What happened

On 30 December 2012, a Cessna 210 aircraft registered VH-DQI (DQI) was returning to Broome from Cape Leveque WA. On board were the pilot and five passengers. The aircraft was part of a two aircraft scenic tour of the area.

Early in the take-off run, the aircraft veered to the left, and the pilot applied right rudder. With the aircraft about 1 metre left of the runway centreline he continued the take-off. At about 45 knots the aircraft again veered to the left. The pilot attempted to re-align the aircraft with full right rudder, but DQI did not respond. As he retarded the throttle and applied the brakes, the aircraft’s left wing clipped trees along the edge of the airstrip and DQI swung almost 90 degrees, striking the right wing on the ground.  One passenger sustained a minor injury, and the aircraft was substantially damaged.

The Chief Pilot reported extensive washout on the edge of the airstrip had contributed to the accident. He also used the occurrence as an educational opportunity for all staff pilots.

Aviation Short Investigation Bulletin - Issue 16

What happened

On 15 January 2013, at about 1500 Coordinated Universal Time (UTC), a Cessna Citation 750, registered VH-RCA departed Faleolo International Airport, Samoa for Sydney Airport, New South Wales, with two flight crew and five passengers on board. About 1 hour 35 minutes into the flight the crew received a WSHLD HEAT INOP L (windshield heat inoperative left) message on the engine-indicating and crew-alert system (EICAS) and approximately 2 minutes later the windshield outer ply shattered with a loud bang. An immediate descent was commenced along with a turn towards Nadi International Airport, Fiji. The flight continued to Nadi without further incident and there were no injuries to passengers or crew.

The manufacturer reported that they had experienced two reliability issues with the windshield part number installed on the aircraft (9914380-11/-12). It was likely that the electrically heated windshield had been affected by moisture ingress resulting in a degradation of the electrical connection between the bus bar and the heating film. Changes to the windshield to address the issue were incorporated into part number 9914380-13/-14. There have been no reported cases of either of the failure modes in the -13/-14 windshields.

While the failure of the windshield involved the outer pane only, and did not result in a depressurisation, the precautions taken by the flight crew to descend to a lower altitude and diversion to the alternate airport highlighted the importance of good flight planning.

Aviation Short Investigation Bulletin – Issue 17

What happened

On 7 January 2013 at 0900 Eastern Daylight-saving Time a Piper PA28, registered VH-JXR, departed Mangalore Airport, Victoria on a navigation training exercise. The student pilot was the only person on board. 

An instructor on the ground watched the aircraft depart and observed an object trailing behind the aircraft following the take-off. During a low-level pass, the right main wheel and inner cylinder of the oleo assembly were observed to have detached from the upper cylinder and to be hanging off the brake line. After a second low level pass, it was observed that the wheel had completely detached.

The instructor advised the student to hold over the airfield to burn off fuel and allow time for a plan to be formulated. After several hours and with emergency services in attendance the student was instructed to make a normal approach to runway 36. The aircraft touched down on the runway and slid off to the side coming to rest on the grass. The student was uninjured; however, the aircraft was substantially damaged.     

The examination of the right landing gear assembly revealed that the lower torque link attachment bolt had fractured allowing the inner cylinder to become detached from the torque link and to fall from the outer cylinder when the aircraft became airborne. The examination indicated that the failure of the bolt was due to single-point bending fatigue due to asymmetrical loading i.e. bending from one side.

Since this incident, the aircraft operator has undertaken to replace all torque link attachment bolts during the next scheduled maintenance on any Piper PA-28 aircraft they operate. The operator also advised that they will be treating all landings where a sideways load may have occurred with caution.

Aviation Short Investigation Bulletin Issue 20

What happened

On 3 January 2013, the student pilot of a Robinson R44 (R44) Raven 1 helicopter, registered VH-RYO (RYO), was preparing for a training flight at Moorabbin, Victoria.

During the takeoff, the student slowly raised the collective and applied some left cyclic and left yaw control pedal, the helicopter became light on the skids, and started to slide and yaw to the left. The left skid then caught on the ground twice. The student became tense and inadvertently raised the collective instead of lowering it to reject the takeoff. He reported that his subsequent movements of the controls were erratic. The helicopter pitched upwards and the tail boom contacted the ground. The helicopter rolled and came to rest on its right side. The student received minor injuries and the helicopter sustained serious damage.

