What happened

On 23 February 2013, a Robinson R44 Raven I helicopter, registered VH-HGF, was engaged in agricultural operations in a paddock near Clarks Hill, Victoria. The pilot was the only person on board.

As the helicopter approached the paddock from the south, at 50 kt and at spray height, the pilot remembered a wire that extended halfway across the southern boundary of the paddock to a pump house. The pilot judged that it was too late to attempt to pull up over the wire and attempted to avoid the wire by flying underneath it. The vertical stabiliser contacted the wire and the tail rotor gearbox separated from the tail boom. The pilot was able to exit the helicopter with minor injuries however the helicopter was substantially damaged.

The practice within the aerial agricultural industry is to extensively pre-plan an application task that takes into account the specific hazards affecting an application. Any change from the previously planned application runs, including an unplanned change of direction has the potential to affect a pilot’s awareness of the relative position of previously known power lines and other hazards.

Aviation Short Investigation Bulletin Issue 19

What happened

On 12 February 2013, a Skywest Airlines ATR72 aircraft, registered VH-FVH (FVH), departed Sydney on a scheduled passenger service to Port Macquarie, New South Wales, under the instrument flight rules (IFR). The crew planned to enter the Port Macquarie non-directional (radio) beacon (NDB) holding pattern at 3,600 ft and then conduct an NDB approach to runway 21.

When inbound to Port Macquarie, the crew heard a taxi call from the crew of an Eastern Australia Airlines Bombardier DHC-8-315 aircraft, registered VH-TQZ (TQZ), operating an IFR scheduled passenger service from Port Macquarie to Sydney.

The crews of both FVH and TQZ discussed their respective positions and intentions and the crew of TQZ stated that they would advise FVH when they were about to take-off.

When lined up on runway 03, the crew of TQZ observed FVH on the aircraft’s traffic alert and collision avoidance system (TCAS), positioned directly overhead the airport and turning outbound in the holding pattern. The crew of TQZ broadcast a call advising FVH they were about to commence the take-off run and intended to conduct a left turn at 600 ft.

When on downwind, approaching 3,000 ft in IMC, the captain of TQZ observed an aircraft on the TCAS, above. The captain identified the aircraft as FVH and instructed the first officer to stop the climb and turn the aircraft to the right. Shortly after, the crew received a TCAS traffic advisory (TA) and then an initial resolution advisory (RA) to descend, followed shortly after by an RA to ‘adjust vertical speed’. At the same time, while also in IMC, the crew of FVH also reported receiving a TCAS TA and then a TCAS RA to climb. The captain of FVH immediately responded and climbed the aircraft.  Both flights continued without further incident.

It is essential that pilots monitor their surroundings and have an awareness of traffic disposition. It is important to know where the traffic is and where it will be in relation to you, so that potential issues can be identified and actioned, before they escalate. This is particularly important when operating at non-towered aerodromes, where aircraft separation is pilot responsibility.

Aviation Short Investigation Bulletin - Issue 23

What happened

On 23 February 2013, a Cessna 210M, registered VH‑PBV (PBV), was returning to Broome Airport, Western Australia, from Lombadina with a pilot and four passengers on board. The weather on the day was windy and wet with thunderstorms and rain moving through the area, requiring the pilot of PBV to alter the aircraft’s flight plan and flight path.

The aircraft tracked to a position north of the airport, in order to land on runway 10. The pilot reported selecting the landing gear down as part of his landing checks, and a passenger later reported that he heard what he believed to be the landing gear being lowered.

The air traffic controller (controller) cleared PBV to land when the pilot reported turning base and advised the pilot of an 18-knot crosswind. Just prior to PBV crossing the runway threshold, the controller sighted the aircraft on short final and conducted a final scan of the runway to ensure it was still clear

Shortly before landing the pilot completed his final checks, but did not look out the window to visually check that the landing gear was down. However, he did observe a green light, indicating that the landing gear was down and locked. To compensate for the crosswind, the pilot operated the aircraft at a slightly higher throttle setting, until flaring to land. PBV then landed on the runway with the landing gear retracted and skidded about 300 to 350 m down the runway on the underbelly. The controller activated the airfield emergency response.

The pilot later reported that the landing gear warning horn had not activated.

