaan Persekutuan
62570 PUTRAJAYA

Tel: 603-88714000
Fax: 603-88714069

______________

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

What happened

At 0710 Western Standard Time, a Fokker F28‑100 (F100) aircraft, registered VH‑FKJ (FKJ), was approaching Karratha, Western Australia, on the 204 radial, 11 NM behind a Boeing 717 (B717).

At 0714, a Cessna 310R, registered VH‑AEY (AEY), departed Karratha on a VFR flight to Exmouth. During the climb, the Karratha tower controller instructed AEY to track to intercept the 180-radial outbound, to provide segregation with the inbound F100.

As FKJ was approaching 21 NM from Karratha and 7,000 ft on descent, the crew was cleared to make a visual approach and track direct to Karratha. FKJ was 10 NM behind the B717, which was conducting an approach to a 5 NM final for runway 08.

At 0718, the pilot of AEY was given the F100 as traffic, on approach to Karratha on the 204-radial at about 13 NM. The pilot of AEY replied that they had the traffic visual, in their 2 o’clock position. They were instructed by the controller to pass behind that aircraft and track direct to Exmouth. The pilot subsequently reported that they had sighted the B717, mistaken it for the F100, and turned to track to Exmouth.

At 0719, AEY appeared on the traffic collision avoidance system (TCAS) display in FKJ as proximity traffic. As AEY came within 5 NM on the TCAS display, the crew levelled the aircraft off at about 4,000 ft, as a precaution.

The TCAS then went from a proximity warning to a traffic advisory (TA). Neither of the crew sighted AEY, which was climbing and approaching 4,000 ft. The pilot of AEY made a visual scan and saw FKJ coming towards AEY in a 10 o’clock high position about 1 to 2 NM away. The pilot descended AEY about 200 ft as FKJ passed overhead. At 0720, the crew of FKJ received a TCAS resolution advisory (RA) climb instruction, which they complied with. The TCAS display showed AEY passed about 700 ft below FKJ.

The pilot of AEY reported that they had misidentified the B717 as the F100 and commented that if they had been given information on the B717, they may not have misidentified the traffic.

Aviation Short investigation Bulletin Issue 22

What happened

On 19 May 2013, the pilot of a Pietenpol Air Camper commenced pre-flight checks in a paddock behind his home in St Leonards, about 9 km north of Launceston Airport, Tasmania. The pilot was taking a passenger on a scenic flight around Launceston.

The pilot had operated the aircraft from the paddock in the past, but not for a few years. Prior to landing in the paddock, a week earlier, the pilot had surveyed the area by car.

The aircraft was operating normally and became airborne at about 35 knots indicated airspeed. The pilot held the aircraft low, aiming to clear a fence at the end of the paddock. Nearing the fence, the pilot heard a loud noise, and the nose of the aircraft jolted to the right.

The airspeed quickly decreased, as the pilot attempted to hold the wings level. After initially climbing to about 10 ft, the aircraft impacted the ground, breaking the landing gear. The aircraft skidded on its nose and then pitched over onto its back, breaking the propeller.

Both the pilot and the front seat passenger exited the aircraft without injury. On surveying the accident site, the pilot realised the aircraft’s landing gear had caught the top wire of an electric fence he had not been aware of, located a short distance before the paddock’s main fence.

When not operating from a designated landing area, pilots should ensure the area is suitable. A thorough survey of the area to be used for take-off and landing should be completed prior to use.

 Aviation Short investigation Bulletin Issue 21

What happened

On 10 May 2013, at about 2000 Eastern Standard Time, a Sunstate Airlines Bombardier DHC‑8‑402 aircraft, registered VH‑QOD (QOD), departed Townsville on a scheduled passenger flight to Cairns, Queensland. 

About 20 minutes into the flight, the aircraft was in the cruise at FL 180 and flying in clear air when the aircraft encountered light turbulence. The captain immediately switched on the seat belt sign. A second later, the aircraft encountered abrupt severe turbulence.

 The autopilot disconnected and the captain, as pilot flying, assumed manual control of the aircraft. The flight crew reduced the speed of the aircraft to below the turbulence penetration speed. The turbulence event lasted about 10 seconds, during which time the aircraft climbed about 400 ft above the cruising altitude. The flight crew then re-engaged the autopilot and returned the aircraft to the assigned level.

