On 11 October 2013, the student pilot of a G-115C2 Grob aircraft, registered VH-ZIV, departed the Merredin aeroplane landing area (ALA) on his first solo flight to the designated training area located near Lake Brown, Western Australia.
After about 1.4 hours the student elected to return to Merredin, tracking via Burracoppin Township. The student was unable to sight Merredin (ALA) and broadcast on the universal communications (UNICOM) frequency indicating that he was unsure of his position. The UNICOM operator gave him directions to locate Merredin.
The student located Merredin and joined the circuit for runway 28. When on short final he determined that he was too high and initiated a go-around. The student commenced a second circuit to runway 28. When on short final, the student reported there was a crosswind with slight windshear, and the glare from the sun was making it increasingly difficult to see the runway. The aircraft touched down heavily and bounced. The student reported that the sun glare made it very difficult to judge the height of the aircraft and he believed that the aircraft had not bounced very high. At about 1700 Western Standard Time the aircraft touched down again on the nose landing gear, which subsequently collapsed. The aircraft slid along the runway and came to a stop. The student pilot was uninjured and the aircraft sustained substantial damage.
The aircraft operator conducted an internal investigation and determined the student’s last meal was at 0600, which consisted of a sandwich and the operator’s flight risk assessment tool (FRAT) for the accident flight was incomplete. If all values for the flight had been entered, the total risk value for the flight would have been in the red area stating ‘No dispatch’.
The student indicated he had about 6 hours sleep the night before the accident as he was finishing his ground school homework and preparing for the next day.
This accident highlights the importance of pilots also assessing their own wellbeing, to determine if they are physically and mentally prepared, and if the operating conditions are suitable for the conduct of the flight. The effect of sun-glare when relying on visual cues is an important consideration for all pilots.
On 7 October 2013, the pilot of a Fairchild SA227 aircraft, registered VH‑UZP (UZP), was preparing for a freight charter flight from Ballina/Byron Gateway Airport (Ballina) to Coffs Harbour, New South Wales.
At the same time, the flight instructor and pilot of a Bell 47G helicopter, registered VH‑UTF (UTF), were conducting circuit training at Ballina. After landing, the pilot broadcast on the common traffic advisory frequency (CTAF) that UTF was entering runway 06 to conduct left hand circuits. Shortly after, UTF departed and recommenced circuit training.
The pilot of UTF broadcast turning onto a left base for runway 06. Soon after, UTF landed about two-thirds of the way along the runway and came to a stop, facing east. The instructor briefed the pilot prior to commencing a further circuit.
The pilot of UZP broadcast a taxi call and commenced taxiing to runway 06. After hearing no further broadcasts from the pilot of UTF, the pilot of UZP broadcast on the CTAF that he was entering and backtracking runway 06. The pilot again received no response. He taxied UZP onto the runway and lined up on runway 06. The pilot broadcast a lining up and rolling call and commenced the take-off run. Just prior to rotation, he sighted UTF stopped on the runway, towards the departure end. He elected to continue the take-off and increased the climb angle to provide separation with UTF.
The instructor of UTF then attempted to contact UZP, with nil response received. He then realised that the radio volume had been turned down. UTF then vacated the runway.
Broadcasting and monitoring the CTAF and maintaining a good lookout are useful strategies to improve safety at non-towered aerodromes.
On 5 October 2013, a Piper PA-44 aircraft, registered VH-CZH (CZH), was enroute to Rottnest Island, from Perth, Western Australia, to conduct instrument flight rules (IFR) navigation aid (navaid) training. On board were a flight instructor and student.
There was other IFR training aircraft on the Rottnest Island common traffic advisory frequency (CTAF) when CZH arrived over the navaid to commence the practice non-directional (radio) beacon (NDB) training. Both the instructor and student made frequent broadcasts on the CTAF to advise other traffic of the aircraft’s position and their intentions. The weather was instrument meteorological conditions and conditions were deteriorating as a large cold front was moving rapidly in from the south-west.
At about 1509 Western Standard Time (WST), as CZH was inbound in the holding pattern at 2,000 ft, Perth Centre air traffic control (ATC) advised the crew that an IFR Mooney M20 aircraft, registered VH‑DJU (DJU), was inbound to Rottnest Island, and would be on descent from 3,000 ft, for instrument navaid training. The estimated time of arrival overhead the NDB would be 1518. The instructor in CZH acknowledged this traffic information.
Shortly after, the instructor and student in DJU requested a descent to 2,000 ft due to severe turbulence at their current level. This descent took DJU from controlled to uncontrolled airspace and thus a change from ATC separation responsibility, to pilot responsibility for maintaining separation in the Rottnest Island area.
When the crew in CZH had not heard from DJU on the CTAF, the instructor tried unsuccessfully to raise them on this frequency. He then contacted ATC on the Perth Centre frequency, who provided traffic information. The pilots subsequently arranged mutual separation
The ATSB SafetyWatch campaign highlights the broad safety concerns that come out of our investigation findings and from the occurrence data reported to us by industry. One of the safety concerns is safety around non-controlled aerodromes. Insufficient communication between pilots, and breakdowns in situational awareness were the most common contributors to occurrences in the vicinity of non-controlled aerodromes.
On the evening of 7 October 2013, the pilot of a Cessna 172 aircraft, registered VH‑NUU (NUU), commenced night circuits at Archerfield Airport, Queensland. He reported that there were also four other aircraft and a helicopter conducting night circuits at the time. The pilot reported that the aircraft in the circuit were flying a ‘modified’ due to a strong tailwind and to make allowances for a helicopter that had been conducting stop-and-go circuits.
At the same time, the pilot of a Beech F33A aircraft, registered VH‑ZBZ (ZBZ), inbound to Archerfield, was advised by air traffic control that there were four or five aircraft in the circuit area. ZBZ joined the circuit between an aircraft on downwind and another on upwind. The pilot of ZBZ reported that he had the aircraft in front of him (NUU) sighted on downwind and extended the downwind leg to maintain separation with NUU.
NUU turned onto base and about 20 seconds later, the pilot of ZBZ also broadcast that he was turning onto base. Soon after, the pilot of ZBZ broadcast that he was established on final. At that time, he had sighted an aircraft well ahead on late final and believed it was NUU. The pilot of NUU immediately broadcast that he was on final.
The pilot of ZBZ then saw NUU below his aircraft. The pilot of ZBZ conducted a go‑around and NUU continued the approach.
Airservices Australia surveillance data indicated that the vertical separation reduced to 300 ft.
Maintaining a vigilant lookout at all times and standardisation of the circuit pattern is important for safe operations in the vicinity of non-towered aerodromes.
On 7 October 2013, a crew member on board the general cargo ship Toucan Arrow was crushed between the ship’s aft gantry crane and a cargo hold hatch lid while the crane was being prepared for cargo loading operations in Portland, Victoria.
First aid treatment was provided to the injured crew member on-site and he was transported by ambulance to the local hospital where he died as a result of his injuries.
