On 21 November 2012, at about 1055 Eastern Daylight-saving Time, a Cirrus SR22 aircraft, registered VH-WYH, departed Emerald, Queensland for Dubbo, New South Wales, on a private flight conducted under the instrument flight rules. The pilot and one passenger were on board.
At about 1122, the oil pressure annunciator light illuminated, the engine oil pressure indicated 30 pounds per square inch. As the oil pressure continued to slowly drop, the pilot became increasingly concerned and tracked via Gilgandra, New South Wales. At 1401, the engine failed the pilot turned the aircraft towards Gilgandra aerodrome. It became evident that a landing at Gilgandra aerodrome was not achievable and at about 1405, the pilot deployed the ballistic parachute. The aircraft impacted the ground the pilot received minor injuries and the passenger was uninjured.
The pilot reported that the oil pressure indication dropped very gradually giving a false sense of security and that he normally maintained the oil level between 5 and 5 ½ quarts.
The engine was removed, and a detailed examination did not identify any external oil leaks or internal defects that were not attributed to a lack of oil.
The pilots operating handbook recommends that the engine should not be operated with less than six quarts of oil. Seven quarts is recommended for extended flights.
The accident highlights the importance of understanding the information contained in the manufacturer's publications.
On the evening of 8 November 2012, the crew of a Regional Express Saab Aircraft Co. 340B, registered VH-TRX, were conducting a scheduled passenger flight from Sydney to Williamtown (Newcastle Airport), New South Wales, under the instrument flight rules.
After the crew reported on descent to Williamtown, the aircraft was cleared by the approach controller for a visual approach via a right base to runway 12. At 10 NM (19 km) south of Williamtown, the crew transferred to the aerodrome controller. Instead of tracking toward Williamtown as anticipated, the controller observed the aircraft manoeuvring at a greater distance than usual from the runway and advised the crew of their position. The crew then requested radar guidance and were directed toward the airport.
The crew visually identified runway 12 and landed the aircraft about 14 minutes before last light. After landing the crew advised the controller that they were unfamiliar with locating the airport at night.
What the ATSB found
The ATSB found that, in the low light conditions, the captain misidentified a coal loading and storage facility, 6 NM (11 km) south-west of Williamtown, as the airport environment.
What's been done as a result
Following an internal investigation, Regional Express alerted its crews to the possible misidentification of features in the Williamtown area and reminded them of the importance of using navigation equipment to verify their position. In addition, crews were advised that visual approaches were no longer to be conducted at Williamtown during normal operations and additional material on situation awareness and assertiveness skills was also incorporated into existing human factors and non-technical skills training.
The Williamtown air traffic control unit reminded its controllers of the need to provide assertive safety alert instructions, including the provision of minimum sector altitudes and prompt position information to aircraft that deviated from a cleared route, or whose observed position differed from that reported.
Safety message
This occurrence highlights the possibility of crews misidentifying ground features for the airport environment during visual approaches, especially in conditions of poor light. To avoid misleading visual cues during visual approaches, crews should confirm that they have correctly identified and are tracking to the intended destination by crosschecking with the aircraft’s navigation equipment.
On 11 November 2012, an Emirates A380 aircraft, registered A6-EDA, departed Sydney Airport for Dubai, United Arab Emirates. While climbing through an altitude of approximately 9,000 ft, the crew reported hearing a loud bang, accompanied by an engine No 3 exhaust gas temperature over-limit warning. Shortly thereafter, the engine went through an uncommanded shut down. The crew jettisoned excess fuel and returned the aircraft to Sydney for a safe landing and disembarkation of the passengers and crew.
What the ATSB found
The investigation found that the increase in the exhaust gas temperature and subsequent engine shut down was a result of significant internal damage that had initiated within the high-pressure turbine (HPT) module. The damage had resulted from the effects of HPT stage-2 nozzle distress, likely caused by exposure to hotter than expected operating temperatures. The nozzle distress led to eventual failure and separation into the gas flow path. Over the preceding weeks there were two other engines within the operator’s fleet that had experienced a similar problem, and a number of steps had been taken by the manufacturer to address the issue, including the increased monitoring of distress development. During the previous flight, the engine health and trend monitoring program had identified a performance trend shift with this particular engine, and it was due to be inspected upon return to the main base in Dubai.
What's been done as a result
The engine manufacturer, Engine Alliance, had issued a service bulletin in June 2010 for the replacement of affected HPT stage-2 nozzle segments with new, more durable components during the next workshop visit when the HPT stage-2 was removed from the engine. Following this occurrence, another service bulletin was released on 6 December 2012, requiring the direct inspection of the nozzle segments that had not yet been replaced. The US Federal Aviation Administration also released an Airworthiness Directive which required inspection of the nozzle segments and their removal from service if distress was identified.
