On 23 September 2013, the pilot of a De Havilland DH-82 Tiger Moth aircraft, registered VH-RAY, taxied at Sandy Beach aeroplane landing area (ALA), New South Wales to conduct circuits in visual meteorological conditions. The pilot was the only person on board.

The pilot taxied to the end of the runway and applied the brakes to conduct engine run up checks. The pilot released the brakes and lined up on the runway heading and then applied full power for take-off. The aircraft accelerated down the runway. As the airspeed increased the tail rose to the take-off position, at about 200 meters down the runway and at about 30 knots indicated air speed the nose of the aircraft dropped very rapidly, and the aircraft flipped onto its back.

The aircraft was inspected by the maintenance organisation and it was determined that the left main landing gear brake drum had evidence of corrosion, and the brake operating rod was found stiff to operate. When the brakes were applied and released the left brake did not release fully. After the brake was cleaned and lubricated the brake operated normally. The maintenance organisation suspects that the left brake was partially engaged on take-off. The maintenance organisation determined that the aircraft was last flown on 12 February 2013 and the aircraft was normally stored in a high corrosion environment.

This accident is a timely reminder of the work that the Civil Aviation Safety Authority (CASA) is conducting on the safety of ageing aircraft in Australia.

Aviation Short Investigation Bulletin - Issue 28

On 21 October 2013, an Air Tractor AT-502B aircraft, registered VH-FLH, was conducting rice sowing operations north-east of Deniliquin, New South Wales. At about 1145 Eastern Daylight-savings Time (EDT), the pilot was conducting his fourth landing for the day onto the property airstrip located about 11 NM north-east of Deniliquin Airport.

The pilot reported that the approach was normal, at an airspeed of about 58-60 kt, with a predominately south-west wind of about 5-8 kt. The wind fluctuated between the west and south, but remained light.

During the landing, the main wheels touched down first, followed by the tail, which was locked into place. Shortly after, the aircraft suddenly veered right about 45°. The pilot considered a go around, but was concerned that the aircraft would not clear the boundary fence running along the side of the runway. Consequently, he elected to continue the landing and selected reverse thrust, applied left brake, left rudder and left aileron in an attempt to re-align the aircraft with the runway.

The wheels began to grab and the left undercarriage leg detached causing the aircraft to swing facing about 90 ° from the runway.

The pilot was not injured, but the aircraft was substantially damaged. An investigation could not determine what led to the loss of ground control, however a wind gust may have been a contributing factor.

Aviation Short Investigation Bulletin Issue - 27

Safety summary

What happened

On 24 October 2013, the pilot of a modified PZL Mielec M18A Dromader, registered VH-TZJ, was conducting a firebombing mission about 37 km west of Ulladulla, New South Wales. On approach to the target point, the left wing separated. The aircraft immediately rolled left and descended, impacting terrain. The aircraft was destroyed, and the pilot was fatally injured.

What the ATSB found

The ATSB found that the left wing separated because it had been weakened by a fatigue crack in the left-wing lower attachment fitting. The fatigue crack originated at small corrosion pits in the attachment fitting. These pits formed stress concentrations that accelerated the initiation of fatigue cracks.

The ATSB also found that, although required to be removed by the aircraft manufacturer’s instructions, the corrosion pits were not completely removed during previous maintenance. During that maintenance, the wing fittings were inspected using an eddy current inspection method. This inspection method was not approved for that particular inspection and may not have been effective at detecting the crack.

Data from a series of previous flights indicated that the manner in which the aircraft was flown during its life probably accelerated the initiation and growth of the fatigue crack.

Finally, the ATSB also found a number of other factors which, although they did not contribute to the accident, had potential to reduce the safety of operation of PZL M18 and other aircraft. These included the incorrect calculation of the flight time of M18 aircraft and a lack of robust procedures for the approval of non-destructive inspection procedures.

What's been done as a result

The Civil Aviation Safety Authority (CASA) revised the airworthiness directive for inspection of the wing attachment fittings to ensure that they were inspected using the magnetic particle inspection method. CASA also made, or plans to make, a number of changes to their systems and procedures to address issues identified in this report.

Separately, the ATSB reminded operators of M18 aircraft of the importance of the correct application of service life factors when operating at weights above the original maximum take-off weight. In addition, PZL Mielec plans to release additional maintenance documentation clarifying the need for removal of the wings for proper inspection of the wing attachment fittings. Finally, at the request of the owner, the supplemental type certificate for operation of the modified M18 Dromader at take-off weights up to 6,600 kg has been suspended by CASA.

Safety message

This accident shows that even when flying within operational limits, the ‘harder’ and faster an aircraft is flown the more rapidly the structure will fatigue.

To help ensure that maintenance objectives are consistently met, the ATSB reminds aircraft maintenance personnel of the importance of only using properly approved maintenance instructions. This accident confirms the importance of referring directly to those maintenance instructions when conducting maintenance.