What the ATSB found
The ATSB found that the crew member did not comply with the ship’s safe working procedures and did not ensure that the crane driver was advised and that the gantry crane’s electrical power supply was isolated before he began working in the vicinity of the crane. The investigation also found that the audible and visual crane in motion warning devices were not fully operational and effective.
The ATSB further found that there was a lack of mapping information available to assist the emergency services ‘triple zero’ operator in providing the emergency responders with directions to a defined location within the port area. It was also found that the ambulance service had not ensured that its officers were familiar with the port area and the protocols for opening the locked port access gates.
What's been done as a result
Toucan Arrow’s managers have updated the checklist titled ‘Induction for new joiners’ to ensure that all new crew members are informed of the precautions required when working on deck while the gantry cranes are in operation. Limit switches which detect the presence of a person on the cargo hatch ladder and stop the crane’s travel have also been fitted to the gantry cranes.
The Port of Portland has changed its procedures and informed its tenants that all emergency services are to be met at the port gates and escorted to the scene of an emergency. The updated emergency response plan has been distributed to all port users including shipping agents and the ambulance service.
Marker signs are also being placed around the port. The location of each sign, along with its GPS co-ordinates has been provided to the Emergency Services Telecommunications Authority, the operator of the ‘triple zero’ phone service, to better direct emergency services to the scene or meeting point for further directions.
Ambulance Victoria has requested the Emergency Services Telecommunications Authority to change its procedures so that when an ambulance is tasked to the Port of Portland, a telephone call advising the port’s emergency response controller is made.
Safety message
This accident highlights the importance of adhering to the requirements of on board safe working procedures, the effective assessment of risk and the implementation of appropriate risk controls.
On 3 October 2013 at 1223 UTC[1] an Airbus A330-302, registered B-18358 and operated by China Airlines, departed Sydney Australia on a scheduled passenger transport flight to Taipei, Taiwan ROC. Approximately 4 hours into the flight, the flight crew completed a precautionary shutdown of the number one engine in response to a low oil pressure warning. The aircraft diverted to Cairns, Australia where it landed without further incident.
What the ATSB found
The model ATS200-61 air turbine starter from the number one engine sustained an uncontained failure. Released debris from the starter severed an adjacent oil sump scavenge pipe, resulting in the loss of oil from the engine and necessitating the in-flight shutdown.
The starter manufacturer’s investigation concluded that the starter failure resulted from failure of the output shaft bearing. Damage to the bearing was reported as being consistent with a transient loading event, typical of that resulting from crash engagement of the starter clutch during engine starts or from axial loads transferred from the horizontal driveshaft. There was no evidence in the recorded data from the most recent series of engine starts to indicate that a crash engagement had occurred, however, it was possible that the transient loading event had occurred outside this timeframe.
What's been done as a result
Following the occurrence, the starter manufacturer, the engine manufacturer and the operator made a number of changes to their procedures for starter oil level check and starter oil changes.
To eliminate the potential for future crash engagements, the starter manufacturer was phasing out the single pawl and ratchet clutches such as that in the model ATS200-61 to be replaced by a full range pawl and ratchet or sprag clutch. The engine manufacturer had initiated a design change in the horizontal driveshaft to eliminate this as a source of axial load on the bearing.
The aircraft was fitted with both a cockpit voice recorder (CVR) and flight data recorder (FDR). The aircraft operator provided a download of the FDR for analysis by the ATSB. Analysis of the data confirmed the sequence of events and showed that the engine oil quantity for the No. 1 engine decreased to zero at a steady rate, commencing at 16:10:33 UTC, for a duration of approximately 1 minute. The engine oil pressure subsequently started to decrease once the oil quantity reached the minimum recordable level. This resulted in the oil pressure warnings received by the flight crew. There were no other anomalies noted in the recorded data.
The FDR data also contained the 20 previous flight sectors and start sequences for the aircraft engines. The data was examined by the ATSB and the engine manufacturer and showed no evidence of any errors or anomalies relating to the air turbine starter or starter air valve.
Engine details
Aircraft propulsion was provided by two General Electric CF6-80E engines. Engine serial number 811612 was installed in the No. 1 position and was a new engine at the time of installation. The engine had completed 4,096 hours and 1,169 cycles at the time of the occurrence. The failed air turbine starter was the original part fitted to the engine at the introduction to service.
Air turbine starter
Manufacturer:
Honeywell International Inc.
Part number:
59364-3505468-6
Model number:
ATS200-61E (Series 1)
Serial number:
GRTF6248
Time since new:
4096
Cycles since new:
1169
The air turbine starter utilises pressurised air from either the aircraft auxiliary power unit, another aircraft engine or a ground power unit to drive a turbine at high speed. The high-speed, low-torque from the starter turbine is converted to a lower-speed, high torque output via a reduction gear and the engine accessory drive system. The starter output is used to drive the engine high pressure rotor. Air supply to the starter is controlled by the starter air valve, which is pneumatically operated and electrically controlled.
Engagement of the air turbine starter with the engine is controlled via a ratchet and pawl clutch assembly (Figure 3). At zero or low speeds the three pawls are engaged with the ratchet, which is driven by the starter turbine. The pawl carrier is integral with the starter output shaft, which is constantly engaged with the engine. On a normal start, after ignition, the engine will accelerate to a speed whereby the pawls, acting like flyweights, will disengage from the ratchet to prevent the engine from back-driving the starter. The output shaft continues to rotate with the engine.
The 3505468-6 starter design was introduced to service in February 2009 beginning at serial number GRTF2607. The -6 designation included improvements to turbine axial containment.
Figure 3: Ratchet and pawl clutch example
Source: Aircraft Gas Turbine Engine Technology, Treager, 1996.
Air turbine starter investigation
Disassembly and examination of the starter was conducted by the starter manufacturer at their investigation facility and a detailed report was provided to the ATSB. The report concluded that the failure sequence was initiated by failure of the output shaft support bearing. This allowed contact between the rotating pawl carrier and ratchet, which subsequently failed, along with the hub gear. Failure of these components resulted in the fracture of the starter casing and release of debris with enough energy to sever the adjacent B-sump scavenge pipe on the engine.
Recovered output shaft bearing components were limited to fragments of the bearing cage, one fractured ball and one ball with significantly reduced diameter. The inner and outer bearing races were extensively damaged, but intact. It was likely that the output shaft continued to run for some time after the loss of oil, which caused additional damage to the bearing. It was therefore difficult to accurately assess the bearing failure mechanism. Nevertheless, the report indicated that based on analysis of the starter components, the most probable factor contributing to failure of the output shaft bearing was damage caused by a prior crash-engagement[3] of the clutch.