As the nozzle degradation mechanism was an emerging issue for the engine manufacturer at the time of the occurrence, the information and experiences associated with this occurrence have been used to refine and improve the trend monitoring program. Under the new limits set, this engine would have been inspected two flights prior to the occurrence flight. At the time this report was released, the manufacturer was continuing work to better understand the initial onset of nozzle distress and potential for further design improvements.
Safety message
While the distress to the HPT was severe enough in this case to result in an in-flight engine shutdown, the associated risks to the safety of continued flight were relatively low, given the failure had been contained and the operator’s procedures were effective in managing the engine shut down. This occurrence also pointed to the value of real-time engine condition monitoring, since advanced warning of engine degradation and efficiency loss allows inspection and corrective action before damage progresses to a level where it can cause an in-flight shut down.
On the 6 November 2012 at about 1250 Eastern Standard Time, a Bombardier DHC-8-315, registered VH-SBG (SBG) was conducting a visual approach to Brisbane airport while at the same time a Eurocopter EC120B, registered VH-EHA (EHA) was departing Doomben racecourse, which was located near to the approach path of SBG. To facilitate the departure from Doomben, the pilot of EHA was cleared by the air traffic controller for take-off with a requirement to maintain visual separation with the approaching SBG. Despite this, SBG received a Traffic Collision Avoidance System (TCAS) alert.
As EHA became airborne and SBG continued to descend as part of its approach, the vertical and lateral distances between the two aircraft reduced. The result was that the flight crew of SBG received a TCAS Resolution Advisory (RA), which meant that they must take immediate action to resolve the potential conflict. A mandatory climb in response to the TCAS RA was actioned by the flight crew which then improperly positioned the aircraft for a continued approach to land. The flight crew elected to conduct a missed approach.
The TCAS RA and missed approach significantly increased the flight crew’s workload, increased the controller’s workload and was a precursor for later aircraft sequencing issues. To facilitate another circuit for SBG, and to assist with the sequencing of other aircraft arrivals, the controller decided to temporarily suspend departures from runway 01. The flight crew of SBG were re‑sequenced for another approach and landed on runway 01 without further incident.
As a result of this occurrence, Airservices Australia has advised the ATSB that they are taking the following safety actions:
The Manual of Air Traffic Standards (MATS) was updated on 15 November 2012. The update requires air traffic controllers to provide additional consideration of performance characteristic prior to assigning visual separation to the pilot.
Specifically, MATS 10-50-221 (d) requires the controller to consider the possibility of a TCAS Resolution Advisory due to closer proximity of operation prior to assigning visual separation.
On 12 November 2012, Beechcraft Bonanza VH-SQI, was departing Kumarina Roadhouse airstrip, Western Australia for a fire reconnaissance flight. On board were the pilot and one passenger.
As the aircraft accelerated for takeoff, the forward cabin door next to the passenger opened. The pilot elected to continue the takeoff and return to land at Kumarina, to secure the door.
To expedite the circuit and landing, the pilot left the aircraft in the take-off configuration, apart from retracting the landing gear. The pilot flew a lower and tighter circuit than normal.
As the aircraft was flared for landing, the pilot realised he had forgotten his downwind and pre-landing checks. These included extending the landing gear. The aircraft landed with the wheels up and skidded to a halt on the runway.
This report highlights the risks associated with the distraction of an abnormal event during flight, and looks at Canadian research statistics from similar events at:
Transport Canada: Recommendations Concerning In-flight Opening of Doors on Small Aircrafts
On 9 November 2012, a student and instructor departed Gold Coast Airport, Queensland for a training flight in a SOCATA TB 20, registered VH-HBB, to Lismore Airport, New South Wales. This included circuit training as part of the student’s conversion to the aircraft type. On their fifth circuit, and while making a left turn from downwind to base, the aircraft aerodynamically stalled, and the left wing dropped steeply. A recovery was commenced, but the aircraft collided with terrain in a paddock to the east of the Bruxner Highway, about 3 km south of Lismore Airport. Both occupants received fatal injuries, and the aircraft was destroyed by the impact and an intense fuel-fed, post-impact fire.
What the ATSB found
The ATSB found that while making a left turn in the circuit, an aerodynamic stall occurred, resulting in a significant left-wing low and nose-down attitude in close proximity to the terrain. The instructor was unable to prevent the stall from occurring due to either insufficient warning or available time to react. Although it appeared that a stall recovery was commenced, the aircraft stalled at an altitude from which they were unable to fully recover to controlled flight before the aircraft collided with the terrain.
