What happened

On 5 April 2013, a Mitsubishi MU‑2B aircraft, registered N64MD, departed Honiara, Solomon Islands with two pilots on board. The purpose of the flight was to ferry the aircraft from Honiara to Essendon, Victoria, with an intermediate stop at Townsville, Queensland.

Shortly after take-off at Townsville, both pilots received a considerable amount of static in their headsets. Townsville Tower air traffic control (ATC) then instructed the crew to transfer to the Townsville Approach frequency. The pilot in command (PIC) read back the instruction; however, ATC advised that he was transmitting carrier wave only (no voice communications were heard).

About 5 minutes after the aircraft departed, Townsville ATC offered the crew the option of returning to Townsville. The PIC reported that they could hear the transmissions made by Townsville ATC but were unable to return to as the fuel quantity in each wing tip tank was in excess of the maximum landing limitation and the aircraft was carrying additional fuel in the ferry tank. The PIC was unable to advise Townsville ATC of this as the aircraft’s very high frequency (VHF) radios were now inoperable. Consequently, the PIC elected to continue the flight as per the submitted flight plan.

The PIC attempted to resolve the radio problem, but without success. Townsville ATC, Brisbane Centre ATC and Melbourne Centre ATC also continued attempts to establish communications with the crew.

When about 230 NM north of Essendon, Victoria communications with ATC were re-established. The crew were not in normal communications with ATC for about 3 hours and 35 minutes.

An examination of the radio determined that water leakage from a small access door had corroded two main radio isolator breakers/switches, which subsequently resulted in the radio failure.

It is important that ATC is made aware of any problems as soon as possible. This provides ATC with sufficient time to manage a situation, rather than having to react when an issue has developed into a major problem. In the event of a communications failure, it is important that pilots follow the appropriate procedure, and if communications cannot be re-established, consider utilising alternative methods such as mobile telephones.

Aviation Short investigation Bulletin Issue 21

Safety summary

What happened

On the morning of 1 April 2013, the pilot of a Cessna 210 was one of a group intending to fly various light aircraft under the visual flight rules from Bullo River homestead to Emkaytee, a private airstrip near Darwin, Northern Territory. Low cloud delayed all of the departures from Bullo River and the aviation forecasts and weather radar images accessed by the group via the internet indicated isolated thunderstorms, low cloud, and rain in the intended area of operation. Some improvement was forecast after 1130 local time.

By lunchtime the weather had lifted at Bullo River and the pilots observed that the weather radar images were indicating an improvement en route. All of the pilots departed between 1300 and 1500, some electing to track via the coast and the rest tracking as required more or less on the direct track. The pilot of the Cessna 210 departed at about 1415 with three passengers to track via the coast.

The pilots in the group were communicating by radio on a discrete frequency and the Cessna 210 pilot was heard to report at about 1510 that he was approaching Cape Ford and the weather ahead was gloomy, or words to that effect. That was the last radio transmission from the pilot.

When the aircraft did not arrive at Emkaytee a search was initiated. Bodies and a small amount of wreckage were found on the southern shoreline of Anson Bay, about 10 km south-east of Cape Ford. There were no survivors.

What the ATSB found

During the flight from Bullo River to Emkaytee, the pilot continued to track along the planned coastal route towards a thunderstorm, probably encountering conditions such as low cloud, reduced visibility and turbulence, and as a result of one or more of those factors the aircraft descended and collided with water.

Safety message

Tracking visually via a coastal route in marginal weather conditions can be advantageous in terms of ease of navigation and absence of elevated terrain, but can also increase the risk of spatial disorientation in the context of drastically reduced visibility exacerbated by a lack of surface definition when over water.

In situations where significant weather is forecast or otherwise expected, pilots are encouraged to access the Bureau of Meteorology detailed weather briefings (via the phone number on the area forecast) to assist with understanding the conditions at the time as well as the immediate trend.

What happened

On 29 March 2013, at about 1000 Eastern Daylight-saving Time, a Piper PA-30 aircraft, registered VH-HPR (HPR), departed Bankstown Airport for Griffith Airport on a private flight. On board were the pilot and two passengers.

