On 13 August 2013, the pilot of a Cessna 210 aircraft, registered VH-HGZ (HGZ), was conducting a charter flight from Groote Eylandt to Gove Airport, Northern Territory. Prior to commencing the descent, the pilot broadcast an inbound call on the Gove common traffic advisory frequency (CTAF). Soon after, the pilot reported broadcasting a call advising he was at 10 NM, inbound, with the intention of joining the base leg of the circuit for runway 31.
At about the same time, the pilot of a Cessna 206 aircraft, registered VH-LHX (LHX), broadcast a call on the CTAF advising that he was taxiing at Gove. Shortly after, the pilot broadcast another call stating that he was entering and backtracking runway 13.
The pilot of HGZ joined base for runway 31 and broadcast a call. The pilot stated that he was aware of LHX taxiing.
The pilot of LHX contacted the pilot of HGZ and confirmed that he was approaching runway 31. The pilot of LHX then immediately broadcast a call advising that he was on the runway and was lining up for runway 13, but no response was received. The pilot of LHX then broadcast his intention to hold at the turning node, which was located mid-way along the runway, but within the confines of the flight strip. The pilot of HGZ responded and advised that he had LHX sighted and was on final approach for runway 31.
HGZ landed on runway 31 and vacated the runway. At the time, LHZ was positioned at the turning node, but the runway was still occupied. LHX subsequently departed from runway 13.
On 22 September 2013, the pilot of a Piper PA‑28-140 aircraft, registered VH‑RVJ, was conducting a pre-flight inspection in preparation for a local private flight from the Kilcoy aeroplane landing area (ALA), Queensland. The pilot conducted fuel drains checks, with nil contaminants found.
The pilot taxied the aircraft to the threshold of runway 27 and conducted engine run-ups. The pilot reported that the engine operated as normal. In preparation for take-off, he selected the right fuel tank and turned the fuel pump on.
During the take-off on runway 27, the pilot reported that the engine performed as expected, but at about 50-80 ft above ground level, the engine suddenly stopped. The pilot immediately confirmed that the fuel tank selection and fuel pump were on. He also noted that the engine revolutions per minute were reading zero.
The pilot elected to land ahead on the remaining runway. The aircraft touched down with about 50 m of runway remaining, but the pilot was unable to brake sufficiently to stop the aircraft prior to the end of the runway.
The aircraft collided with a fence, and continued through a paddock and a ditch before coming to rest after colliding with a second fence.
This accident highlights the importance of remaining proficient in emergency procedures. Having a plan prior to an emergency situation may mitigate some of the effects of decision making under stress.
This preliminary report details factual information established in the investigation’s early evidence collection phase and has been prepared to provide timely information to the industry and public. Preliminary reports contain no analysis or findings, which will be detailed in the investigation’s final report. The information contained in this preliminary report is released in accordance with section 25 of the Transport Safety Investigation Act 2003.
The occurrence
On 20 September 2013, a loss of separation1 occurred between an Airbus A330 aircraft, registered VH-EBO (EBO) operating a scheduled passenger service from Sydney, New South Wales to Perth, Western Australia, and an Airbus A330 aircraft, registered VH‑EBS (EBS), operating a scheduled passenger service from Perth to Sydney. Both aircraft were within radar surveillance coverage at the time of the occurrence.
At 1159:56 Eastern Standard Time2, following a handover/takeover, an air traffic controller in Airservices Australia’s Melbourne Centre accepted control jurisdiction for the Augusta and Spencer airspace sectors (Figure 1), which were permanently operated in a combined configuration. The Augusta/Spencer controller had previously been monitoring another controller who was conducting a familiarisation shift, following a period of leave, on the air traffic control (ATC) group’s other two sectors (Tailem Bend and Kingscote), which were also permanently combined. The Augusta/Spencer controller was preparing to also take over the Tailem Bend/Kingscote sectors on the same one console, as sector traffic levels and controller workloads were relatively low.
It was normal practice for all of the group’s sectors to be combined at that time of day due to low traffic levels.
Figure 1: Augusta/Spencer and Tailem Bend/Kingscote airspace sectors
Source: Airservices Australia. Image modified by the ATSB.