Following on from the initial report from the starter manufacturer, the engine manufacturer conducted further analysis of the starter failure. Their investigation concluded that a high transient load sustained by the output shaft bearing could subsequently lead to overrunning bearing failure. Further work by the engine manufacturer showed that trimming of the engine accessory gearbox horizontal drive shaft could prevent this axial load. As a result, a change in design had been approved at the time of writing this report, with the redesigned shafts to be available from November 2015. The change will be introduced to both the CF6-80C2 and the CF6-80E1 engines, which utilise a common Horizontal Driveshaft (HDS). It should be noted that the CF6-80C2 design already included extra axial clearance, which has prevented the over-running bearing failures, like those seen on the CF6-80E1.
Maintenance history
The Aircraft Maintenance Manual (AMM) recommended air turbine starter oil level checks at intervals of 800 hours and oil changes at intervals of 1,600 hours or 800 cycles. At the time of the occurrence, the AMM stated that the oil quantity until overflow was 800mL and that the quantity if visible at the bottom of the sight gauge was 700mL. At an oil check or change, if the oil level quantity was less than the sight gauge (700mL), a further check for evidence of oil leakage around the seals was required, and if recorded at less than 600mL the starter was to be replaced. Additional information stated that the output shaft bearing could fail from lack of lubrication and overheat when the oil level dropped below 600mL.
The AMM advised that normal oil consumption between maintenance operations was 30 – 200mL. The airline’s task card instructed that the starter had to be replaced if more than 200mL of oil was required during an oil check.
It was a requirement to record the level of oil drained from the starter during each oil change. Maintenance records indicated that the starter had undergone a previous oil check on 3 September 2013 at 3,715 hours since new (TSN) and 1,075 cycles since new (CSN) and an oil change on 8 July 2013 at 2,979 TSN and 887 CSN. At that most recent change, only 610mL of oil was recorded to have been drained, which was close to the lower limit of 600mL.
There was a discrepancy between what was included in the maintenance documentation and the data plate attached to the starter motor. The data plate on the starter stated an oil change at 800 hours as opposed to the 1600 hours stated in the AMM.
As a result of the findings related to potential low oil levels in the starter, the manufacturer conducted a number of tests running the starter with varying levels of oil. Their testing found that the starter actually had a capacity of 1000mL and was more susceptible to damage during operation with high oil levels rather than low. The starter could also be operated with almost zero oil without failure. However, it was noted that it would be unlikely to survive a series of engine starts with no oil due to failure(s) of the starter bearings, particularly turbine shaft bearings.
Following the occurrence, oil samples were collected from various sources, including oil from the same container that was used to service the failed starter, oil from in-service starters that had been serviced by the same container, and oil from the current container that was being used at the time of the sampling. Analysis of the oil samples found them to be within acceptable limits.
Starter air valve
The starter air valve (SAV) regulates the flow of pressurised air to the starter. The SAV was examined and subjected to functional testing at the manufacturer’s test facility. The results showed that the SAV was functioning as designed and had no pre-existing condition that would preclude normal operation.
Previous occurrences
There had been 13 over running bearing failures relating to the ATS200-61 starter model between January 2007 and August 2014. Five of these failures were identified as being uncontained relative to the starter housing;
On 7 July 2014, an Airbus A330 aircraft performed an air turn back following low oil quantity and pressure indications approximately 90 minutes after departure. Post-flight inspection revealed a fire in the starter area as a result of the uncontained failure of part number 3505468-6 starter. The starter had been installed in November 2013 and had accumulated 3,105 hours and 483 cycles since that time. The most likely failure scenario was low starter oil quantity as a result of leaking pressure fill fittings.
In November 2013, a part number 3505468-6 starter sustained an uncontained failure on an Airbus A330-300 aircraft. The mechanism of failure was similar to that of the subject occurrence, except that the failure occurred while the aircraft was on the ground and there was no secondary damage to the engine. The air turbine starter failed 16 days after the last oil change, and 2,758 hours since new. The failure was directly attributed to a lack of lubrication.
In July 2013, an uncontained starter failure was found during the post-flight inspection. The starter had 216 hours since new. The failure was related to a lack of lubrication with no oil found in the sump.
The fourth uncontained starter failure was in December 2011, and was again attributed to a lack of oil with the sump being found to completely dry. The starter was 27 hours since an oil change, and 6,180 hours since overhaul.
In 2007, the ATSB investigated an uncontained air turbine starter occurrence (AO-2007-052), featuring a 3505468-4 starter. In that occurrence, the turbine bearings failed, allowing the turbine disk to move axially inside the starter. The starter was fitted with cutter pins to remove the turbine blades in such an event, to prevent the starter going into a free-run condition. The pins partially separated the blades, but the starter did not contain the blades as designed, resulting in secondary damage to the engine. As a result of this occurrence, the manufacturer implemented corrective actions to prevent reoccurrence of this failure mechanism.
The starter manufacturer used the current failure data to perform a risk analysis of the hazard of a dual inflight shut down due to over running bearing failures. Three of the failures above were used to calculate the risk to the fleet, the two in flight shut down events and the diversion. They identified that bearing failures could be attributed to three main scenarios: axial overload from the main engine, crash engagement or improper oil servicing. The manufacturer’s risk assessment concluded that the risk to the fleet from all failure scenarios was at an acceptable level.
From the evidence available, the following findings are made with respect to the in-flight engine shutdown, involving an Airbus A330-302 aircraft, registered B-18358 that occurred 887 km ENE of Darwin, Northern Territory on 3 October 2013. These findings should not be read as apportioning blame or liability to any particular organisation or individual.
Safety issues, or system problems, are highlighted in bold to emphasise their importance. A safety issue is an event or condition that increases safety risk and (a) can reasonably be regarded as having the potential to adversely affect the safety of future operations, and (b) is a characteristic of an organisation or a system, rather than a characteristic of a specific individual, or characteristic of an operating environment at a specific point in time.
Contributing factors
The number one engine air turbine starter experienced an in-flight failure of the over-running output section as a result failure of the output shaft bearing.
Debris originating from the starter failure was not contained by the starter casing and severed the number one engine B-sump oil scavenge pipe. (Safety issue)
Complete loss of engine oil through the severed oil scavenge pipe resulted in a forced-shutdown of the number one engine.
Other factors that increase risk
The starter was operated for a period of time with a marginal oil level which may have affected the longevity of the output shaft bearing.
Safety analysis
The most likely failure sequence of air turbine starter (part number 3505468-6, serial number GRTF6248) was a failure of the output shaft bearing, followed by the hub gear, pawls and ratchets and then finally failure of the housing. The starter manufacturer determined that the most probable cause was excessive loading, which could have been associated with a previous crash engagement or a transient load provided by the horizontal driveshaft. While direct evidence of a crash engagement was not detected on the previous 20 starts, the starter manufacturer indicated that it did not necessarily mean the output shaft had not been damaged prior to this time and that it may have taken operation over an extended period to manifest in a failure. The starter manufacturer demonstrated that the impact load and subsequent damage to the shaft was a function of velocity and acceleration at engagement and the backlash in the start system at the moment of engagement. The engine manufacturer also performed some analysis which showed that a high transient load applied to the bearing could lead to overrunning bearing failure.