Aircraft fuels are a primary hazard in a post-accident aircraft fire. If ignited they pose danger to survivors, rescue personnel, fire services personnel, etc. This accident highlights the importance of considering all the potential hazards on an accident site before entering, and if there is any doubt, remain clear.

Aviation Short Investigation Bulletin – Issue 17

On 25 December 2012, a Fokker 100 aircraft, registered XY-AGC, collided with terrain on approach to Heho Airport, Myanmar, fatally injuring one of the aircraft’s occupants and a motorist on the ground.

The Myanmar Accident Investigation Bureau (MAIB) is responsible for investigating this occurrence. As part of its investigation, the MAIB requested assistance from the Australian Transport Safety Bureau (ATSB) in the recovery and download of data from the aircraft’s Flight Data Recorder (FDR) and Cockpit Voice Recorder (CVR) units. In accordance with clause 5.23 of Annex 13 to the Convention on International Civil Aviation (ICAO Annex 13), the ATSB appointed an accredited representative to assist the MAIB and initiated an investigation under the Australian Transport Safety Investigation Act 2003.

Following receipt of the CVR and FDR units on 21 January 2013, both units were successfully downloaded in accordance with the relevant manufacturer’s instructions. The download and data recovery operations were overseen by representatives of the MAIB and an Accredited Representative from the Dutch Safety Board (DSB). During preparations for the download process, ATSB specialists found that the crash survivable memory units (CSMU’s) from the both recorders had suffered damage from fire exposure. The CSMU is the module which carries the solid state chips that contain the recorded information.  The CVR CSMU was dismantled and the data recovered using data retrieval techniques appropriate for an accident-damaged flight recorder. However, the FDR CSMU had sustained a significantly greater degree of thermal damage and required specialised data recovery techniques involving recovery and downloading of individual chips. The data recovered from the discrete chips was later compiled into a single coherent data file using a specialised utility provided by the recorder manufacturer.

The downloaded audio and flight data was examined and confirmed as containing detail from the accident flight. The recovered information, together with a selection of graphical and tabular presentations of the flight data was provided to MAIB representatives on 25 January 2013.

Fire-damaged flight data recorder as-received

Thermally-damaged flight data recorder crash-survivable memory unit

The MAIB investigation has now been finalised and in accordance with the provisions of ICAO Annex 13, a copy of the final investigation report was provided to the ATSB on 28 January 2014.

A copy of the final report may be requested through the contact details below:

Myanmar Accident Investigation Bureau
First Floor, DCA HQ Building (B)
Yangon 11021, Myanmar
Tel: 951 533162
Fax: 951 533016
Email: ddmaib@dca.gov.mm

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

On 15 November 2012, an amateur-built SeaRey amphibious aircraft, registered VH-RRZ, was being operated on a private flight with only the pilot on-board. When the aircraft failed to arrive at its destination, search and rescue authorities were notified, and the aircraft was subsequently located on 16 November, having collided with terrain approximately 76 nautical miles north of Weipa, Qld. The aircraft was destroyed by impact forces and the pilot had sustained fatal injuries.

The QLD Police Service (Northern Coronial Office) is investigating this occurrence. Following examination of the aircraft wreckage, QPS officers requested assistance from the Australian Transport Safety Bureau (ATSB) in the recovery of data from a GPS unit found at the accident site. To protect the information supplied by the QLD Police Service and any data recovered from the examined device, the ATSB initiated an external investigation under the provisions of the Transport Safety Investigation Act 2003.

The examination found that the GPS memory chip which contains the flight data was damaged and the data was therefore not able to be recovered. The GPS was returned to the QLD police.

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

On 25 December 2012, a Bombardier DHC-8-202 aircraft, registered as P2-PXI, sustained an engine failure during approach to Pt. Moresby Airport, Papua New Guinea (PNG). The aircraft continued the approach and landed safely, with no injuries reported.

As the incident occurred in PNG, the PNG Accident Investigation Commission (AIC) was responsible for investigating this occurrence. To assist its investigation, the AIC requested assistance from the Australian Transport Safety Bureau (ATSB) in the download of data from the aircraft’s Flight Data Recorder (FDR) and Cockpit Voice Recorder (CVR).