The ATSB also found that the aircraft’s engine contained crankcase through bolts from a different engine manufacturer that were installed in the engine prior to the aircraft’s importation into Australia and were probably unapproved for use in that engine. Although these bolts did not contribute to the accident, their installation meant that the continued safe operation of the engine could not be assured.
Safety message
The accident highlights the need for pilots to minimise the risk of aerodynamic stall, particularly when in proximity to the ground, such as during take-off and landing.
In addition, aircraft owners and maintainers should ensure that all parts fitted to their aircraft are appropriately approved for the application. The use of unapproved parts means that aircraft safety cannot be assured.
History
Update 18 December 2012
At about 0825 Eastern Standard Time1 on 9 November 2012, a student pilot and instructor departed Gold Coast/Coolangatta Airport, Queensland, for a training flight in VH-HBB, a SOCATA TB‑20 Trinidad. The student pilot had passed the general flying progress test (GFPT)2, but the student had recently acquired the Trinidad aircraft and was under the supervision of an instructor to undergo conversion training for the new aircraft.
The student had primarily carried out their previous flight training on Cessna 172 aircraft (172) that had fixed landing gear and a fixed pitch propeller. The Trinidad differed from the 172 in a number of ways that included having retractable landing gear and a variable pitch, constant speed propeller. Those features were considered to be ‘special design features’ and the conversion training being undertaken included endorsements for those special design features. The flight on 9 November was the student pilot’s sixth and the instructor’s seventh flight in the aircraft, having accumulated 7.8 hours and 8.9 hours, respectively, during the previous flights.
On the day, the aircraft departed from Coolangatta to the north before turning south. The aircraft was initially being tracked by the air traffic control radar, but at about 60 km south-south-west of Coolangatta the aircraft flew outside radar coverage (Figure 1).
Figure 1: Flight path of VH-HBB
Source: Google Earth
The path taken by the aircraft following the loss of radar coverage was unknown. However, at about 0845, the pilot broadcast on the Lismore common traffic advisory frequency (CTAF) that they were about 8 NM (15 km) north of Lismore Airport, New South Wales (NSW) and inbound to conduct circuits3 on runway 33 at Lismore. Reports indicated that the aircraft had completed a number of circuits prior to the accident.
At about 09154, a number of witnesses travelling along the Bruxner Highway between Lismore and Casino, NSW observed the aircraft make an abrupt steep left bank before pitching nose down and rapidly descending. The aircraft’s nose was then observed to have been raised and its rate of descent reduced before crossing the Bruxner Highway at very low height. The aircraft impacted the ground in a paddock adjacent to the highway. Both occupants on board the aircraft were fatally injured.
The Australian Transport Safety Bureau (ATSB) initiated an investigation and attended the accident site. The ground impact marks observed by the ATSB indicated that the aircraft impacted the ground in a left wing-low attitude with the nose of the aircraft level, or slightly nose-up. The left main and nose landing gear separated from the aircraft and it continued to skid along the ground. The aircraft continued through a wire fence, where the fuel escaped from the tanks and caught alight, before the right wing impacted the ground and the aircraft flipped over, coming to rest inverted about 170 m after the initial impact point (Figure 2). The engine separated from the fuselage during the impact sequence and came to rest about 13 m beyond the main aircraft wreckage.
Figure 2: Accident site
Source: NSW Police
An intense fuel-fed fire continued to burn around the aircraft following the accident. That fire destroyed a substantial amount of the aircraft structure (Figure 3).
The investigation is continuing and will include:
examination of the engine and propeller
examination of the experience of the student and instructor
assessment of the aircraft’s handling qualities.
The evidence will be analysed and a final report completed detailing the findings of the investigation.
Figure 3: Main wreckage
Source: ATSB ______________
[1] Eastern Standard Time was Coordinated Universal Time + 10 hours.
[2] A GFPT indicates that a pilot has attained a standard in the safe control and handling of an aircraft. The test does not assess flight navigation beyond an ability to fly in the vicinity of the departure aerodrome and the approved training area. The pilot remains a student pilot until a private or a commercial flight test has been passed.
[3] A standard rectangular traffic pattern flown around an aerodrome when taking off from, or landing on a runway.
[4] The local time at Lismore was 1015 Eastern Daylight-saving Time (UTC+11).
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 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 occurrence as outlined in the web update. As such, no analysis or findings are included in this update.
Update 12 November
ATSB investigators began the on-site phase of the investigation on Saturday 10 November.
The team has been liaising with the local police to secure perishable evidence, including the pattern of the wreckage and marks from impact.
The ATSB has retained the aircraft’s engine for later technical examination.