The risk analysis conducted by the starter manufacturer, covering the period from January 2007 to August 2014, identified 13 bearing failures in the starter type. The overall risk to the fleet was determined to be at the acceptable level.
At the most recent oil change, the quantity of oil drained was just above that required for a replacement starter to be installed. While a lack of lubrication did not appear to be an issue in this case, the high loss of oil between maintenance leading up to the failure was potentially indicative of a leak. This allowed the oil level to get down to around the lower limit of 600 mL, where previously the oil had shown little loss between inspections. The engine manufacturer indicated that output shaft seal leaking was responsible for a high number of starter shop findings. The design of the output shaft seal assembly meant that it was installation-sensitive and steps have been taken by both the engine and starter manufacturers to clarify and provide additional information to operators and maintainers of the affected starters.
Furthermore, while the aircraft operator had been conducting maintenance on the starter in accordance with the CMM, the discrepancy between information in the CMM and on the air turbine starter data plate had the potential to affect future air turbine starter maintenance. At the time of writing, the starter manufacturer had initiated an engineering change to remove maintenance information from the data plate.
Safety issues and actions
The safety issues identified during this investigation are listed in the Findings and Safety issues and actions sections of this report. The Australian Transport Safety Bureau (ATSB) expects that all safety issues identified by the investigation should be addressed by the relevant organisation(s). In addressing those issues, the ATSB prefers to encourage relevant organisation(s) to proactively initiate safety action, rather than to issue formal safety recommendations or safety advisory notices.
All of the directly involved parties were provided with a draft report and invited to provide submissions. As part of that process, each organisation was asked to communicate what safety actions, if any, they had carried out or were planning to carry out in relation to each safety issue relevant to their organisation.
The initial public version of these safety issues and actions are repeated separately on the ATSB website to facilitate monitoring by interested parties. Where relevant the safety issues and actions will be updated on the ATSB website as information comes to hand.
Uncontained failure of air turbine starter led to loss of engine oil
Safety issue description: Debris originating from the starter failure was not contained by the starter casing and severed the number one engine B-sump oil scavenge pipe.
Sources and submissions
Sources of information
The sources of information during the investigation included the:
China Airlines
Honeywell
General Electric
Airbus
References
Treager I E, 1996, Aircraft Gas Turbine Engine Technology, Third Edition, Glencoe/McGraw-Hill New York, p 381.
Submissions
Under Part 4, Division 2 (Investigation Reports), Section 26 of the Transport Safety Investigation Act 2003, the ATSB may provide a draft report, on a confidential basis, to any person whom the ATSB considers appropriate. Section 26 (1) (a) of the Act allows a person receiving a draft report to make submissions to the ATSB about the draft report.
A draft of this report was provided to China Airlines, Honeywell, General Electric, the Aviation Safety Council (ASC, Taiwan ROC), The National Transportation Safety Board (NTSB, USA), Airbus and the Bureau d’Enquêtes et d’Analyses (BEA, France).
Submissions were received from to China Airlines, Honeywell, General Electric, the Aviation Safety Council (ASC, Taiwan ROC), The National Transportation Safety Board (NTSB, USA), Airbus and the Bureau d’Enquêtes et d’Analyses (BEA, France). The submissions were reviewed and where considered appropriate, the text of the report was amended accordingly.
The occurrence
History of the flight
On 3 October 2013 at 1223 UTC, an Airbus A330-302 aircraft, registered B-18358 and operated by China Airlines, departed Sydney, Australia on a scheduled passenger transport flight to Taipei, Taiwan ROC. On board the aircraft were 205 passengers and 13 crew.
At 1611, when the aircraft was approximately 890km ENE of Darwin, Australia, the flight crew received an ECAM[2] low oil quantity advisory and, a minute later, a low oil pressure warning for the No. 1 engine. The flight crew initiated a precautionary shutdown of the affected engine at 1613 and then diverted the aircraft to Cairns, Australia where it landed at 1813 without further incident. There were no injuries as a result of the occurrence.
Post-occurrence
Preliminary examination of the No. 1 engine by maintenance personnel at Cairns found that the air turbine starter had sustained an uncontained failure. Debris released from the starter had severed the adjacent B-sump engine oil scavenge pipe and damaged (without rupturing) the C-sump oil scavenge pipe (Figure 1). This resulted in the complete loss of oil from the No. 1 engine, necessitating the engine shut down.
The starter (Figure 2) and associated starter air valve were initially sent to the ATSB for visual examination before being forwarded to the starter manufacturer for detailed disassembly and inspection.
Figure 1: Damage to oil pipes visible after removal of the starter
Source: China Airlines
Figure 2: The air turbine starter removed from B-18358, as-recovered
Purpose of safety investigations & publishing information
Purpose of safety investigations
The objective of a safety investigation is to enhance transport safety. This is done through:
identifying safety issues and facilitating safety action to address those issues
providing information about occurrences and their associated safety factors to facilitate learning within the transport industry.
It is not a function of the ATSB to apportion blame or provide a means for determining liability. At the same time, an investigation report must include factual material of sufficient weight to support the analysis and findings. At all times the ATSB endeavours to balance the use of material that could imply adverse comment with the need to properly explain what happened, and why, in a fair and unbiased manner. The ATSB does not investigate for the purpose of taking administrative, regulatory or criminal action.
Terminology
An explanation of terminology used in ATSB investigation reports is available here. This includes terms such as occurrence, contributing factor, other factor that increased risk, and safety issue.
Publishing information
Released in accordance with section 25 of the Transport Safety Investigation Act 2003
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On the morning of Saturday 5 October 2013, the pilot of a Rand Robinson KR-2 aircraft, registered VH-CTE, took off from an airstrip on private property 12 km west of Tumut, New South Wales. The pilot was reported to have intended flying to Holbrook, New South Wales, and return home the following evening.
When the pilot had not returned by early Sunday evening, authorities were notified. A search located the aircraft wreckage in the early morning on 7 October 2013. The wreckage was found about 450 m east-north-east of the departure airstrip. The pilot was fatally injured, and the aircraft was destroyed by impact forces.
What the ATSB found
Data from a global positioning system receiver recovered from the wreckage identified that the pilot turned back towards the departure airstrip shortly after take-off. During the attempt to land back on the airstrip, the aircraft likely entered a stall. The pilot was unable to recover the aircraft before impacting terrain.
The ATSB’s examination of the wreckage found that a spark plug had been ejected from its respective cylinder head mount. The failure of the cylinder head spark plug mount was probably the result of an incorrectly installed thread insert. There were reports and evidence that the pilot maintained and modified the aircraft, despite not being qualified or authorised to do so. As well, in the previous 2 years, an authorised maintainer had not completed the required regular aircraft maintenance.
The pilot’s decision not to have proper maintenance performed on the aircraft most likely contributed to the ejection of the spark plug, resulting in the accident.