To facilitate the work, and in accordance with clause 5.23 of Annex 13 to the Convention on International Civil Aviation, the ATSB appointed an accredited representative to assist the PNG AIC and initiated an external aviation safety investigation under the Australian Transport Safety Investigation Act 2003.

Following receipt of the CVR and FDR units on 14 January 2013, both units were successfully downloaded in accordance with the relevant manufacturer’s instructions. The downloaded audio and flight data was examined and confirmed as containing detail from the occurrence flight, before being provided to AIC representatives on 16 January 2013, together with a selection of graphical and tabular presentations of the flight data.

Contact details for the PNG Accident Investigation Commission are available at: www.aic.gov.pg/contact.html

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

What happened

On 14 December 2012, an Airbus A320 operated on a scheduled passenger flight from Hobart, Tasmania to Melbourne, Victoria, without the runway lights being activated for the taxi and take-off roll.

Outside tower hours, Hobart Airport operated as a non-towered uncontrolled airport, operating on a common traffic advisory frequency (CTAF). When operating as a CTAF, the runway lighting was controlled by a pilot activated lighting (PAL) system that was combined with an aerodrome frequency response unit. Two pilot activated lighting systems exist at Australian airports, Pilot Activated Lighting (PAL) and Aerodrome Frequency Response Unit plus PAL (AFRU+PAL). Hobart Airport is equipped with the ARFU+PAL type installation. The two systems differ in their activation methods.

A number of situational factors were associated with the crew not activating the runway lights prior to departure. Defining a specific place for PAL tasks in the crew’s sequence of procedures, and incorporating this into a pre-taxi checklist, could potentially ensure more reliability in performing these tasks.

Aviation Short Investigation Bulletin Issue 19

What happened

On 15 December 2012, four DH-82A (Tiger Moth) aircraft departed runway 12 at Luskintyre airport, NSW, for a practice formation flight. The pilot flying VH-DDA (DDA), the formation lead aircraft, applied full power for take-off. Passing through about 50 ft above ground level, the pilot flying noted that the aircraft was not climbing as expected and, realising that full power was not selected, applied full power by moving the throttle fully forward and lowered the nose of the aircraft slightly to gain speed.

As there was insufficient distance remaining to land on the runway, and it had become evident that a forced landing was imminent, the instructing pilot input a slight left bank so that the left wing of DDA took the main force of the impact. The aircraft landed and struck a tree before coming to rest. Both pilots were able to undo their four-point harnesses and exit the aircraft without assistance, although the pilot flying received serious facial injuries.

While both pilots reported that they had not reduced engine power after take-off, the accident was a result of decreasing airspeed and the aircraft being unable to recover following the reapplication of full power. The ATSB could not resolve this ambiguity.

The positive aspects of wearing full restraint harnesses, evacuating the aircraft quickly and extinguishing the fire ensured neither pilot experienced further injuries.

Comprehensive pre-flight briefings are important for all flights to ensure each crew member is aware of their respective roles as well as normal and non-normal operations.

Aviation Short Investigation Bulletin – Issue 17

Safety summary

What happened

On 17 December 2012, a Cessna 182A aircraft registered VH-SGB, impacted with electrical powerlines that ran alongside a parachute drop zone at Burrum River, Queensland. The pilot was planning to attend a Christmas function at the drop zone and was flying to an airstrip located about 1.5 km to the north. After contacting the powerlines, the aircraft was seen to climb and continue to fly for approximately 500 m before the right wing separated from the aircraft. The aircraft subsequently impacted the ground and the pilot was fatally injured.

What the ATSB found

The powerlines that the aircraft impacted were at a height of approximately 9 m (30 ft) above ground level (AGL) and ran perpendicular to the aircraft’s flight path. The relevant cable marking standards did not require the powerlines to be marked. Weather conditions were fine, and there was no emergency broadcast from the pilot prior to the impact with the powerlines. No pre-existing defects with the aircraft could be identified.

No operational reason for the pilot to fly at a height below 500 ft AGL could be identified by the investigation.

Safety message

A minimum height of 500 ft AGL for flight over non-populated areas is promulgated for very long standing safety reasons. Pilots who choose to fly below this height without an operational reason to do so are exposing themselves, and any passengers that may be on board, to an increased risk of striking powerlines, many of which are difficult to see from the cockpit of an aircraft in flight. The circumstances of this accident highlight that risk.