At the time the controller assumed control of the Augusta and Spencer sectors, EBS was within the Augusta/Spencer airspace at a position 140 NM (259 km) west of Adelaide, South Australia, eastbound on the one-way route Y135 at flight level (FL)3 390. EBO was within the adjoining eastern airspace (Tailem Bend/Kingscote), 79.6 NM (147 km) to the east of Adelaide and westbound at FL 380.
At 1210:15, EBO’s flight crew contacted the Augusta/Spencer controller as the aircraft approached the airspace boundary. The controller observed that the ATC computer system’s human machine interface prompts displayed on their screen provided a conflicting indication as to whether onwards coordination with the adjoining western sector (Forrest) controller had been completed. To assure that this coordination had been carried out, the Augusta/Spencer controller called the Forrest controller via the internal coordination line at 1211:34 and was advised that coordination had already been completed. In addition, the Forrest controller advised that they had no vertical restrictions for EBO. The Augusta/Spencer controller entered that information into the operational data line of the aircraft’s label in the ATC computer system, and then completed other tasks in preparation for assuming control of the Tailem Bend/Kingscote sectors.
At 1212:57, EBO’s flight crew requested climb from FL 380 to FL 400, which the controller immediately approved. This resulted in a loss of separation assurance4 between EBO and EBS as the vertical separation standard of 1,000 ft would not exist when the aircraft passed on their one-way routes at a point where there would be less than the required radar separation standard distance laterally of 5 NM (9.3 km).
At the time the climb request was approved, EBO was west of Adelaide and tracking in a westerly direction on the one-way air route designed Q12 (Figure 1). EBS was west of Adelaide, tracking in an easterly direction on one-way route Y135. On receipt of the level change clearance, EBO’s flight crew reported leaving FL 380 and recorded data from the aircraft showed that it commenced climbing at 1213:08.
At about 1213:32, before both the radar and vertical separation standards were infringed, the ATC system’s Short Term Conflict Alert (STCA) activated, alerting the controller to the imminent loss of separation between EBO and EBS. The controller immediately instructed EBO’s flight crew to maintain FL 380, which the crew acknowledged with advice that they were descending back to that level. Recorded data from EBO showed that the aircraft reached a maximum altitude of 38,350 ft at 1213:37.
Recorded data from EBS showed that, at 1213:27, the crew received a traffic advisory (TA)5 from their aircraft’s traffic collision avoidance system (TCAS)6 At 1213:37 the TA changed to a resolution advisory (RA),7 and at 1213:44 the EBS flight crew advised the controller that they were responding to an RA and the aircraft started to climb.
Recorded data from the two aircraft showed that the minimum vertical separation was 650 ft at 1213:37, when the two aircraft were 4.1 NM (8 km) apart laterally. The minimum lateral separation was 1.6 NM (3 km) at 1213:51, when the aircraft were 870 ft apart vertically (Figure 2). At that time both the vertical and lateral separation were increasing as the aircraft were on separate one-way routes. The vertical and radar separation standards were re-established a short time later.
Figure 2: Aircraft positions at 1213:53
Source: Airservices Australia. Image modified by the ATSB.
Note: Data in this figure is provided from the ATC system with a different level of resolution compared to the data provided from the aircraft’s recorders. The figures ‘55’ and ‘39’ refer to the ground speeds of the aircraft (divided by 10).
Air traffic control information
The Augusta/Spencer controller was initially rated as a controller in 2005. Prior to 20 September 2013, they had the previous 3 days off duty. They reported receiving a normal amount of sleep in the previous two nights, and they commenced their shift on 20 September at 0700.
Controllers reported that workload was relatively low at the time of the occurrence and that there were no operational distractions.
TCAS information
The flight crew of EBS reported that, at the time that the EBO flight crew requested clearance to climb to FL 400, they had acquired EBO visually and observed it on their TCAS display. They could see EBO was heading in the opposite direction and that it appeared to be on a diverging route. They also saw EBO climbing and diverging to the south on the TCAS display before receiving the TA and the RA.