Safety message
Unauthorised maintenance increases the risk of mechanical failure. This, in turn, reduces the level of safety and increases the risk of injury or death.
Authorised aircraft maintenance is mandated to assure a level of safety for aircraft operations. That directive also identifies the requisite qualifications for the maintainer.
As well, managing airspeed and bank angle is critical to preventing an aerodynamic stall following partial engine failure after take-off. Research shows partial engine power loss is more complex and more frequent than a complete engine power loss. These accidents are typically a result of the aircraft entering an aerodynamic stall from a height where recovery is not possible.
On the morning of the accident, it was reported that the pilot arose at 0600 and had breakfast, then left for the airstrip. Reports state that the pilot was in good health, was not on any medication and had recently completed a medical examination required for drivers of commercial coaches.
Pilot licences and certificates
The pilot held a Private Pilot (Aeroplane) Licence issued by the Civil Aviation Safety Authority on 26 February 1990. The licence included an endorsement for single-engine aeroplanes below 5,700 kg. Additionally, the pilot held a special design feature endorsement for manual propeller pitch control. The pilot did not hold the special design feature endorsement for tail wheel or for retractable landing gear, which were required for operation of an Australian (VH) registered aircraft with those features, such as the KR2. The pilot held a valid Class 2 medical certificate with a restriction that reading correction must be available while flying.
Before flight as pilot in command in an Australian registered aircraft, Civil Aviation Regulation 5.81 required that a pilot holding a private (aeroplane) pilot’s licence must successfully complete an aeroplane flight review within the period of 2 years immediately before the day of the proposed flight. The last Aeroplane Flight Review recorded as being completed by the pilot was on 20 August 2009.
The pilot also held a Recreational Aviation Australia (RA-Aus) pilot certificate. This certificate included endorsements for high-performance aircraft, tail wheel aircraft, and in-flight adjustable pitch propeller. The certificate did not include an endorsement for retractable landing gear. The certificate recorded the date of the last RA-Aus flying review as 18 November 2012. The pilot had previously held a senior instructor qualification for flight training in RA-Aus-administered aircraft.
Flight experience
The pilot’s logbook contained a record of the pilot’s flying from 1989 to November 2012. The logbook recorded the pilots total flying time as 988 hours. The last entry in the logbook was the Biennial Flight Review in a RA-Aus-administered aeroplane on 18 November 2012. From 2003, nearly all of the pilot’s logged flying time was in RA-Aus-administered aeroplanes, a considerable amount of which was logged as instructional flight. The last recorded flight in an Australian registered aircraft was an Aeroplane Flight Review on 20 August 2009.
Meteorological information
The weather conditions in the Tumut area on the morning of the accident were reported to be fine, with a light to moderate westerly wind. Recorded weather observations in the region of the planned flight also identified fine weather conditions with good visibility and light winds below 5,000 ft. Weather was not considered to be a contributing factor.
Wreckage information
The aircraft, a Rand Robinson KR-2 (KR-2), impacted terrain about 450 m to the east-north-east of the northern end of the Adelong airstrip (Figure 2).
Figure 2: Overview of accident site looking south, away from the direction of take-off
Source: NSW Police Force
Examination of the aircraft wreckage (Figure 3) determined the following:
All components of the aircraft were located at the impact site.
The aircraft was in a left wing low, steep nose-down attitude and heading in a south-westerly direction on impact.
Damage to the landing gear was consistent with the landing gear being extended at impact.
The position of the flap could not be determined.
All flight controls appeared to be intact and securely connected at impact. The position of the aircraft’s electrical elevator trim at impact could not be determined.
The engine was producing low or no power at impact.
The engine controls were disrupted by the impact and their position at impact was uncertain.
There appeared to be sufficient fuel remaining on board the aircraft at impact.
The number three cylinder upper spark plug (No.3 upper) was dislodged from its cylinder head hole. The spark plug remained attached to the engine through the spark plug lead and the engine cylinder head temperature gauge wiring. The dislodgment was not a result of impact forces.
Shaped aluminium panels with fire-resistant material attached were located in a shed adjacent to the airstrip. These panels were probably cooling air baffles previously fitted to the aircraft’s engine.
Figure 3: Aircraft wreckage
Source: ATSB
A number of aircraft components were removed from the accident site for testing and more detailed examination. The following additional evidence was determined from this examination:
Six of the eight spark plugs were of the type originally fitted by the builder of the aircraft (builder). The remaining two spark plugs, which included the dislodged No. 3 upper spark plug, were of a different type.
All engine cylinder lower spark plug holes were fitted with heli-coil inserts.
Both right hand cylinder upper spark plug holes, which included the No. 3 cylinder, were fitted with threaded inserts.
The No. 3 upper spark plug displayed evidence of having been blown out from its cylinder head hole before the aircraft impacted terrain. The failure of the cylinder head spark plug hole thread was probably the result of an incorrectly installed thread insert.
The fuel system and ignition system components tested normally.
The engine was disassembled and found to be in good condition with no mechanical defects.
The airspeed indicator displayed an impact witness mark at 48 kt.
The vertical speed indicator displayed an impact witness mark at 1,850 ft/min rate of descent.
The aircraft was fitted with a stall warning indicator. The stall warning sensor was significantly damaged by the impact with terrain. It was not possible to determine the stall warning system’s serviceability before the accident.
The engine manufacturer advised that the ejection of one spark plug from the cylinder head mounting would result in a loss of power in the order of 30 per cent.
Aircraft information
Construction, certification and registration
The KR-2 was an amateur-built, two-place, low-wing monoplane aircraft with retractable landing gear. The airframe was constructed of wood, foam and fibreglass composite. The builder purchased a partially completed KR-2 kit with a Revmaster engine in 1994.
The Sport Aircraft Association of Australia (SAAA) provided oversight and supervision of the construction of amateur built and kit aircraft. The builder registered with the SAAA in 1995.
The aircraft was fitted with a 4 cylinder, horizontally opposed, air-cooled Revmaster 2100D engine and a fixed-pitch, 2-blade, wooden propeller. The Revmaster 2100D engine was a modified Volkswagen automotive engine. Regulations required that, prior to fitment, this engine type be dismantled and inspected. The engine was dismantled, inspected and rebuilt at an authorised facility in Australia in 1990, before being fitted to the aircraft.
The builder entered the aircraft onto the Australian register on 31 March 2000. On 18 March 2001, a Civil Aviation Safety Authority (CASA) delegate issued a Special Certificate of Airworthiness (SCOA) for the aircraft to enable flight testing. The SCOA was in the Experimental airworthiness category for Amateur Built Aircraft and had an unlimited expiry date. Attached to the SCOA was an annex that caused the SCOA to expire in March 2003. That annex permitted operation of the aircraft for flight-testing only and limited those test flights to a specified restricted area. The issue of a second annex to the SCOA on 12 March 2003 identified the successful completion of the test flight programme. The second annex returned the SCOA to an unlimited status, but included a number of conditions attached to the operation and maintenance of the aircraft. The maintenance conditions included that:
The aircraft shall not be operated unless within the preceding 12 calendar months it has a Condition Inspection performed in accordance with the relevant CASA maintenance schedule.