Following the take-off, the pilot selected the landing gear up. Passing through 400 ft, the tower advised that the landing gear was still down. The pilot responded that he would continue with the departure and hold at 2,000 ft to troubleshoot the problem. 

At 2,000 ft, the pilot engaged the autopilot and confirmed that the gear was selected up, but the gear down and locked light remained illuminated. The pilot checked the circuit breakers and could not see any that had tripped. The pilot then cycled the gear a number of times, however, the gear did not retract and the gear down and locked light remained illuminated. 

The pilot elected to return to Bankstown and was cleared for a straight in approach. On short finals, the tower advised HPR to ‘check wheels’, the pilot confirmed that the green down and locked light was still illuminated and that the gear selector was in the down position.

HPR touched down on the main wheels followed by the nose wheel, which collapsed when it contacted the ground, followed by the left main wheel and right main wheel. The pilot and passengers exited the aircraft without injury and the aircraft sustained substantial damage. 

Inspection of the aircraft by a licenced maintenance organisation was arranged by the insurer. The landing gear mechanism was visually inspected, and the worm drive was almost to the full retraction position, indicating the gear was retracted electrically.

The reason for this electrical retraction despite the gear selector being in the down position was not determined.

Aviation Short Investigation Bulletin Issue 20

On 9 September 2011, a Cessna 208B ‘Grand Caravan’ aircraft, registered PK-VVE, collided with terrain and was destroyed on a cargo flight from Wamena to Kenyam in the Pasema District of West Papua, Republic of Indonesia. The pilot and copilot, the only persons on board were fatally injured. 

As the accident took place in Indonesia, the Indonesian National Transportation Safety Committee (NTSC) is responsible for investigating this occurrence, consistent with Indonesia’s obligations as State of Occurrence under Annex 13 to the Convention on International Civil Aviation Aircraft Accident and Incident Investigation (Annex 13).

The pilot of the aircraft was an Australian citizen and, in accordance with the ‘special interest’ provisions of paragraph 5.27 of Annex 13, the Australian Transport Safety Bureau (ATSB) appointed an expert to the NTSC investigation. This allowed the ATSB to receive relevant factual information that was approved by the NTSC for public release and a copy of the NTSC’s final investigation report. 

The NTSC subsequently requested ATSB support in the analysis of the available recorded data from the flight and with finalising the draft investigation report. To facilitate this support, the ATSB appointed an accredited representative in accordance with paragraph 5.23 of Annex 13 and, in order to protect the information supplied by the NTSC, commenced an external investigation under the Transport Safety Investigation Act 2003. The ATSB completed its work as accredited representative in March 2013.

The National Transport Safety Committee of Indonesia is responsible for releasing the investigation report.

National Transportation Safety Committee 
Ministry Of Transportation Republic Of Indonesia 
Transportation Building 3^rd Floor
Jalan Medan Merdeka Timur No. 5
Jakarta Pusat 10110
Indonesia

Phone  :  +62 21 384 7601
Email    :  knkt@dephub.go.id

Website: http://knkt.dephub.go.id/knkt/ntsc_home/ntsc.htm

______________

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

What happened

On 27 March 2013, a Raytheon B200, registered VH-ZCO, was being operated on an aero-medical flight from Darwin to Port Keats, Northern Territory. On board the aircraft were the pilot and two flight nurses.

In preparation for landing at Port Keats the pilot selected the gear down. The left and right main landing gear down indication lights did not illuminate, while the nose landing gear down indication light (green) illuminated. The pilot elected to return to Darwin and advised air traffic control.

The pilot reported that on landing, the right main landing gear wheel touched down first and when the left landing gear wheel touched down the pilot felt the left side of the aircraft start to sink. The pilot shut down the left engine and feathered the left propeller, then shut down the right engine and feathered the right propeller. The left wing then contacted the runway, and the aircraft skidded to a stop, at about 1551. The pilot and flight nurses evacuated the aircraft via the overwing exit. The aircraft sustained minor damage, while the pilot and flight nurses were not injured.

The operator determined that during the last overhaul of the left main landing gear, a washer was not installed, which resulted in the landing gear contacting the aircraft structure preventing the landing gear from locking in the down and locked position.