Immediately following the occurrence, EBO’s flight crew advised the Augusta/Spencer controller that they did not receive any indications on their TCAS display of the presence of EBS. The flight crew later reported that they did not see EBS on their TCAS display, and they did not receive a TA or RA. They also reported not being able to see other aircraft on their TCAS display during the rest of their flight in situations where the other aircraft’s crews could see them, until reaching the Perth Terminal Area, where traffic returns were evident. They had been able to see other aircraft on departure from Sydney and there was no indication of a TCAS failure prior to the loss of separation event.
Examination of recorded data from EBO showed that no TA or RA was received. After the aircraft landed in Perth, a built-in test equipment (BITE) test was conducted on the TCAS with no faults indicated. A minimum equipment list (MEL)8 was applied for the unserviceable TCAS for the return flight to Sydney. A full system test was conducted in Sydney with a failure identified between ATC transponder 2 and the TCAS computer and TCAS antennas. The TCAS computer and ATC transponder 2 were replaced with spare units and a further system test carried out with nil faults detected.
Although all air transport aircraft are required to have a TCAS, on rare occasions the system can fail or lose functionality during a flight. In such situations a flight crew is usually provided with a fault message, and the flight crew are required to advise ATC. In addition, under specific conditions, aircraft are able to be dispatched for short periods of time without a serviceable TCAS.
Additional information
In high reliability systems, there are multiple risk controls in place to reduce the likelihood that safety-critical personnel will make an error. However, on rare occasions an error will still occur, and systems have additional risk controls in place to detect and recover from such errors, or mitigate the consequences of such errors. In this occurrence, one of these detection and recovery controls did not work effectively (that is, the TCAS on EBO). However, other risk controls were functioning effectively. These included the ATC STCA, EBS’s TCAS, and the use of one-way routes.
Further investigation
The investigation is continuing and will include:
further analysis of the ATC radar and audio data and the recorded data from the two aircraft
analysis of the context in which the controller’s actions occurred
examination of the TCAS computer and related components from VH-EBO
review of the reliability and availability rates of TCAS.
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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Copyright in material obtained from other agencies, private individuals or organisations, belongs to those agencies, individuals or organisations. Where you wish to use their material, you will need to contact them directly.
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1 Controlled aircraft should be kept apart by at least a defined separation standard. If the relevant separation standard is infringed, this constitutes a loss of separation (LOS).
2 Eastern Standard Time (EST) was Coordinated Universal Time (UTC) + 10 hours.
3 At altitudes above 10,000 ft in Australia, an aircraft’s height above mean sea level is referred to as a flight level (FL). FL 390 equates to 39,000 ft.
4 Loss of separation assurance describes a situation where a separation standard existed but planned separation was not provided or separation was inappropriately or inadequately planned.
5 Traffic Collision Avoidance System Traffic Advisory, when a TA is issued, pilots are instructed to initiate a visual search for the traffic causing the TA.
6 Traffic collision avoidance system (TCAS) is an aircraft collision avoidance system. It monitors the airspace around an aircraft for other aircraft equipped with a corresponding active transponder and gives warning of possible collision risks.
7 Traffic Collision Avoidance System Resolution Advisory, when an RA is issued pilots are expected to respond immediately to the RA unless doing so would jeopardise the safe operation of the flight.
8 A minimum equipment list (MEL) is a list which provides the operation of aircraft, subject to specified conditions, with particular equipment inoperative.
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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 the 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 accident as outlined in this web update. As such, no analysis or findings are included in this update.
Final report
What happened
On 20 September 2013, a loss of separation occurred about 17 km west of Adelaide, South Australia, between an Airbus A330 aircraft, registered VH-EBO (EBO) operating a scheduled passenger service from Sydney, New South Wales to Perth, Western Australia, and an Airbus A330 aircraft, registered VH-EBS (EBS), operating a scheduled passenger service from Perth to Sydney.
Both aircraft were within radar surveillance coverage at the time of the occurrence and were equipped with a traffic collision avoidance system (TCAS).