Condition inspections may be performed by a Licenced Aircraft Maintenance Engineer (LAME) or by the builder.
In January 2012, the builder sold the aircraft to the pilot. The pilot transferred the aircraft’s registration into their name in January 2012. The pilot had discussed the possibility of transferring the aircraft from the Australian register to the RA-Aus register. However, this process had not been commenced prior to the accident.
Transport, maintenance and modification
The pilot was reported to have transported the aircraft by road to Tumut, New South Wales. Transporting the aircraft required the removal of the wings and disconnection of the aileron flight control system. At Tumut, the pilot had the aircraft repainted and on completion, the aircraft was reassembled. The reassembly required re-rigging the wings and reattachment of the flight control system. The first flight recorded by the pilot in VH-CTE (CTE) was on 4 August 2012.
The builder stated that the aircraft that was sold to the pilot in the following condition:
All spark plugs were of the same type.
Neither heli-coils nor the threaded inserts were fitted into the engine cylinder head spark plug holes.
The aircraft was fitted with a mechanical elevator trim system of a type similar to that fitted to DH82 Tiger Moth aircraft.
The builder also stated that the aircraft’s engine cooling system was specially designed to overcome cooling problems often experienced by aircraft fitted with Volkswagen-type engines. Finally, it was reported that during the builder’s ownership of CTE, the engine temperatures were normal at all times.
It was reported to the ATSB that the pilot began discussing high temperature issues with the aircraft’s engine in the months leading up to the accident. When discussing the problem, the pilot believed that the high temperatures were the result of the aircraft’s engine cooling system configuration, and that this would be corrected through modifying the cooling system to a more conventional layout. The pilot removed the cooling baffling and modified the engine cowl. The modified engine cowl was returned from repainting the day before the accident flight.
The aircraft’s maintenance documentation did not have any record of any of the above maintenance actions or aircraft modifications.
The builder completed and signed the last recorded Maintenance Release (MR) on 30 October 2010.
Authorisation to conduct maintenance
Civil Aviation Regulation 42ZC stated that the holder of a Certificate of Registration for an Australian aircraft must ensure that maintenance on that aircraft is conducted by a person authorised by that regulation. This obligation also applied to the pilot of that aircraft. The regulation then identified the class of persons authorised to conduct maintenance on certain types of aircraft.
With respect to CTE, that class of person included a LAME and a person authorised in writing by CASA. CASA normally issues written authorisations through the publication of an instrument. In March 2013, CASA published an instrument, CASA 33/13, which authorised certain persons who were not a LAME to carry out maintenance on amateur-built aircraft with special certificates of airworthiness. That instrument also authorised those persons to issue maintenance releases. To qualify as a person, other than a LAME who could conduct maintenance on CTE, that person was required to have been the primary builder of CTE, or an aeroplane that was essentially similar to CTE. The pilot did not meet these criteria.
GPS data
The GPS unit found in the wreckage contained data for a number of flights. These recorded flights were consistent with reports and observations of flights that the pilot conducted in CTE. The data included the accident flight. The flight recordings identified that the pilot would depart the Adelong airstrip to the north-east before turning left and setting heading for Holbrook. For the return legs, the pilot would position the aircraft for a left hand circuit to land to the south-west. A comparison of the recorded circuits for landing at the Adelong airstrip is at Figure 4. The flight profiles are for flights that departed Holbrook and landed at Adelong, with the following exceptions:
the accident flight (white)
a flight that departed Adelong and then turned back to the Adelong airstrip from a position near Holbrook (blue).
Figure 4: GPS flight data with accident flight shown as the white track
Source: Google earth modified by ATSB.
The data for the accident flight was analysed to determine the aircraft’s flight profile. The data is presented at Table 1 and graphically presented in Figure 5. The following conditions and limitations apply to this data:
There was no vertical component (altitude) in the GPS data.
The positional data with associated time enables ground speed to be determined. The actual airspeed may be greater or lesser due to wind as well as any vertical component of the aircraft’s velocity vector.
The wind component is unknown, however, the meteorological data and local reports identify that the wind was probably calm.
The track, groundspeed and bank angle values are derived values based on the latitude/longitude and time data provided by the GPS.
Based on the GPS data, the estimated time of impact was at 0859:55.
Table 1: GPS data
Position Number
EST
Track (Degrees)
Ground speed (kt)
Bank Angle (Degrees)
1
08:59:42
18
62
11
2
08:59:47
358
62
20
3
08:59:51
330
57
28
4
08:59:54
295
54
19
5
08:59:55
283
29
42
6
09:04:46
155
0
0
Figure 5: Accident flight with final data points from Table 1
Source: Google earth modified by ATSB.
The aircraft’s maintenance logbook recorded the stall warning system as being set to activate at 45 knots indicated airspeed (KIAS). The builder stated that the aircraft stalled at about 40 KIAS. Table 2 contains data for the stall warning activation speed when the aircraft is in a level turn at various angles of bank.
Table 2: Stall speed for angle of bank
Angle of Bank (Degrees)
Airspeed KIAS
0
45
20
46
30
48
37
50
45
54
60
64
The following observations in relation to the accident flight are also of note. The ground speed for the majority of the flight was between 58 kt and 70 kt, except for the last 8 seconds of flight. The average angle of bank remained below 10°, except:
when the pilot turned towards the north-east onto a downwind heading, where the bank angle increased to just under 25°
during the last 13 seconds of flight.
Survivability
To assist an emergency response in the event of an accident, the Aeronautical Information Publication Australia, En Route section 1.10 paragraph 2.11 stated the criteria under which a VFR flight was required to submit flight notification. That requirement could be met through the notification of SARTIME[2] to Air Traffic Services, or the use of a Flight Note. For the accident flight, the pilot was not required to and did not notify a SARTIME, or leave a Flight Note.
In addition, the aircraft was not equipped with an emergency locator transmitter (ELT), nor did the pilot carry an approved substitute for the ELT. The carriage of an ELT or substitute was not required.
The accident was not considered to have been survivable due to the magnitude of the impact forces during the collision with terrain.
Previous occurrences
ATSB research report AR-2007-043(2), published 26 March 2013 made the following conclusions in relation to amateur built aircraft accidents:
Between 1988 and 2010, amateur-built aircraft on the Australian VH-register had an accident rate three times higher than comparable VH-registered factory-built aircraft conducting similar flight operations.
The fatal and serious injury accident rate was more than five-times higher in amateur-built aircraft than similar factory-built aircraft.