What happened

On 23 October 2013, the pilot of a Cessna 182Q aircraft, registered VH-KKM and operating under the visual flight rules, departed Moruya Airport, New South Wales on a private flight to Mangalore Airport, Victoria. The flight route encompassed the Alpine National Park, where the forecast and actual weather included extensive thick cloud and severe turbulence.

Shortly after passing Mount Hotham Airport, Victoria, the aircraft collided with terrain on the eastern side of Mount Blue Rag, at about 5,000 ft above mean sea level. The pilot sustained fatal injuries and the aircraft was destroyed.

What the ATSB found

The ATSB found that the visual flight rules-qualified pilot had minimal total and recent flying experience and departed Moruya with less than visual meteorological conditions forecast along the planned route. It was very likely that these conditions were encountered shortly after passing Mount Hotham Airport, while flying over the Alpine National Park. From the evidence available it was likely that the pilot encountered reduced visibility to the extent that terrain avoidance could not be assured, resulting in the aircraft colliding with terrain in controlled flight.

Safety message

This accident highlights the risks associated with operating under the visual flight rules in adverse weather, particularly when flying in a challenging environment such as in mountainous terrain.

Thorough pre-flight planning is essential for avoiding weather. It is not only important to obtain the relevant weather forecasts to develop a mental picture of the conditions that may be encountered, but also to assess this information and understand how it relates to the planned flight. In forecast marginal weather, this involves consideration of alternative options such as diverting or turning back and pilots assessing their skills and/or aircraft’s suitability for the task in the conditions.

During flight, pilots must continuously assess the weather for conditions that may adversely affect the safety of the flight and be prepared to use an alternative course of action if conditions deteriorate. This can include seeking assistance, such as that available from air traffic control.

The ATSB is concerned about the frequency of accidents – many fatal – that involve pilots flying with reduced visual cues. This has been highlighted on the ATSB website as a SafetyWatch priority, along with a number of strategies to help manage the risk and links to relevant safety resources.

What happened

On 18 October 2013, the pilot of an Ayres Corporation S2R Thrush, registered VH-JAY, was conducting aerial agricultural spraying activities on a property near Hyden, Western Australia. At about 1330, following the completion of a number of spray runs and a break for lunch, the pilot departed to complete further spraying. Following the failure of the aircraft to return, a search was initiated. The aircraft wreckage was found a short time later about 1,700 m from the departure airstrip. The aircraft was destroyed, and the pilot was fatally injured.

What the ATSB found

The ATSB found that the aircraft departed controlled flight from which the pilot was unable to recover, leading to the collision with terrain. On the basis of the available evidence, it was not possible to determine the reasons for the loss of control.

The ATSB identified two aspects of the aircraft’s operation which had the potential to adversely affect safety. These were the use of an unapproved fuel mix and operation of the aircraft above its published maximum take-off weight.

Safety message

Operators and pilots are reminded of the dangers of operating aircraft engines on an unapproved fuel mix as this increases the likelihood of engine damage which could affect the safety of operations. Pilots and operators are also reminded of the need to adhere to an aircraft’s maximum take-off weight to ensure the on-going safety of the aircraft and operations.

On 19 October 2013, an ATR-42-320F cargo aircraft (registered P2-PXY) with three persons on-board was substantially damaged following a high-speed rejected takeoff and subsequent runway overrun at Madang Airport, Papua New Guinea.

An investigation of the occurrence is being undertaken by the Accident Investigation Commission (AIC) of Papua New Guinea, in accordance with Papua New Guinea's obligations as the State of Occurrence under Annex 13 to the Convention on International Civil Aviation.

The aircraft was fitted with a cockpit voice recorder (CVR) and a separate flight data recorder (FDR). The AIC requested assistance from the Australian Transport Safety Bureau (ATSB) in the download and analysis of information from both recorders. In accordance with paragraph 5.23 of Annex 13, the ATSB appointed an Accredited Representative to assist the AIC and commenced an investigation under the Australian Transport Safety Investigation Act 2003.

After removal from the aircraft, the recorders were transported by an AIC officer to the ATSB’s technical facilities in Canberra, Australia, and were received on 22 October 2013.

The CVR and FDR were successfully downloaded and it was confirmed that both recorders had recorded the accident sequence. The recorders were returned to the AIC on 23 October 2013 together with a copy of the downloaded CVR audio files, FDR plots and data listings.

The PNG AIC is responsible for the final investigation report into this accident. Any enquiries regarding the AIC investigation should be directed to:

PNG Accident Investigation Commission

Telephone: +675 323 2911

Fax: +675 323 2139

Website: www.aic.gov.pg/

Address:
Accident Investigation Commission
PO Box 1709
Boroko
National Capital District
Papua New Guinea

______________

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

On 15 October 2013, at about 0410 Eastern Daylight-savings Time (EDT), the flight plan for a Qantas Airways Airbus A330 aircraft, registered VH-QPD, was automatically generated and released by the dispatcher at about 0420. The flight was scheduled to depart Sydney, New South Wales at 0600 on a passenger service to Perth, Western Australia. At about 0430, the captain of QF 565 downloaded the weather package and flight plan onto his iPad.