What the ATSB found
The ATSB determined the en route air traffic controller did not adequately assess the traffic for potential conflicts before issuing a climb instruction to the EBO flight crew. The air traffic control computer system subsequently alerted the controller to the conflict and they promptly commenced compromised separation recovery actions. The flight crew of EBS responded to alerts generated by the aircraft’s TCAS. The TCAS in EBO malfunctioned and did not provide the flight crew with traffic information or generate any safety alerts. The reason for the malfunction could not be determined and the equipment manufacturer considered it to be a unique event.
The ATSB identified a safety issue relating to the convergence of many published air routes overhead Adelaide, combined with the convergence point being positioned on the sector boundary of the Augusta and Tailem Bend sectors, which reduced the separation assurance provided by strategically separated one-way air routes and increased the potential requirement for controller intervention to assure separation.
What's been done as a result
Airservices Australia is undertaking a review of air routes and of the Australian airspace design that contributes to risk. There is also consideration to providing more flexible route structures using modern navigation technology to create traffic directional flows and remove convergence points.
In addition, Airservices undertook pro-active safety action associated with safety alerting and traffic avoidance advice by air traffic services.
Safety message
This occurrence is a reminder of the potential for skill-based errors to occur when experienced personnel are performing their tasks and highlights the importance of controllers following their normal processes to ensure traffic is assessed prior to providing control instructions.
Although this investigation report highlights a low incidence of accidents and incidents involving insecure canopies in Lancair Legacy aircraft, the potential consequences of such occurrences have generated discussion among Lancair Legacy owners, builders and pilots. In particular, the ATSB is aware of a discussion paper, available on the United States Lancair Owners & Builders Organization website at www.lancairowners.com, which examines a number of canopy-related accidents and incidents in this type, and reviews the pilot actions in each case in response.
As highlighted in its investigation report, the ATSB reiterates the importance of owners, operators and pilots of aircraft with canopies reviewing the adequacy of their existing measures that are intended to ensure canopies are securely latched before flight (such as pre-take-off checks and warning systems), and the actions in case of inadvertent canopy opening during take-off. In this respect, and without endorsing any particular recovery procedure, the above Lancair discussion paper could be expected to enhance that review.
Summary
What happened
On 18 September 2013, the pilot of an amateur-built Lancair Legacy aircraft, registered VH-ALP, was taking off from runway 32 at Geraldton Airport, Western Australia. Late in the take-off roll the canopy came open – the pilot continued the take-off and manoeuvred at low level for a landing. During the approach the aircraft undershot the runway, touched down across a road then collided with the airport perimeter fence and caught fire. The aircraft was destroyed and the pilot sustained injuries that were later fatal.
What the ATSB found
The ATSB found that the pilot conducted the take-off with the canopy down but inadvertently unlatched. As the aircraft accelerated the aerodynamic loads on the canopy increased and resulted in it suddenly lifting up to a partially open position. The pilot did not reject the take-off and during the subsequent manoeuvring for landing, likely encountered control, performance and forward visibility difficulties associated with the open canopy. This adversely affected the pilot’s capacity to conduct a normal approach.
Safety message
The ATSB advises owners, operators and pilots of aircraft with canopies to review the adequacy of their existing measures that are intended to ensure canopies are securely latched before flight (such as pre-take-off checks and warning systems), and the actions in case of inadvertent canopy opening during take-off.
Where possible in abnormal situations, pilots should take time to assess the nature of the abnormality to rectify the situation or mitigate the effects.
On 7 September 2013, an Airbus A320, registered VH-VFJ, was on descent into Auckland, New Zealand via a Required Navigation Performance (RNP) approach to runway 23L. During the later stages of their descent, the crew managed the aircraft speed to meet an Air Traffic Control request and according to applicable company speed restrictions.
The auto-flight system sequenced to final approach mode passing about 4,200 ft, but exited final approach mode when the crew subsequently levelled the aircraft approaching 3,000 ft. The crew levelled the aircraft to reduce speed to comply with a company speed restriction of 210 kt maximum below 3,000 ft. Having slowed sufficiently, subsequent manipulation of the auto-flight system resulted in the inadvertent engagement of open climb mode, which resulted in an increase in engine thrust and aircraft acceleration.
