What happened

On 26 November 2012, a flight instructor and student flight instructor of a Piper PA-28 (Warrior) registered VH-LXH (LXH) were conducting circuits at Moorabbin Airport, Victoria. Soon after LXH had conducted a touch and go, the flight instructor and student pilot of another Warrior, registered VH-TAU (TAU), commenced circuits. ATC advised TAU that they were cleared for take-off and to follow the ‘Cherokee’ (LXH) that was currently on the runway.

At 1528, TAU was observed commencing the turn onto crosswind, at 700 feet above mean sea level (AMSL). At that time, LXH was on mid-crosswind, maintaining 1,100 feet. A review of the radar data indicated that the turn occurred earlier than other aircraft in the circuit. The instructor of LXH also observed TAU turn onto crosswind early and continued to monitor the aircraft.

Soon after, TAU commenced the turn onto downwind. The instructor of LXH continued to monitor the location of TAU and at 1529, observed TAU pass 100 feet below. About 30 seconds later, the instructor of TAU observed LXH to the left advised ATC and asked if they were to be following that aircraft. ATC confirmed that TAU was to follow LXH and that they should widen their circuit to ensure separation.

When operating in an area of high traffic density, it is crucial that pilots utilise both alerted and unalerted see-and-avoid techniques. Also, pilots should be mindful that when the circuit area is busy, it is important to conform to the circuit pattern being employed at the time to ensure sufficient separation with preceding and following aircraft.

Aviation Short Investigation Bulletin - Issue 16

At about 0715 eastern daylight time on 23 July 2011, a Moyes Dragonfly airplane, registration N402HA, was substantially damaged when it impacted terrain at Ridgely Airpark, Ridgely, Maryland, US. The pilot was fatally injured. The aircraft was being operated on a glider-tow flight.

As the accident took place in the US, the National Transportation Safety Board (NTSB) was responsible for the investigation. As part of its investigation (reference ERA11FA413), the NTSB requested assistance from the Australian Transport Safety Bureau (ATSB) to gather information from the aircraft's manufacturer, who is based in Australia.

In accordance with clause 5.18 of Annex 13 to the Convention on International Civil Aviation (Annex 13), the ATSB appointed an  accredited representative to assist the NTSB and initiated an investigation under the Australian Transport Safety Investigation Act 2003. In addition to obtaining the aircraft information for the NTSB investigation from the Australian manufacturer, the ATSB facilitated the development of safety action by the aircraft manufacturer and provided comments on the NTSB’s draft investigation report in accordance with clause 6.3 of Annex 13 in November 2012.

The NTSB is finalising its report and, when complete, this report will be available on the NTSB website at www.ntsb.gov.

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

Safety summary

What happened

On the morning of 23 November 2012, the pilot of a Piper Cherokee Six, registered VH-TSZ, with two other owner-pilots on board, took off from runway 24L at Jandakot Airport, Western Australia. After turning onto the track to Beverley and at about 700 ft above ground level, the engine lost power. The pilot immediately turned the aircraft towards runway 30 and focussed on flying the aircraft while the owner-pilot in the copilot seat conducted some of the troubleshooting checks. The engine did not regain power.

With insufficient height and speed to reach the runway, the pilot force landed the aircraft into wooded bushland within the airport precinct, approximately 150 m short of a cleared area in the undershoot of runway 30. The aircraft was substantially damaged by impact with trees. The occupants exited the aircraft with only a minor injury to one passenger.

What the ATSB found

The ATSB found no mechanical defects or fuel supply anomalies that would have prevented normal engine operation. The evidence for carburettor icing was equivocal and therefore, could not be ruled out as a contributing factor. No other likely contributing factors were identified.

It was also found that the pilot did not ensure all of the available procedures for an engine power loss and power-off landing were followed, which resulted in reduced gliding performance and a higher-than-necessary landing speed.

The pilot had not completed a flight review in the 2 years prior to the occurrence, increasing the operational risks including the response to emergency situations.

Safety message

The conduct of emergency procedures relies on the application of established knowledge and skills, reinforced by the use of a pre-take-off emergency briefing, and conduct of flight reviews. By not complying with the periodic flight review requirements, the pilot missed an opportunity to maintain those critical skills.

What happened

On 17 November 2012, a Piper PA-28R aircraft, registered VH‑HKZ, departed Bairnsdale on a private flight to Geelong (Grovedale), Victoria. After landing at Geelong, the pilot noticed that the office buildings were unoccupied and a fence had been placed across runway 09/27. The pilot and passenger exited the aircraft and were subsequently advised that the airstrip had been closed and was being redeveloped.

This incident highlights the importance of reviewing flight information in its entirety, ensuring that operational documents are current, and the benefits of contacting the airstrip operator to not only obtain landing permission, but to also receive information on the runway and its condition, any hazards and/or obstructions, and if there are any special procedures applicable to the airstrip.

Aviation Short Investigation Bulletin – Issue 15

What happened

On 21 November 2012, a Beech 200 Kingair aircraft, registered VH-VAH (VAH) turned onto final approach for runway 26 at Swan Hill aerodrome, Victoria.  At the same time, an Ag-Cat aircraft VH-IFE (IFE) was approaching the circuit at about one hundred feet above ground level, from the north-west.

The pilot of VAH had made all mandatory radio broadcasts on the CTAF frequency and had not received a reply since earlier negotiating separation with a departing aircraft.

When at about four hundred feet above ground level and configured for landing, the pilot of VAH first noticed IFE. He broadcast his position and intentions, but received no reply. IFE continued a curved approach and landed on the grass section, north of the sealed section of runway 26. To maintain a safe separation, VAH landed long and well clear of IFE.

IFE was not fitted with a radio. The pilot always relied on a hand-held one. On this occasion he had inadvertently left the radio at home.

The ATSB’s Safety Watch initiative highlights safety around non-towered aerodromes as one of the major safety concerns that arise from investigation findings.

Aviation Short Investigation Bulletin - Issue 16

What happened

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.

Aviation Short Investigation Bulletin – Issue 17

Safety summary

What happened

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.

Safety summary

What happened

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.

What happened

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.

Aviation Short Investigation Bulletin - Issue 16

What happened

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

Aviation Short Investigation Bulletin – Issue 15