The weather radar did not show any significant weather for the entire flight. Both members of the cabin crew were standing when the aircraft encountered the turbulence and impacted the roof before falling to the floor. Both sustained head injuries and one was knocked unconscious.

The aircraft landed in Cairns about 20 minutes later, without further incident and the cabin crew were transferred to hospital.

In this event, all passengers were seated with their seat belts fastened, even though the seat belt sign had been switched off earlier. The fact that none of the passengers were injured highlights the benefits of keeping your seatbelt fastened during the flight.

Cabin crew are at greater risk of injury during turbulence encounters as they are moving around the cabin and not seated with a seat belt fastened.

Aviation Short Investigation Bulletin - Issue 23

What happened

On 2 May 2013, a Mooney M20 aircraft, registered VH‑FRO (FRO) was inbound to Dubbo, New South Wales. The pilot was conducting a private flight and was the only person on board. The pilot reported that he broadcast on the Dubbo common traffic advisory frequency (CTAF) indicating that he was on descent and would join base for runway 05.

At about 1217 Eastern Standard Time, the pilot of a Piper PA‑31 aircraft, registered VH‑HJE (HJE) was preparing to depart Dubbo. He broadcast on the Dubbo CTAF his intention to conduct a flight under instrument flight rules from Dubbo to Lighting Ridge. The pilot and a flight nurse were on board. The pilot taxied via taxiway A, to the holding point for runway 05. At the holding point, the pilot conducted his engine run ups and pre-flight checks. 

The pilot of FRO reported that he heard the pilot of HJE’s broadcasts and when he broadcast that he was on final for runway 05, he saw HJE stationary at the holding point. 

At about 1220, the pilot of HJE had completed the engine run ups and broadcast his intention to enter and back track to runway 05. Before moving, the pilot reported that he looked down the flight path of runways 05 and 23 and did not see any aircraft. He stated that he had not heard any broadcasts from FRO.

On short final, about 200 feet above the runway, the pilot of FRO heard the broadcast from HJE and saw HJE move. At the same time, the pilot of HJE spotted an aircraft, which was previously obscured by the aircraft’s window frame, on short final for runway 05 and brought the aircraft to a stop. The pilot of FRO applied full power and commenced a go around.

This incident highlights the importance of not solely relying on monitoring the radio to achieve traffic awareness, especially around non-towered aerodromes.

 Aviation Short investigation Bulletin Issue 21

What happened

On 3 May 2013, the pilot of a Cessna 182 aircraft, registered VH‑EFY (EFY), was conducting parachute operations overhead Nagambie (ALA). The pilot of a Piper PA‑28 aircraft, registered VH‑FZW (FZW), was conducting a private ferry flight from Mangalore to Bendigo and planned to track from Mangalore to the Nagambie Township and then to Bendigo, to avoid the Restricted Area, R351, and Danger Area, D360. 

After completing the parachute drop, the pilot of EFY conducted a circling descent, to the west of Nagambie ALA. He joined the base leg of the circuit for runway 02, at about 4,500 ft, and made a broadcast on the CTAF. 

When about 6 NM to the west of the Nagambie Township, maintaining 2,500 ft, the pilot of FZW reported observing an aircraft (EFY) above, on descent, tracking from left to right. The pilot took avoiding action.

The pilot of EFY reported that, as he entered the Danger Area, descending through 2,000 ft, he sighted an aircraft (FZW) in his 12 o’clock position taking avoiding action. The pilot banked the aircraft heavily to avoid FZW and estimated the aircraft came within 50 ft of each other. 

On 8 May 2013, the pilot of a Bell 206 helicopter, registered VH‑CHA (CHA), was conducting a private flight from Mangalore to Echuca, Victoria, tracking via the Nagambie Township to avoid the Restricted Areas R351, maintaining 1,000 ft. 

After passing in the vicinity of the Nagambie Lakes area, the pilot received a call on the CTAF from the drop zone safety officer on the ground at Nagambie ALA advising that he had just flown over a parachuting landing area. At that time, five parachutists had just landed and six were still airborne. 