Attempting to avoid exceeding the limiting speed applicable to the existing aircraft configuration, the captain retarded the thrust levers to the idle stop, inadvertently disconnecting the auto-thrust system. The crew resumed the approach, unaware that the auto-thrust system was disconnected, and therefore no longer controlling aircraft speed. As the aircraft continued to decelerate, soon after the final stage of flap was selected for landing, the Flight Management Guidance System generated a low energy warning. As the crew was responding to the low-energy warning, alpha-floor auto-thrust mode engaged. The crew accelerated the aircraft to approach speed using manual thrust control, and was able to continue the approach for an uneventful landing.
The operator’s investigation into the incident found that, among other things, there may be some commonly held misunderstandings with respect to some aspects of instrument approach procedures, particularly their application to RNP approaches. The operator planned to communicate relevant procedural information to flight crew, with appropriate explanatory information, and communicate with flight crew regarding procedural requirements associated with auto-flight system mode awareness and speed monitoring. The operator also planned to include more guidance in appropriate documentation dealing with transfer of aircraft control between flight crew.
This incident highlights the need for robust and clear instrument approach and auto-flight system management procedures. It also highlights the need for consistent attention to aircraft auto-flight modes and energy state.
In the early evening of 23 September 2013, the student pilot of a Cessna Aircraft Company 182R aircraft, registered VH‑AUT, was conducting solo night circuit consolidation training at Hamilton Airport, Victoria. On the fourth circuit the pilot made a radio call indicating he was aborting the landing. Witnesses observed the aircraft climb, then turn to the right and descend, followed by a collision with terrain. The aircraft was destroyed by the impact and post‑impact fire and the pilot was fatally injured.
What the ATSB found
The ATSB found that following an aborted landing during circuit training in dark night conditions, the solo student pilot lost control of the aircraft, resulting in a collision with terrain. There was insufficient evidence to determine the reason for the loss of control.
The student pilot’s post-mortem examination identified a cardiac condition capable of causing incapacitation and their medical history included another condition that, if having effect at the time, had the potential to have contributed to the development of the accident. The Civil Aviation Safety Authority (CASA) was unaware of either condition.
In addition, the aircraft’s flaps were found to have been in the fully-extended position at impact, which was not consistent with either the operator’s or manufacturer’s procedures for a go-around. The ATSB was unable to determine when the flaps were extended and to what extent the misconfiguration influenced the accident.
Safety message
This accident highlights the importance of the shared responsibility by holders of aviation medical certificates, examining physicians and CASA to report, assess and manage medical and other conditions as they might affect the issue/renewal of those certificates. A full understanding by CASA of an aviation medical certificate applicant’s current and prior medical conditions, and use of medications, informs the consideration and development of appropriate risk controls to ensure continued safe flight. This can include the applicant continuing in, or recommencing their participation in the industry.
On 15 September 2013, the pilot of a Robinson R44 helicopter, registered VH-NUZ, was flying passengers on a private scenic flight over the Montgomery Reef and Buccaneer Archipelago area of Western Australia. The pilot had completed several take-offs and landings at that site already on the day.
After a routine landing at the reef, the pilot shut down the engine. The passengers had disembarked and were standing about 20 to 30 m away.
At about 1530 Western Standard Time the pilot, who was the sole occupant, then started the helicopter’s engine and completed the pre-flight checks. When the pilot raised the collective to bring the helicopter into a hover, it suddenly rotated three times while airborne. The pilot could not regain control and elected to land immediately, however the helicopter landed heavily. The pilot shutdown the engine and exited the helicopter.
The direction that the helicopter rotated could not be ascertained by the pilot or witnesses. The pilot and bystanders were not injured but the helicopter sustained substantial damage as a result of the hard landing.
Based on the information provided, the Australian Transport Safety Bureau (ATSB) was unable to determine what led to the loss of control.
During the investigation, the ATSB was made aware that instances of ‘sudden and violent yawing in forward flight’ had occurred on other ‘low time’ R44 helicopters, being attributed to a ‘sticky inlet valve’, with no recurrence after maintenance rectification.
There were no Service Difficulty Reports (SDR) regarding this issue in the Civil Aviation Safety Authority’s SDR database, making it difficult to pursue this line of enquiry.
The ATSB encourages reporting of occurrences to the ATSB and defects to CASA to allow for continued improvements to aviation safety.