Following the accident, an assessment conducted by an insurance assessor found that the pilot had failed to extend the landing gear prior to landing. The assessor noted that the micro switch that activated the landing gear warning horn was set for a throttle setting lower than that used by the pilot during the landing.

Bad weather and changed plans can distract attention away from a pilot’s primary function – to safely fly the aircraft. However, the failure of the gear warning horn to activate removed a defence against landing with the landing gear retracted.

Aviation Short Investigation Bulletin Issue 20

Safety summary

What happened

At about 1320 on 12 February 2013, the 1250 Swan Hill to Melbourne passenger train collided with the rear corner of a semi-trailer on the B. McCann Road level crossing near Lake Charm, in northern Victoria.  The semi-trailer was travelling towards the Murray Valley Highway having taken on a load of gypsum at a nearby mine.

As a result of the collision there were minor injuries to one train passenger and to the drivers of the train and truck.  The truck’s trailer was destroyed and there was minor damage to the front of the locomotive.

What the ATSB found

The ATSB found that the truck driver’s view of the track was restricted due to the acute road-to-rail interface angle and the resulting limited opportunity to observe the train through the truck cabin’s passenger-side window.  When the truck driver stopped to look for trains, his view along the track to the north was probably no more than 220 m and insufficient to observe the approaching train.

An embankment in the crossing’s northwest quadrant also affected sighting and vegetation either side of the road approach meant that the installed give-way protection was inconsistent with the available sighting distances. 

In the three years prior to the incident, the risk profile of the crossing had changed significantly due to a large increase in truck movements associated with a greater demand for gypsum from the mine.  The safety interface management of the crossing by V/Line and the Gannawarra Shire did not identify this changing risk profile and did not involve consultation with a key stakeholder, the mine owner.

What's been done as a result

The operator of the gypsum mine has undertaken to re-align the road approaches to the crossing to address the acute road-to-rail interface angle, and to reduce the incline of the road on the approaches.

Safety message

This incident highlights the need for rail and road authorities to be proactive in addressing identified sighting deficiencies at level crossings and to monitor the risk profile of crossings.

The occurrence also highlights the need to involve all key stakeholders in road-rail interface safety management processes.

What happened

At about 1730 Western Standard Time on 25 February 2013, a Cessna 337F (337), registered VH‑JUP (JUP), JUP departed Onslow Western Australia for a 30-minute charter flight to Exmouth with three passengers. The front seat passenger and the pilot conversed for most of the flight.

On about 5 NM final for runway 20, the pilot of JUP commenced pre-landing actions by extending the first stage of flap. The pilot later reported that this was where she normally lowered the landing gear but could not recall why this step was missed.

About 1 NM from landing, the pilot conducted the final pre-landing checks. Again, the pilot could not recall why she had not checked that the undercarriage was down as part of the final pre-landing checks.

At 1800, the pilot commenced the flare about 3 ft above the runway and as the aircraft touched down on the bitumen, the pilot realised that the undercarriage had not been selected down.

The passengers and pilot exited the aircraft without injury. The fiberglass cargo pod fitted to the aircraft was damaged. The aircraft hull was undamaged; however, the rear propeller contacted the ground.

As a result of this occurrence, the pilot advised that from at least 5 NM final, she will ask the passengers not to speak to her, except to alert her to the presence of animals on the runway.

The sterile cockpit rule, where crew do not preform non-essential activities during critical phases of flight, including taxiing, take-off and landing, assists in ensuring that critical information is not missed or misinterpreted.

By explaining the sterile cockpit rule in their pre-flight brief, pilots can give passengers an awareness of the importance of minimising discussions, questions, and conversation during critical phases of flight.

Aviation Short Investigation Bulletin - Issue 18

What happened

At 1453 Eastern Daylight-saving Time on 16 February 2013, a Beech B200C, registered VH-VAE (VAE), was about 15 NM from Wangaratta on descent when the pilot observed a white glider with red markings approaching at the same level. The glider passed the left side of the aircraft with separation reducing to about 70 m at the same altitude. The pilot of VAE did not have an opportunity to take evasive action, nor did he observe the glider take evasive action. The pilot of VAE did not hear any broadcasts from the glider pilot on the area very high frequency (VHF).

Attempts to identify the glider were unsuccessful.

