On 31 October 2012, the pilot of a Robinson R22 helicopter, VH-HOA, was conducting mustering operations at Innamincka Station, South Australia on a hot, cloudless day.
The helicopter had been assisting ground personnel move a large mob of cattle through sandy and swampy terrain. The pilot was tasked with flying a low-level east-west grid pattern well behind the main herd, checking for stray cattle.
The pilot’s visibility through the windscreen had deteriorated during the day, due to a build-up of dust, sand and mud. During his final run, the pilot conducted a right turn from west to east over the edge of Lake Marradibbadibba. Although wearing sunglasses, the pilot received significant sun-glare from the water. He became disoriented and did not detect a rate of descent. The helicopter contacted the water and sank. The pilot exited the helicopter without injury and swam to shore.
The effect of sun-glare when relying on visual cues has contributed to a number of accidents, and has been documented in US Federal Aviation Administration research report Sunlight and its association with aviation accidents.
On 26 October 2012, a Piper PA-39 (Twin Comanche) aircraft, registered VH‑MMN (MMN), was landing at the Innamincka Township aeroplane landing area (ALA), South Australia. On board the aircraft were the pilot and a passenger.
MMN joined the circuit, and when on the downwind leg, the pilot noted that the windsock was indicating a strong crosswind. As a precaution, the pilot elected to increase the aircraft’s airspeed for the approach by about 5 knots and selected ½ flaps (about 15 degrees).
The pilot turned the aircraft onto final about 200 ft higher than normal. At that time, the windsock was showing a 15 kt crosswind, from the south-west. The pilot focused on the crosswind and ensured that the aircraft remained aligned with the runway.
During the landing, at about 100 ft above the runway, the flare was commenced. The aircraft floated and touched down about a quarter the way along the runway. The pilot reduced the throttle setting to the idle position and applied light braking.
When the aircraft was about half way along the runway, the pilot realised that the aircraft’s speed was too fast and he applied full braking. The pilot determined that it was too late to commence a go‑around. He reported that the braking appeared to be ineffective due to the surface of the runway and the aircraft continued beyond the runway end. The left landing gear struck a depression, and then the aircraft spun to the left and came to rest in a 1 m deep gully. The pilot and passenger exited the aircraft, the pilot received a minor injury whille the passenger was uninjured. The aircraft sustained serious damage.
This accident demonstrates the importance of assessing the operational and environmental conditions at the time in order to determine the most suitable landing type. Pilots should also establish a decision point along the runway at which a go-around should be initiated if the requirements for a safe landing can no longer be met. Additionally, it highlights the benefits of using all available resources, including persons on the ground, for gathering information on the actual conditions.
On 25 October 2012, at about 1510 Eastern Daylight-saving Time a Helicopters Guimbal Cabri G2 (Cabri G2) helicopter, registered VH-CDU (CDU), departed Bankstown Airport New South Wales on a local training flight. On board the helicopter were an instructor and student. The instructor proceeded to demonstrate the recovery from low main rotor RPM in the hover. During the demonstration the helicopter began to rotate to the left. The instructor opposed the rotation with full right pedal however the rotation could not be stopped, and the helicopter was landed heavily. There was minor damage to the helicopter as a result of the incident and the instructor and student were able to exit the helicopter without injury.
As a result of this incident the helicopter manufacturer is preparing a service letter with the intention of preventing training sequences being performed that are inappropriate for the helicopter type.
On 29 October 2012, a Cessna 172N, registered VH-TKI (TKI), was being operated on a visual flight rules (VFR) flight from Coldstream to a private aircraft landing area (ALA) at Bagshot, Victoria, with a pilot and two passengers on board.
A witness at the airfield stated that as TKI approached short final on the approach, the aircraft contacted a powerline located at the southern end of the airfield. The powerline significantly reduced the aircraft’s forward speed, causing it to rotate about its nose and impact the airstrip in an almost inverted attitude. A post-impact, fuel-fed fire initiated at the wing roots almost immediately and witnesses assisted the aircraft occupants from the aircraft. However, the front-seat passenger was fatally injured, the pilot was seriously injured and the rear seat passenger sustained minor injuries.