Loss of aircraft control led to 25 per cent of all amateur-built accidents; slightly more than for factory-built aircraft accidents, however, the loss of control accident rate was over four times higher. Against factory built aircraft, serious injury was three times more likely after loss of control in amateur-built aircraft accidents. In respect of amateur-built aircraft, loss of control accidents were more likely to arise from aircraft handling issues where pilots had comparatively lower levels of experience on the aircraft type. Similarly, loss of control was more likely to occur in the initial climb phase of flight.
Amateur-built aircraft pilots involved with accidents were significantly more experienced overall than factory-built aircraft accident pilots. However, they were significantly less experienced on the aircraft type that they were flying at the time of the accident, compared to both pilots of factory-built aircraft accidents and amateur-built aircraft owners in general. Twenty per cent of amateur-built aircraft accident pilots had less than 10 hours experience on the accident aircraft type.
Engine failures and partial power loss occurrences were twice as likely in amateur-built aircraft accidents (accounting for 30 per cent of accidents) when compared with factory-built aircraft accidents.
This analysis will examine the operational and maintenance factors surrounding the accident. Evidence from the accident site as well as data from the pilot’s global positioning system receiver indicate that the pilot most likely lost control of the aircraft while approaching to land back at the Adelong airstrip. The pilot was unable to recover the aircraft before colliding with the ground. The departure from controlled flight was consistent with a probable aerodynamic stall. The analysis will consider the development of circumstances that preceded that event.
Partial engine failure
Shortly after departing the Adelong airstrip, the pilot turned back towards the airstrip. The turn back was probably the result of the loss of power caused by the ejection of the number three cylinder upper spark plug. While the engine manufacturer indicated that the ejection of a spark plug would result in a loss of power in the order of 30 per cent, the investigation was unable to determine whether any power was available to the pilot post the engine failure event. Analysis of the wreckage indicated that the engine was producing low or no power at impact.
The aircraft maintained a relatively stable ground speed during the return to land and manoeuvring onto downwind. It is probable that the aircraft was at a low altitude when it probably entered an aerodynamic stall as it turned towards the runway. The following evidence supports this conclusion:
the rapid speed loss during the last 8 seconds of flight, combined with
the short time duration from the point of rapid speed loss until the aircraft impacted terrain.
The recorded data, instrument witness marks, the aircraft’s impact attitude and finally the wreckage distribution are all consistent with the aircraft having entered an aerodynamic stall in the last seconds of the flight.
Unapproved modifications and maintenance
The pilot had reported that the aircraft was operating at high engine temperatures. The pilot attempted to correct the problem through self-diagnosis and maintenance action. However, the pilot did not have the requisite qualifications nor authorisation to conduct the necessary maintenance action to correct the reported temperature problems.
The attempt by the pilot to correct the temperature problem was not the only conduct of unauthorised maintenance or modifications on the aircraft. There is sufficient evidence to identify that the pilot also conducted a number of other unauthorised maintenance and modification actions on the aircraft, including the fitment of an electric trim system and the rigging of the aircraft wings and flight controls.
In addition, the aircraft’s maintenance release (MR) had expired almost 2 years prior to the accident flight.
There were a number of missed opportunities where qualified maintenance action could have identified and corrected the impending failure of the number three cylinder upper spark plug mount. These opportunities were the conduct of regular MR maintenance action, as well as specific maintenance action to address the engine temperature issues. The pilot's decision not to have qualified engineers perform maintenance action on the aircraft prior to the accident flight therefore likely contributed to the partial engine failure that triggered the accident sequence.
Flight notification
The pilot did not use a recognised method of flight following, or search and rescue alerting through the use of an emergency locator beacon or recognised substitute. This resulted in significant delays before the authorities were notified that the pilot was missing, and search and rescue action initiated. However, due to the significant impact forces evident from the aircraft’s collision with terrain, these factors did not affect the survivability of the accident.
Currency and qualifications
The pilot had not completed the required aeroplane flight review within the requisite period before the flight. Nor had the pilot obtained the required endorsements to command an aircraft of the KR-2 type with retractable undercarriage and tailwheel. The pilot held a pilot’s certificate to operate a similar type of aircraft using the Recreational Aviation Australia (RA-Aus) based system. The pilot also had considerable experience in similar types of aircraft under the RA-Aus system before the accident. Therefore, the pilot’s lack of qualification and experience were not determined to have contributed to the accident; however, these matters were significant breaches of the Civil Aviation Regulations.
Sources and submissions
Sources of information
The sources of information during the investigation included the:
pilot’s family members
previous aircraft owner/builder
the engine manufacturer
other pilots
NSW Police Force
State Coroner of NSW.
Submissions
Under Part 4, Division 2 (Investigation Reports), Section 26 of the Transport Safety Investigation Act 2003 (the Act), the ATSB may provide a draft report, on a confidential basis, to any person whom the ATSB considers appropriate. Section 26 (1) (a) of the Act allows a person receiving a draft report to make submissions to the ATSB about the draft report.
A draft of this report was provided to the Civil Aviation Safety Authority and the previous aircraft owner/builder.
Submissions were received from the previous aircraft owner/builder. The submissions were reviewed and where considered appropriate, the text of the report was amended accordingly.
The occurrence
At about 0855 Eastern Standard Time[1] on Saturday, 5 October 2013, the pilot and owner of a Rand Robinson KR-2, registered VH-CTE (CTE) took off from an airstrip on private property near Adelong and 12 km west of Tumut, New South Wales (NSW). Reports stated that the pilot intended to fly to Holbrook, NSW, for the weekend. The pilot was due to return home on the evening of Sunday, 6 October. Holbrook is 89 km to the south-west of the departure airstrip.
The pilot’s family reported the pilot missing early on the evening of 6 October. A search commenced, but was suspended due to darkness without locating the pilot or the aircraft. On recommencing early the following morning, the wreckage of the aircraft was found about 450 m east-north-east of the airstrip. The pilot was located in the aircraft wreckage and was fatally injured. The aircraft was destroyed by impact forces. There was no fire.
A portable Garmin Pilot III global positioning system (GPS) satellite navigation receiver was found in the wreckage. The GPS held recorded data for a number of flights, including flight path data for the day of the accident (Figure 1). The accident data started at 0853:21. It recorded the aircraft departing the airstrip towards the north-east before turning left onto a south-westerly heading. At a point adjacent to the downwind threshold of the airstrip the aircraft turned left 90° and tracked south-east. The aircraft then turned left again to make what appeared to be a close-in left downwind leg. This appears consistent with positioning to land toward the south-west, the opposite direction to that used for the take-off. The data showed that in the last 20 seconds of the flight, the aircraft’s groundspeed was steady at about 63 kt before rapidly decreasing during the final left turn. The recorded data indicated that the aircraft impacted terrain at about 0900.
From the evidence available, the following findings are made with respect to the loss of control following partial engine failure involving the amateur-built Rand Robinson KR-2, registered VH-CTE that occurred near Tumut, New South Wales on 5 October 2013. These findings should not be read as apportioning blame or liability to any particular organisation or individual.