At about 0440, the company meteorologist advised the dispatcher that a new terminal aerodrome forecast (TAF) had been issued for Perth, which required QF 565 to have an alternate destination due to forecast fog and the dispatcher produced a new flight plan for the flight.

The crew arrived at the airport before 0500. The FO downloaded the flight plan and weather (briefing package) at about 0504. The flight plan downloaded by the FO was the original flight plan, despite dispatch having released the new plan prior to this time.

The crew reviewed the information and noted that there were no weather requirements for Perth and that they both had the same flight plan. The captain noted that their initial cruising altitude was flight level (FL) 320. The crew completed the briefing and requested 32.1 tonnes of fuel be uploaded and the flight departed at about 0600. When at the top of climb, the captain retrieved the deck log and noticed that the initial flight level on the log was different to the initial planned level and a departure fuel of 45 tonnes on the log and realised that they were using the original, incorrect, flight plan data. Due to improving weather at the Perth, the flight was able to continue to the destination.

As a result of this occurrence, the aircraft operator has highlighted the occurrence to the dispatch team and issued an Internal Notice to Airmen (INTAM) to the flight crews to ensure they are in receipt of the latest flight plan data before flight.

This incident highlights the importance of ensuring vital information is relayed to crews in a timely manner.

Aviation Short Investigation Bulletin - Issue 26

On 23 September 2013, the crew of a Boeing 777-3ZGER aircraft operated by Virgin Australia, registered VH-VPE (VPE) conducted a scheduled passenger flight from Brisbane, Australia to Los Angeles, United States. At about 0305 Coordinated Universal Time in the cruise at flight level (FL) 310 and flying in clear air the aircraft encountered abrupt severe turbulence.  The flight crew turned on the seat belt sign, reduced the speed of the aircraft and requested from air traffic control a descent to a block altitude from FL310 to FL 290.

At the same time, the cabin crew had begun the meal service and the seat belt signs were turned off. Cabin crew members reported being thrown around the cabin by the turbulence with two of the 12 cabin crew hitting their heads on the aircraft cabin ceiling. Food and catering equipment were spread over seats, passengers and the aisles with the rear section of the aircraft affected the most. All passengers were seated at the time with their seat belts on. One passenger reported a sore neck and another passenger reported a burn injury as a result of a spilt hot meal. There were no reported injuries to the four flight crew.

This incident is a timely reminder for passengers to keep their seatbelt fastened when seated, pay attention to the safety demonstration and any instructions given by the cabin crew and read the safety information card in the seat pocket.

Aviation Short Investigation Bulletin - Issue 28

On 15 October 2013, the pilot of an Air Tractor AT‑502 aircraft, registered VH‑CJY, was preparing to conduct aerial spraying operations about 33 km west of Temora, New South Wales. 

The owner of the property had provided the pilot with a map of the area to be sprayed, which included power lines. There was a road and a row of trees to the south of the paddock, with double power lines (as marked on the map) about 130 m north of the treeline. The pilot planned to fly over the trees and under the power lines on each leg, before turning to commence the next run.

At about 1730 Eastern Daylight-saving Time, when to the south of the paddock at about 15-20 ft above ground level (AGL), after turning to commence the next run, the pilot saw a cross arm indicating the presence of a wire attached to a derelict homestead. He decided not to climb the aircraft as it would have collided with the larger double power lines. The pilot then heard a bang, with the aircraft’s propeller spinner contacting the wire.

The pilot flew the aircraft under the double power lines and climbed to about 150 ft AGL. The engine was vibrating, but continued to produce power. The engine then steadily lost power. The pilot secured the engine and conducted a forced landing in a paddock. During the landing, the aircraft ground-looped and the left wing contacted the ground. The aircraft was substantially damaged, and the pilot received nil injuries.

The pilot did not see the wire at any stage, nor was it marked on the map provided to the pilot by the property owner.

Aviation Short Investigation Bulletin - Issue 24

On the evening of 8 October 2013 a Dornier DO228 aircraft, registered VH-VJN (VJN) was taxiing to the company hangar at Brisbane Airport, Queensland after the completion of a charter flight.

As the flight crew turned right onto the Hotel 2 South taxiway, two vehicles were travelling along the designated movement area along Hotel 2 South from the opposite direction.

This incident did not involve an on-site investigation by the ATSB and the investigation includes differing recounts of the event from the flight crew and the driver of the second vehicle.

Aircraft movements at Brisbane Airport have increased from 123,000 in 2004 to 222,000 in 2013. At the time of the incident there were about 1,700 vehicles approved to access the taxiway hotel system.

The ATSB published a research paper on ground operation occurrences at Australian Airports over a 10 year period. Of the 282 ground occurrences reported to the ATSB between 1 January 1998 and 31 December 2008, about 37 per cent of those incidents occurring as the aircraft approached a gate, were attributed to near collisions with vehicles. This report is available at: www.atsb.gov.au/publications/2009/ar2009042.aspx.

Aviation Short Investigation Bulletin Issue - 27