What the ATSB found
Examination of the aircraft showed that its nose landing gear contacted the powerline. The powerline was located 8 m above ground level and about 140 m south of the displaced threshold of the landing strip.
The ATSB found that the pilot was aware of the powerline, but that his recollection was that they were closer to the tree line in the undershoot to the landing strip. In addition, a lack of adequate displaced threshold markings and the mown undershoot area led him to believe that the entire strip was useable for landing. This combined with the inherent difficulty of visually detecting wires and the distraction of another recently-landed aircraft on the airstrip to reduce the likelihood of the pilot detecting the wire.
No high visibility devices were attached to the powerlines, nor were they required to be under the current Australian Standards.
What's been done as a result
In response to this accident, the owner of the ALA has made significant changes to the runway markings, landing permission procedures affecting operations at the ALA and the available safety and firefighting equipment. In addition, markers have been erected near the powerline.
Safety message
Aeroplane landing area owners can help manage the risk of collisions with obstacles by assessing their airstrips against the guidance in Civil Aviation Advisory Publication (CAAP) 92-1(1) Guidelines for Aeroplane Landing Areas. Such risk assessments should explicitly consider the needs of first time users of the ALA.
Operational risk can also be reduced by pilots ensuring sufficient time to make appropriate decisions including, if in doubt, an early decision to go around. Pilots should also ensure that everyone in their aircraft is wearing seatbelts correctly, affording the best chance of survival in case of an accident.
Previous updates
Update 18 December 2012
The occurrence
On 29 October 2012, a Cessna 172N, registered VH-TKI, was being operated on a flight from Coldstream, Victoria to a private airstrip at Bagshot, Victoria, with a pilot and two passengers on board. The private flight was being conducted to position the aircraft for maintenance.
The aircraft arrived at the airstrip at about 1300 Eastern daylight-saving time. A witness, who was located at the southern end of the airfield, observed a Tecnam aircraft land from the south as the Cessna 172 entered the circuit. The Tecnam landed and backtracked to a maintenance facility located on the southern end of the airstrip.
The pilot of the Cessna overflew the strip then conducted a right circuit to land. The passenger seated behind the pilot stated that all the occupants were focussing their attention on the Tecnam on the airstrip during the circuit and final approach.
The witness at the airfield stated that, as the Tecnam cleared the airstrip, the Cessna was on a short final approach. He saw the aircraft contact a powerline, located at the southern end of the airfield. The aircraft rotated over the powerline, significantly reducing its forward speed and causing it to impact the runway in an almost inverted attitude.
The aircraft came to rest inverted, and a post-impact, fuel-fed fire initiated at the wing roots and destroyed the aircraft (Figure 1). Witnesses reached the aircraft quickly and assisted the occupants. However, the front seat passenger was fatally injured, the pilot was seriously injured and the rear seat passenger sustained minor injuries.
Figure 1: Accident site of the Cessna 172, VH-TKI
Source: ATSB
Examination of the aircraft showed that its nose landing gear contacted the powerline. The powerline was located 7 m above ground level and about 140 m from the end of the 900 m long landing strip (Figure 2).
The powerline had no markers fitted, nor were any required under the current Australian Standards for private landing strips. The owner of the landing strip advised that he routinely provided advice to pilots using the airstrip of the location of the powerline and of the need to land a significant distance down the airstrip to avoid the wire if landing from the south.
Figure 2: High level view of runway
Source: Google
Investigation activities
The on-site phase of the investigation concluded on 2 November 2012. The investigation is continuing and will include analysis of the circumstances surrounding the wirestrike including, but not limited to:
the location of the powerline in relation to the airstrip
requirements for powerline markers
pilots’ knowledge of the powerline’s location
pilot distraction
pilot visibility
pilot experience
the circuit flown by the pilot.
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 2 November 2012
The ATSB team has now completed the on-site stage of the investigation. The team has:
examined the wreckage
interviewed one of the passengers and the aircraft owner
reviewed the aircraft’s maintenance logs.
The ATSB’s investigation will now continue off-site.
This page will be updated as significant information comes to hand.
The ATSB aims to finalise its investigation within 12 months.
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Update 30 October 2012
The ATSB team is on-site:
coordinating activities with local police and Coronial staff
interviewing witnesses
conducting initial site assessment
planning site activities.