The Civil Aviation Safety Authority (CASA) conducted an investigation into the accident and found that there was no conclusive way to determine when the washer installation error occurred. CASA also established that this error was an isolated event.

The manufacturer was informed of the accident and determined that the missing washer would not have led to the failure of the landing gear to lock down. They believed that it was more likely that the drag brace was not installed or rigged correctly when installed on ZCO or that another landing gear assembly or maintenance error occurred, causing the circuit breaker to trip, resulting in the accident.

As a result of this occurrence, the aircraft operator has advised the ATSB that they are taking the following safety actions:

• A medical bag that was located near the overwing emergency exit was relocated.
• All B200 aircraft were inspected. The main landing gear on one aircraft was found not to be correctly assembled and this was rectified before further flight.
• A safety bulletin was issued to all staff to inform them of the accident.
• The training and checking department were to review the part within the proficiency check about this type of landing and ensure it is reiterated at the next base check.

Aviation Short investigation Bulletin Issue 22

In March 2013, the Australian Transport Safety Bureau (ATSB) received a request from the Civil Aviation Safety Authority (CASA) to assist with the non-destructive testing (NDT) and metallurgical examination of a wing spar bolt from a Beechcraft Model 35 (Bonanza) aircraft. The bolt had been removed for inspection as part of compliance activities with airworthiness directive AD/BEECH 35/67 and was reported as showing crack indications during preliminary NDT.

The ATSB was requested to examine the bolt with a view to confirming (or otherwise) the suspected cracking, and to provide commentary as to the likely contributing factors should the cracking be confirmed. To facilitate the work and provide for the issuing of a public report on conclusion of activities, the ATSB initiated an External Investigation under the provisions of the Transport Safety Investigation Act 2003.

Subsequently, the ATSB's non-destructive inspection of the bolt using both Magnetic Particle (MPI) and Fluorescent Dye Penetrant (DPI) techniques failed to reveal any indications of the reported cracking. To verify the NDT findings, the ATSB offered to conduct destructive metallurgical sectioning and metallographic examination, and in preparation for this, the wing spar bolt was returned to CASA and subsequently to the owner for re-examination to confirm the original findings.

In September 2013, following no further requests or confirmation of follow-up work, the ATSB discontinued the investigation in accordance with the provisions of section 21 (2) of the Transport Safety Investigation Act 2003.

What happened

On the evening of 22 February 2013, the crew of a Regional Express Saab 340B aircraft, registered VH-ZRL, were conducting a scheduled passenger service from Sydney to Taree, New South Wales.

During the approach to Taree, the crew monitored the weather conditions, with the crosswind initially observed as 50 kt when at about 6,000 ft, although it decreased as the aircraft descended.

At about 700 800 ft above ground level (AGL), the crew became visual with the runway. The crew assessed the approach and determined that it was suitable for landing. At that time, the crew reported that the wind was fluctuating and light rain was experienced.

At about 1904, the aircraft touched down. Immediately after, the crew reported that the aircraft was subjected to a wind gust, which caused the left wing to lift slightly and the aircraft to weathercock to the left, into wind. Reverse thrust had been selected after touchdown.

The aircraft veered left toward the runway edge and the captain assumed control of the aircraft. He applied right rudder, but the aircraft did not respond. As the aircraft’s airspeed decreased, the captain also applied right brake, with no effect. He then simultaneously commenced nose wheel steering using the tiller. As the captain believed that the nose wheel steering was ineffective, he elected to apply asymmetric thrust by reducing the amount of reverse thrust on the left engine and increasing reverse thrust on the right engine. The aircraft commenced moving to the right. The aircraft slowed and was taxied to the parking area.

After shutdown, using a torch, the FO then conducted a post flight inspection, with nil damage found.

The next day, the aircraft returned to Sydney, at which time maintenance personnel conducted an inspection of the aircraft and observed damage to the left propeller blades. All four blades had sustained stone damage predominantly on the back (reverse) of the blades.

Weather can behave in an unpredictable manner, particularly when unfavourable conditions exist. While this incident highlights the adverse effects weather can have on aircraft operations, it also emphasises the impact of complacency and interruptions/distractions.