Over the next few days, the team will be:
interviewing witnesses
meeting with the aircraft operator
retrieving aircraft and pilot records.
The on-site wreckage examination will be completed later today and the ATSB aims to finalise the investigation by November 2013.
This page will be updated as significant information comes to hand.
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9 November 2012
The ATSB is investigating an accident involving a SOCATA TB-20 that collided with terrain at Lismore on 9 November 2012.
The aircraft was seen to bank left and impact the ground. It was destroyed by fire and the two people on board died as a result of the accident.
The ATSB has sent a team of investigators to begin the on-site phase of the investigation.
Investigators will be:
examining the wreckage for evidence
interviewing witnesses and aircraft operator
reviewing maintenance documents.
The ATSB will also review the pilot’s training and experience and collate and analyse witness information.
If you have any information about the accident please call the ATSB on 1800 020 616.
On 5 November 2012, a Hawker B200 aircraft, registered VH-FDT (FDT), departed Bundaberg on an aeromedical retrieval flight to Brisbane, Queensland. On board the aircraft were the pilot, the flight nurse and two patients.
Between 1556 and 1607 Eastern Standard Time, Brisbane Centre and Brisbane Approach attempted to contact FDT on a number of occasions, with no response received.
The nurse also became concerned as she had not yet sighted the geographic features she normally observed. The nurse turned towards the pilot and observed that his chin was slumped onto his chest, and he was not alert. The nurse attempted to arouse the pilot, at which time the stall warning alarm activating. The pilot regained alertness and initiated recovery actions.
The aircraft landed at Brisbane at 1617.
Drug and Alcohol Management Plan (DAMP) testing was conducted, which returned a positive reading for an illicit substance, which had affected the pilot’s sleep cycle.
Flying an aircraft is a complex, demanding and challenging activity, which requires a high level of cognitive functioning and psychomotor skills. The significant performance impairments associated with drug use are widely recognised. Consequently, the use of drugs by pilots can adversely affect their ability to safely operate an aircraft.
On 7 November 2012, at about 1000 Eastern Standard Time a Cessna 172N registered VH-JGR (JGR) departed Archerfield Airport, Queensland on a training flight. The purpose of the flight was to conduct solo pre-test revision, prior to the pilot performing the Private Pilot Licence (PPL) flight test. The aircraft was booked for 2 hours. During the flight, the aircraft impacted terrain and was substantially damaged. The pilot was the only person on board and suffered severe injuries as a result of the accident and was airlifted to hospital.
The aircraft activated air switch indicated that the aircraft was airborne for approximately 45 minutes prior to the accident, placing the time of the accident about 3 hours prior to the aircraft being located.
This accident highlights the importance of lodging a Search and Rescue Time (SARTIME), Flight Plan or Flight Note with a responsible person, to eliminate any major delays in commencing a search. Failure to do this means that you are relying on being able to get an emergency call out, using your Emergency Locator Transmitter (ELT) to alert the Rescue Coordination Centre Australia (RCC) or relying on someone noticing that you have gone missing.
On 26 October 2012, a Bombardier DHC-8-402 aircraft, registered VH-LQG, departed Perth on a scheduled passenger service to Geraldton, Western Australia. Shortly after takeoff, at about 700 ft, the captain observed a weather balloon above, in his 1 o’clock position. The captain advised the first officer, who immediately initiated a slight left turn. The balloon was observed to pass about 10-20 m laterally from the right wingtip. The captain advised air traffic control.
On 28 October 2012, at about 1410 Eastern Daylight-saving Time, an unmanned airship (callsign Airship 11) departed Keysborough, Victoria on a 30 minute test flight to assess the airship’s centre of gravity and manoeuvrability characteristics. The airship was controlled via a portable radio-controlled transmitter.
The crew planned to operate the flight below 200 ft above ground level and within 100-200 m of their location, with the airship remaining clear of the Moorabbin Class D control area.
Shortly after takeoff, the crew noticed that the airship’s centre of gravity was rearward, resulting in a nose-up attitude. About one minute later, when it was at about 130 ft, the pilot realised that he could not turn the airship to the left. The crew had lost control of the airship although the data link was still functioning.
Attempts to contact the Moorabbin control tower were unsuccessful. At about 1428, the air traffic controllers at Moorabbin observed the airship about 2 NM to the south-east at about 1,000 ft. At about 1500, the airship landed on the roof of a commercial building, sustaining minor damage.
As a result of this occurrence, the airship operator is taking the following safety actions:
source an airship from another manufacturer;
develop a safe method for tethered air testing;
develop a simulator for a small X-tail airship;
locate a suitable site for flight testing away from populated areas;
install the ground control station in the support vehicle;