29 October 2012
The ATSB has sent a team of investigators to begin the on-site phase of the investigation. The team comprises experts in engineering and aircraft operations. It is expect they will arrive mid-morning (Tuesday 30 October) and spend three to five days at the accident site.
As part of the on-site investigation, the team 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.
Section 21 (2) of the Transport Safety Investigation Act 2003 (TSI Act) empowers the Australian Transport Safety Bureau (ATSB) to discontinue an investigation into a transport safety matter at any time. Section 21 (3) of the TSI Act requires the ATSB to publish a statement setting out the reasons for discontinuing an investigation.
Two aircraft, both maintaining flight level 350, were on converging tracks with the same estimate for overhead Morawa NDB, Western Australia. A controller noticed the potential conflict and alerted the sector controllers managing the flights, who acted to resolve the situation. There was a loss of separation assurance.
On 26 October 2012, the ATSB commenced an investigation into an airspace event involving a Boeing 717-200 aircraft, registered VH-NXQ, and a Boeing 777-312ER aircraft, registered 9V-SYI, near the Morawa non-directional radio beacon, Western Australia, on 25 October 2012.
Examination of the information collected during the investigation indicated that although there was a loss of separation assurance, the potential conflict between the two aircraft was detected and actively managed by air traffic control. This ensured that the required separation standard was maintained.
The ATSB did not find any systemic issues had contributed to the occurrence and assessed that no safety issues would be identified through further investigation. On that basis, the ATSB has decided to discontinue its investigation.
On 19 October 2012 a Fokker F100 aircraft (F100), registered VH-NQE, was being operated on a passenger charter flight from Perth Airport to Nifty Aerodrome in the Pilbara region of Western Australia. The weather for the approach into Nifty included high-based cumulus cloud and isolated thunderstorms. The temperature on the ground was 38 °C.
As the flight crew were positioning the aircraft for a 5 NM (9 km) straight-in approach into a slight headwind, they received a windshear caution. In response, the crew increased the approach speed and extended the speed brake to stabilise the approach.
The approach continued and apart from a few minor speed variances, the conditions appeared relatively benign. As the aircraft was in the final stages of the approach and descending from 80 ft to 30 ft above ground level, the airspeed dropped from 133 kt to 110 kt and the rate of descent increased to about 1,000 ft/min. The loss of airspeed occurred over a period of 3 seconds and by touchdown the aircraft was being affected by a 32 kt tailwind.
The aircraft touched down on the runway threshold, almost 300 m short of the normal touchdown point, and bounced. The high rate of descent at initial touchdown resulted in a hard landing with significant aircraft damage. There were no reported injuries to passengers or crew.
What the ATSB found
The ATSB found that when the aircraft was on approach to land at about 80 ft above ground level, the flight path almost certainly coincided with the strong outflow of a dry microburst, resulting in a performance-decreasing windshear that led to the rapid drop in airspeed, high sink rate, undershoot and a hard landing. Also, the aircraft was not fully configured for an approach in known or suspected windshear conditions, reducing the capability of the aircraft to recover from the high sink rate associated with a microburst event.
What's been done as a result
As a result of this occurrence, the operator sought to improve the weather information available at aerodromes serviced by their F100 fleet and modified its simulator training program along with consolidation of the windshear procedures/guidance. The operator also provided additional guidance in the use of flap following receipt of a windshear caution during approach and planned to introduce a new threat-based take-off and landing briefing model.
Safety message
The circumstances of this occurrence show that operators of transport category aircraft may need to review the guidance provided to crews to ensure that the risk of windshear associated with both thunderstorms and dry microbursts, is effectively managed.
On 17 October 2012, a Boeing 737-838 aircraft, registered VH-VXB and operated by Qantas Airways Limited (Qantas), was conducting a flight from Adelaide, South Australia to Canberra, Australian Capital Territory. The flight crew received an approach clearance into Canberra via a standard arrival route (STAR) and then an Area Navigation (Required Navigation Performance) (RNAV (RNP)) instrument approach to runway 35 at Canberra Airport. Just prior to commencing descent, at about 2030 Eastern Daylight-saving Time, air traffic control (ATC) cancelled the STAR and cleared the aircraft to track direct to the initial approach fix, HONEY, via a high-speed descent. As the aircraft approached 8,000 ft, ATC provided a descent clearance to 7,000 ft and also cleared the aircraft for the approach. As the aircraft approached HONEY it descended below the 7,000 ft altitude clearance limit. After being alerted to this by ATC, the flight crew climbed the aircraft back to 7,000 ft and continued the approach to land.