Early in 2012 and following a submission from the operator of VAE, the Civil Aviation Safety Authority (CASA) commenced a safety review into the level of risk from gliders in aircraft proximity (airprox) events in uncontrolled airspace. More recently, in response to discussions at a Regional Aviation Safety Forum and following advice from the ATSB of an increase in the number of airprox events across all categories of operations, CASA has established an Industry Airprox Working group to examine ways to reduce airprox events and enhance safety.

When operating outside controlled airspace, it is the pilot’s responsibility to maintain separation with other aircraft. For this, it is important that pilots utilise both alerted and un-alerted see-and-avoid principles. Un-alerted see-and-avoid relies entirely on the ability of the pilot to sight other aircraft. A traffic search in the absence of traffic information is less likely to be successful than a search where traffic information has been provided.

Aviation Short Investigation Bulletin - Issue 18

What happened

On 19 February 2013, at about 1000 Eastern Daylight-saving Time, an Ayres Thrush S2R-T34 aircraft, registered VH-HAH (HAH), struck power lines while conducting aerial agricultural spraying operations, about 7 km south-east of Condobolin aerodrome, New South Wales. The pilot was the only person on board. The aircraft sustained serious damage, while the pilot was uninjured.

The pilot was carrying out the final spray run (clean-up run), before returning to the airstrip. The pilot was flying from west to east, parallel to the main power line, which was located beside the field, outside of the area being sprayed. Another smaller power line with three wires ran diagonally across the field from the main power line. Once the pilot had run out of product, he pulled up to gain altitude, when he struck the smaller power line that ran diagonally across the field. Two of the wires were cut by the aircraft’s wire protection system and the third wrapped around the propeller hub arresting the aircraft and pulling it around in a half circle where it came to rest on the ground.

As a result of this occurrence, the electricity distribution company will install a marking system on the power line.

The practice within the aerial agricultural industry is to extensively pre-plan an application task that takes into account the specific hazards affecting an application. Any change from the previously planned application runs, including an unplanned change of direction has the potential to affect a pilot’s awareness of the relative position of previously known power lines and other hazards. 

For this reason, the Aerial Agricultural Association of Australia recommends that an additional hazard check should be performed from a safe height prior to every change of direction or ‘clean up run’.  The extra safety check for wires is important, as the obstructions are new from the new direction of flight.

For further reading of suggested approaches to risk management for agricultural pilots see the Aerial Application Pilots Manual, available from the Aerial Agricultural Association of Australia (AAAA) at www.aerialag.com.au/Home.aspx.

Aviation Short Investigation Bulletin - Issue 18

Safety summary

What happened

On 17 February 2013, ore train 9614S was departing Spencer Junction en route to Whyalla, South Australia. While the train was traversing 38A points at the northern end of Spencer Junction, the driver noticed a change in the train’s dynamic behaviour and immediately reduced the throttle. The train then quickly came to a stop due to the automatic application of the electronically controlled pneumatic train brake. Upon inspection of the train, the second driver discovered five ore wagons were derailed.

What the ATSB found

The ATSB’s investigation found that the leading edge of the right hand 38A point blade was worn and damaged. The blade damage had created a ramping angle, allowing the lead wheel of the ore wagon to “ride up” the blade and derail. The derailed wheels then impacted and damaged the concrete sleepers, which ultimately failed to maintain track gauge and allowed further wagons to derail. During the derailment sequence, a rupture to the train’s electronic control pneumatic pipe initiated the application of the train brake.

The ATSB found that the Australian Rail Track Corporation’s inspection and maintenance regime, following two similar derailments at the same location, had not been sufficient to identify and remediate the deteriorating condition of the 38A points, and ultimately contributed to the derailment.

What's been done as a result

In the months leading up to this derailment, Genesee Wyoming Australia (GWA) and the Australian Rail Track Corporation (ARTC) had agreed to a rail upgrade programme which included a new turnout incorporating 38A points, using 60 kg rail laid on concrete bearers. At the time of this derailment, a new turnout had been prepared, but had not yet been installed. Upgrade works have since been completed.

Following installation of the upgraded infrastructure, more frequent monitoring for wear rates of the point blade(s) was undertaken. After several months of condition monitoring it became evident that track performance and wear rates could be managed as specified in the Code of Practice and the normal inspection schedule was reinstated.