Contributing factors
Shortly after take-off the number three cylinder upper sparkplug was ejected from the cylinder head hole, resulting in a significant loss of engine power. This failure was the result of an incorrectly installed spark plug thread insert.
While positioning VH-CTE for a return landing onto the departure airstrip after the power loss, the aircraft probably entered an aerodynamic stall from which the pilot was unable to recover before the aircraft impacted terrain.
The pilot's decision not to have qualified engineers perform maintenance action on the aircraft, both with respect to regular maintenance action as well as corrective maintenance action regarding engine overheating problems, represented missed opportunities to identify and correct the impending failure of the number three cylinder upper spark-plug mount.
Other factors that increased risk
During the period that the aircraft was owned by the accident pilot, there were a number of unauthorised modifications and maintenance actions carried out on VH-CTE. None of these maintenance actions were recorded in the aircraft’s maintenance documentation.
The pilot did not use a recognised method of flight notification or search and rescue alerting, resulting in significant delay before authorities were alerted that the pilot was missing.
The pilot had not completed an aeroplane flight review within the requisite period before the flight, and was not endorsed to fly an Australian registered aircraft with tailwheel or retractable landing gear.
Purpose of safety investigations & publishing information
Purpose of safety investigations
The objective of a safety investigation is to enhance transport safety. This is done through:
identifying safety issues and facilitating safety action to address those issues
providing information about occurrences and their associated safety factors to facilitate learning within the transport industry.
It is not a function of the ATSB to apportion blame or provide a means for determining liability. At the same time, an investigation report must include factual material of sufficient weight to support the analysis and findings. At all times the ATSB endeavours to balance the use of material that could imply adverse comment with the need to properly explain what happened, and why, in a fair and unbiased manner. The ATSB does not investigate for the purpose of taking administrative, regulatory or criminal action.
Terminology
An explanation of terminology used in ATSB investigation reports is available here. This includes terms such as occurrence, contributing factor, other factor that increased risk, and safety issue.
Publishing information
Released in accordance with section 25 of the Transport Safety Investigation Act 2003
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On 1 October 2013, at about 0530 Central Standard Time, the crew of a Vincent Aviation Beech 1900C aircraft, registered VH-VNV, was preparing for two return flights from Darwin to Jabiru, Northern Territory.
The crew conducted a pre-flight briefing, which involved reviewing the applicable Notices to Airmen (NOTAMs). This included a NOTAM which advised that the runway 29 threshold would be displaced from 0800 due to works in progress. The flight departed Darwin at about 0615 and returned at about 0800, at which time the displaced threshold was in place.
For the second flight, at about 0900, the first officer (FO) requested and obtained a clearance to taxi to taxiway ‘Bravo 2’ (B2). While taxiing to B2, the captain asked the FO to check the take-off performance data in the manual regarding the displaced threshold; however, he was unable to locate the relevant section prior to approaching the holding point.
When at the B2 holding point, the captain observed an aircraft on final approach. Air traffic control then cleared the crew to line up on runway 11 and asked them to confirm that they were aware of the displaced threshold to the east of taxiway ‘Echo’ (E). The FO replied that he understood.
The crew reported that when they were lined up on runway 11, they could see the tops of vehicles conducting the runway works, but due to a rise in the runway, were unable to see the start of the displaced threshold. The crew were cleared for take-off by ATC.
As the take-off run was commenced, both crew members observed that the displaced threshold was closer than expected and the captain immediately rejected the take-off at low speed.
As a result of this occurrence, the aircraft operator has advised the ATSB that a notice was released to company pilots reinforcing the policy regarding planning of the flight by both members of the crew.
A report previously prepared for the ATSB found that there was a significant potential for oversight of critical information in the NOTAM system. This incident highlights the importance of thorough pre-flight planning and the use of all available information in preparing for flight.
On 1 October 2013, at about 1420 Eastern Daylight-savings Time, a Piper PA-28-161 aircraft, registered VH-CCQ, departed from Lilydale, Victoria for a private flight to Charleville, Queensland via Bourke, New South Wales, with the pilot and one passenger on board.
During the cruise, maintaining 8,500 ft above mean sea level, the pilot selected an engine power setting of 65% and leaned the fuel mixture. The pilot conducted fuel calculations every 30 minutes, and changed between the left and right fuel tanks to maintain the aircraft’s balance within the normal operating limits. When approaching Bourke, the pilot calculated the fuel remaining on board based on the fuel gauge indications and the nominal fuel flow, and elected not to land at Bourke for refuelling, but to divert and continue directly to Charleville.
At about 1900, when about 20 NM east of Cunnamulla, Queensland, the engine began to run rough and surge. The pilot assessed that the most likely cause was fuel contamination in the selected right tank and changed to the left fuel tank. The engine continued to run rough and the pilot elected to divert to Cunnamulla.
The engine power then reduced to idle and the pilot configured the aircraft for a forced landing. As it was dark by this time, the pilot selected the landing light on to illuminate a suitable landing site. The light flashed on and then failed. The aircraft landed in a paddock at about 1920, bounced once and during the subsequent landing roll, the aircraft collided with a tree, detaching the left wing. The aircraft was substantially damaged and the pilot and passenger sustained minor injuries.
This incident highlights the importance of thorough pre-flight planning and understanding the implications of both aircraft and pilot limitations.
On 12 September 2013, at about 0930 Eastern Standard Time, the pilot of an Ayres S2R aircraft, registered VH-WBK (WBK), commenced aerial agricultural operations on a property about 37 km south-southwest of Horsham aerodrome, Victoria.
At about the same time, the operator of an unmanned aerial vehicle (UAV), Sensefly eBee 178, arrived at the Echo mine site to conduct an aerial photography survey. He heard WBK operating about 1-1.5 km away and broadcast on the area frequency advising his intention to conduct unmanned aerial photography operations but did not receive a response. He asked the mine manager to contact the farmer and notify the pilot of WBK.
The UAV operator then commenced the flight at about 390 ft above ground level (AGL).
After completing the first load of fertilizer, the farmer informed the pilot of WBK there would be an ‘aircraft’ conducting aerial photography over the Echo mine site. The pilot assumed this would be a fixed-wing aircraft operating at or above 500 ft AGL, and intended to remain at or below 350 ft AGL to ensure separation.
At about 1000, the UAV operator heard WBK and observed the aircraft conduct a turn about 150 m north of the UAV, before it departed to the north. The operator immediately put the UAV into a holding pattern to maintain its current position. He estimated WBK was at about 100-150 ft AGL and came within about 100 m horizontally of the UAV. He attempted to contact the pilot of WBK on the radio but did not receive a response.
The pilot of WBK reported operating at about 50-100 ft AGL on a block just north of the mine site and did not see the UAV.
This incident highlights the challenges associated with having a diverse mix of aircraft operating in the same airspace and the need for all pilots and operators to remain vigilant and employ see-and-avoid principles.