It is crucial that pilots are aware of the potential hazards that exist on their planned flight routes. When operating near, or within a Danger Area, they should be mindful of the activity within that area and take any appropriate precautions. 

 Aviation Short investigation Bulletin Issue 21

Safety summary

What happened

On 7 April 2013 southbound freight train 5BM7 was travelling at near track speed (115 km/h) on the main line of the Culcairn North passing loop in New South Wales. On rounding a sweeping right-hand curve the driver saw the headlight of an opposing train and also saw that the signal (CN03) ahead was at stop. He immediately made an emergency brake application to stop the train just before signal CN03 thereby averting a collision with the opposing train which was entering the southern end of the passing loop.

There were no injuries or damage as a result of this occurrence.

What the ATSB found

The ATSB investigation of available technical evidence, showed that the signalling system was operating correctly at the time of the incident and therefore the signal (DIS-CN03) preceding the signal at stop (CN03) should have been displaying a caution aspect (yellow). However, the crew of train 5BM7 had perceived signal DIS-CN03 at clear (green) and were therefore not expecting signal CN03 to be at stop (red).

As the train was not fitted with forward facing video equipment the ATSB was unable to substantiate the observations of the train crew with respect to the aspect of signal DIS-CN03.

What's been done as a result

The train operator, Aurizon, has advised that it has forward facing cameras on about 8.5 per cent of its locomotive fleet and that it is likely that this type of technology will be fitted to all locomotives purchased in the future.

The Rail Industry Safety and Standards Board (RISSB) has advised that it will encourage its membership and the wider rail industry to adopt the use of independent data validation systems, such as forward facing video on trains, to assist with coming to a better understanding of rail occurrence events, such as signal irregularities.

Safety message

The Australian Transport Safety Bureau encourages rail operators to consider the use of independent data validation systems, such as forward facing video on trains, to provide a source of information to assist in coming to an understanding of rail occurrence events, such as signal irregularities.

Safety summary

What happened

On 31 March 2013, a Cessna Aircraft Company 441 aircraft, registered VH-XBC, arrived at Coonawarra Airport, SA, following a charter flight from Adelaide, SA. The pilot reported that the initial flare and touchdown was normal, however during the landing roll, he heard a distinct ‘pop’ or ‘bang’ sound, after which the aircraft began veering to the left. Initially the pilot was able to maintain directional control and keep the aircraft on the runway, however as it slowed, it began pivoting around the left landing gear and came to rest to the left of the paved runway surface. There were no injuries to passengers or crew.

What the ATSB found

The runway excursion resulted directly from the failure of the left main landing gear trunnion, which allowed the left main wheel to displace upward and contact the wing underside – producing an asymmetric and uncontrolled braking effect. Both the ATSB and component manufacturers’ laboratory examinations attributed the trunnion failure to the development and growth of progressive fatigue cracking through the horizontal beam and central gusset section, with cracking propagating to the point where nominal landing loads produced the final overstress fracture and collapse of the assembly. Due to the extent of post-failure damage sustained by the fracture surfaces, neither laboratory examination was able to specifically identify the factors behind the initial development of the fatigue cracking.

The ATSB’s research of Australian and international air safety records did not identify any other instances of this specific mode of failure within the trunnion type, nor was the manufacturer aware of any known cracking or related problems with the trunnion in the affected areas. As such, it is likely that the event was an isolated occurrence, and consequently, the likelihood of similar occurrences in the future is low.

What's been done as a result

In response to this occurrence, the aircraft operator undertook a targeted, one-off non-destructive inspection of the trunnions from the four other aircraft in its fleet.  All were found to be defect free. Additionally, the operator’s maintenance schedule has been extended to include the eddy-current inspection of the trunnion gusset/web regions concurrently with the routine 2000-cycle periodic inspections specified by the aircraft manufacturer.

Safety message

While the failure sustained in this instance was an unusual and isolated case, it does highlight the necessity of general vigilance and attention to detail during general visual inspections, or during other examinations of structures and components. Such activity can present opportunities for the detection of emerging or unknown airworthiness issues that may not have otherwise been identified during prescribed maintenance programs.