Aviation Short Investigations Bulletin - Issue 31

What happened

On 22 March 2013, circuits were being conducted to both runway 31 left (31L) and 31 right (31R) at Moorabbin Airport, Victoria. The aircraft in the two circuits were operating on different frequencies and being controlled by different air traffic controllers under the visual flight rules (VFR).

At about 1625 Eastern Daylight-saving Time, a Cessna 172S aircraft, registered VH‑EWX (EWX), entered the Moorabbin control zone from the south-east and was instructed to track for base as number 1 in the landing sequence for runway 31R. Another aircraft, a Piper PA-44 (Warrior) aircraft, had been instructed to follow EWX as number 2 and a Piper PA‑28 aircraft, registered VH‑TXH (TXH), was number 3. A number of aircraft were operating to the west of Moorabbin in the circuit for runway 31L.

As EWX approached base, at about 1626, the pilot became aware of TXH in his 2 o’clock position, tracking contrary to the runway 31R circuit pattern. TXH was observed to pass under the nose of EWX, about 100 to 150 m in front and about 50 ft below. To avoid the other aircraft and to keep it in sight, the pilot of EWX turned to track behind and subsequently follow TXH. As the pilot executed this manoeuvre, Moorabbin Tower broadcast a safety alert.

TXH crossed the runway centreline for both runway 31R and 31L before joining final for runway 31R from the west. Both aircraft subsequently landed without further incident.

While pilots conduct a pre-flight inspection of their aircraft to determine airworthiness, this incident highlights the importance of pilots also assessing their own status. Personal minimums should be considered prior to flight, as well as the impact of stressors such as being unfamiliar with operations from a particular runway or the need to change aircraft due to an unserviceability.

Aviation Short investigation Bulletin Issue 22

What happened

The pilot commenced the landing flare at about 10 ft above the runway, during which time a bird struck the left wing. The aircraft yawed slightly left and the left wing dropped; the pilot applied opposite aileron to maintain wings level. The aircraft then drifted to the right of the runway into an adjacent paddock and the left wing struck a bull. The aircraft landed in the paddock. The aircraft sustained substantial damage from the bull strike and one passenger received minor injuries. The bull was put down as a result of the injuries sustained from the strike.

While the risk of wildlife strikes represents an ongoing challenge, and will always be present, this accident highlights the need to be aware of the hazards that may potentially exist within the vicinity of the runway and the benefits of overflying to alarm wildlife.

Aviation Short Investigation Bulletin - Issue 19

Safety summary

What happened

At about 0518 Eastern Standard Time on 25 March 2013, a Cessna T210N aircraft, registered VH‑MEQ, took off in dark night conditions from runway 36 at Roma Airport on a flight to Cloncurry, Queensland. Following the activation of the aircraft’s emergency locator transmitter, a search was commenced for the aircraft by the Australian Maritime Safety Authority. It was subsequently located 2 km to the north‑west of the airport, having collided with terrain while heading in a south-westerly direction. The aircraft was destroyed, and the pilot and passenger were fatally injured.

What the ATSB found

The ATSB found that the departure was conducted in dark night conditions, despite the pilot not holding a night visual flight rules rating and probably not having the proficiency to control the aircraft solely by reference to the flight instruments. During the climb after take-off, the pilot probably became spatially disorientated from a lack of external visual cues, leading to a loss of control and impact with terrain.

No mechanical defect was identified with the aircraft or its systems that may have contributed to the accident.

Safety message

This accident reinforces the need for day visual flight rules pilots to consider the minimum visual conditions for flight, including the relevant weather information and usable daylight. In this case, if the pilot had delayed the departure by 30 minutes, the flight would most likely have progressed safely in daylight conditions.

There are numerous airports in Australia, including Roma, that have an abundance of ground lighting in one take-off direction but not another. This accident highlights the potential benefits of night visual flight rules and instrument-rated pilots considering the location of ground lighting when planning night operations.

Finally, the benefit of crash-activated emergency locator transmitters that include global positioning system-based location information, thereby providing for a timely emergency response in the event of an accident, is emphasised.