What the ATSB found
The ATSB found that, as the aircraft approached 8,000 ft, the auto-flight system vertical mode changed from a flight management computer‑derived and managed vertical navigation mode into the vertical speed mode. This was followed by a number of automated, but unnoticed, and crew‑initiated changes in the aircraft’s auto-flight system vertical mode. The combination of auto‑flight system mode changes and the management of the airspeed during the descent resulted in a high workload environment where the 7,000 ft altitude clearance limit was overlooked by the flight crew.
The ATSB also found that, on receipt of the approach clearance, the Qantas RNAV (RNP) approach procedures allowed the flight crew to remove the current limiting altitude from the auto‑flight system’s Mode Control Panel (MCP) and set the decision altitude. Application of this procedure by the flight crew removed the last automated safety system available to them to prevent descent through the current altitude limitation, well before the aircraft was established on the approach.
What's been done as a result
Following this occurrence, Qantas changed their RNAV (RNP) approach procedures to only allow the altitude on the MCP to be changed from the current limiting altitude once the aircraft was within 2 NM (4 km) of commencing the approach.
Safety message
This occurrence highlights the importance of paying continuous attention to active and armed auto-flight modes and the need to continually monitor descent profiles and airspace limitations in relation to the aircraft’s position, irrespective of the expectation that the descent is being managed by the auto-flight system. The adverse effect of workload and task focus on flight crew performance and the importance of robust procedures for high-precision approaches are also illustrated.
On 11 October 2012, at 0845 Eastern Standard Time a Robinson R44 Raven 1 helicopter departed a property near Mount Molloy for Georgetown, Queensland, on a private flight. On board the helicopter were the pilot and one passenger. Shortly after becoming airborne the helicopter experienced a loss of power. The pilot performed a 180° turn to the left and autorotated to a suitable area within autorotative distance, which was a contour drain located downslope from the departure point. The helicopter came to rest and remained upright, and the pilot and passenger were able to exit without injury. The helicopter was substantially damaged.
The helicopter was inspected, and the left magneto was found to have a badly worn distributor block, which allowed the timing gear to move and alter the internal timing by approximately 40°.
Pilots are encouraged to perform a self-briefing prior to every take-off to serve as a reminder of the actions to be performed in the event of an emergency.
At about 0444 on 26 September 2012, the 104.5 m LPG tanker MT Norgas Cathinka collided with the 96 m ferry Bahuga Jaya in Sundra Strait, Indonesia. The Bahuga Jaya sank as a result of the collision, with the reported loss of 8 lives.
The Indonesian National Transportation Safety Committee (NTSC) is responsible for investigating this occurrence. The NTSC requested assistance from the Australian Transport Safety Bureau (ATSB) in the replay, display and analysis of voyage data recorder (VDR) data from the MT Norgas Cathinka. To assist the NTSC and provide protection of the recorded data and analyses, the ATSB initiated an External Investigation under the provisions of the Transport Safety Investigation Act 2003.
For further information in relation to the investigation of this accident, please refer to the NTSC.
National Transportation Safety Committee Ministry Of Transportation Republic Of Indonesia Transportation Building 3rd Floor Jalan Medan Merdeka Timur No. 5 Jakarta Pusat 10110 Indonesia
On 29 September 2012, a Cessna P206B aircraft, registered VH-EGG, departed Gympie on a private flight to Monduran, Queensland.
During the landing, a significant wind gust was experienced, resulting in a hard landing on the main landing gear. The aircraft bounced and the pilot applied a small amount of power in an attempt to regain control. A second wind gust of greater intensity then occurred. The aircraft stalled and touched down hard on the nose landing gear. The pilot maintained directional control and the aircraft came to a stop. The aircraft sustained damage to the propeller, nose landing gear, and lower engine cowls.
This incident highlights the importance of conducting a go-around as soon as landing conditions appear unfavourable.