Safety message

Track infrastructure owners and maintainers should consider the associated increase in wear on track infrastructure when there is an increase in the volume of rail vehicles being operated. The high dynamic forces that may be exerted from rail vehicles, specifically those that bear a heavy axle load, will accelerate the rate of wear on track infrastructure.

In these circumstances, increased inspection and maintenance of track components should be considered until it can be established that resulting wear rates can be adequately managed in accordance with the established standards.

What happened

On 17 February 2013, an Enstrom 480B helicopter, registered VH-VDC (VDC), was engaged in agricultural spraying operations, near Trida, Victoria. On the final load of chemical to be applied to the paddock the Global Positioning System (GPS) lost reception during the application run. The pilot immediately aborted the run and climbed to about 400 ft above ground level and attempted to resolve the issue with the GPS. 

Once the GPS regained reception, the pilot commenced a left turn at about 50 knots indicated airspeed to return to the paddock and recommence the application run. The pilot then heard a loud bang and felt a shudder through the airframe. 

The pilot performed a run on landing in the nearest clearing, he had difficulty in maintaining yaw control, because the tail rotor control cables had lost tension. The pilot was able to exit the helicopter without injury, however, the helicopter was substantially damaged.  

The ATSB was advised by the owner of the wire, that wire struck was marked with five marker discs. However, the pilot of VDC advised that the wire was unmarked at the time of the wirestrike. The ATSB was unable to independently confirm that the maker discs were still in place at the time of the wirestrike.

As a result of the occurrence the owner of the wire has advised the ATSB that the broken cable was replaced to restore electricity supply as soon as possible and was replaced without new markers installed. However, arrangements are being made to install markers on the line. 

Wirestrikes pose an on-going problem to aerial agricultural operations. Despite the advantages of marking a wire, not all wires are marked, and it is simply not feasible to mark all wires. It is important that pilots and operators raise any concerns they may have about the visibility of a wire with the wire owner. Electricity distribution and transmission companies may install aerial markers on wires upon request. Landowners can request to have wires on their property marked and pilots who have a need to fly low-level near powerlines can also request wires to be fitted with markers.

Aviation Short Investigation Bulletin Issue 20

Safety summary

What happened

On the afternoon of 8 February 2013, the 42 m Cayman Islands registered motor yacht Calliope departed from the Sydney Superyacht Marina in Rozelle Bay for a cruise around the harbour.

As Calliope transited the Glebe Island Bridge, it was off course and veered towards the bridge structure. To minimise any damage to the vessel, the crew attempted to walk a fender between the yacht’s hull and any possible points of contact. During this process, a crew member, leaning over the side of the yacht positioning the fender, was caught between the yacht and one of the bridge mounted fenders. The crew member was pulled over the yacht’s side and into the water.

The crew member was retrieved from the water shortly afterwards but died as a result of the injuries he had sustained.

What the ATSB found

The ATSB found that a passage plan for the voyage had not been completed and, therefore, the risks associated with the voyage were not appropriately assessed or communicated to the crew. It was also determined that the yacht’s master could not reference any navigational aids from his conning position in front of the navigational bridge. Hence, he was not in a position to properly monitor the yacht’s progress.

The ATSB also concluded that while Calliope was in voluntary compliance with elements of the Large Commercial Yacht Code (a United Kingdom instrument which had been adopted by the Cayman Islands), the yacht did not have to comply with these requirements because it was deemed to be a pleasure yacht. Similarly, the yacht did not have to carry a pilot while operating in Sydney Harbour because it was considered to be a recreational craft.

What's been done as a result

Calliope’s management company has advised that the ship’s safety management system procedures have been updated to require the completion of a passage plan for all voyages. Procedures for transiting bridge openings will be also be issued. A specialist consultant will also be engaged to conduct on board audits of the safety management system.

The Cayman Islands Shipping Registry has advised that the effectiveness of the Large Commercial Yacht Code in meeting the fundamental requirements of a documented safety management system will be raised with the United Kingdom as the authors, publishers and custodians of the Code.

The harbour master for the Port of Sydney has highlighted the details of this accident as part of a review of the NSW Marine Safety Act.

Safety message

Flag States and port administrations should consider the risks associated with operating a vessel when determining regulatory compliance requirements, rather than making such determinations based on the vessel’s mode (commercial or private) of operation.