On 1 September 2013 the pilot of a Cessna 210 aircraft, registered VH-JMG (JMG), conducted a private flight from Port Macquarie to Bankstown, New South Wales.
The pilot regularly flew this route and was very familiar with the airspace. On this day, he was feeling unwell, so departed earlier than usual, at about 1510 Eastern Standard Time.
The flight went as planned, with the aircraft arriving at the cruise level of 8, 500 ft around Taree. The pilot requested and was issued a clearance to enter Class C controlled airspace at Williamtown.
The pilot put the aircraft on autopilot, and listened to music through the radio, whilst monitoring the aircraft.
Soon after, there was no further communication with JMG until the pilot called close to Bankstown.
The pilot had fallen asleep and re-entered Class C controlled airspace prior to waking up again. He conducted a spiral descent down to the Lane of Entry near Brooklyn Bridge. The flight then continued as planned with a safe arrival and landing at Bankstown.
This report highlights the need for all pilots to carefully consider their fitness to fly. This includes assessing fatigue and illness. The following publications provide additional information on pilot incapacitation and the ‘IMSAFE’ checklist:
The ATSB investigation team has completed the on-site phase of its investigation into the collision with terrain involving a Cessna 206 aircraft, registered VH‑WAV, about 156 km south-east of Croydon, Queensland on 15 September 2013. The investigation team examined the area used by the pilot for the take-off, the accident site and wreckage, and interviewed an eyewitness to the accident.
The site evidence and witness report indicated that, during take-off from an unsealed access road to a council work camp, the aircraft’s left wing struck a tree. The wingtip and aileron separated before the aircraft impacted terrain, fatally injuring the pilot and passenger. The aircraft was seriously damaged,1(Figure 1).
Figure 1: Aircraft wreckage
Source: ATSB
The investigation is continuing and will include consolidation of the site evidence, a review of witness reports, consideration as to the suitability of the access road for the take-off and examination of the aircraft’s records and pilot history.
A final investigation report is expected to be published by the end of February 2014.
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1. The Australian Transport Safety Regulations 2003 definition of ‘serious damage’ includes the destruction of the transport vehicle.
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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 the 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 accident as outlined in this web update. As such, no analysis or findings are included in this update.
Summary
What happened
At about 1200 on 15 September 2013, the pilot-owner of a Cessna 206, registered VH-WAV, landed on a public road to repair a truck at a work camp. At about 1516, during take-off from a different, curved road, the aircraft’s left wing struck a tree at a height of about 30 ft. The wingtip and aileron separated before the aircraft impacted terrain, fatally injuring the pilot and passenger. The aircraft was destroyed.
What the ATSB found
The distance available from where the pilot increased power for take-off was much shorter than the distance advised in the aircraft’s pilot operating handbook under the prevailing conditions.
There was no apparent reason for the pilot to attempt a take-off from that location when a more suitable location was nearby. It is most likely that the pilot misjudged the distance available, the prevailing conditions and their effect on the aircraft’s performance, or had a false recollection of the relative layout of the two roads and thought that there was more take-off room available beyond the curve. However, it is also possible that the pilot’s judgement of the available distance, or his decision-making capability, was affected by a serious medical condition and/or prescribed medications that had not been reported to the Civil Aviation Safety Authority (CASA) until after the pilot’s previous medical certificate had expired.
In addition, the ATSB found that the pilot’s seat had broken from its mounts, probably as the result of heavy, unsecured cargo striking it during the accident sequence. This could have had a detrimental effect on the survivability of the accident.
Safety message
The accident highlights the importance of carefully considering all relevant factors that could affect the suitability of a particular landing and take-off area. These include: aircraft weight and engine power; wind direction, speed and gusts; ambient air pressure and temperature; surface slope, material, and condition; other physical characteristics of the area such as its length and width; and the height and location of surrounding obstacles.
Though no link with the accident was established, flying without a valid medical certificate, or omitting to report a diagnosed condition or treatment to a Designated Aviation Medical Examiner or to CASA, can lead to such an impairment being undetected or its effect underestimated.
Unrestrained cargo poses a significant risk to the survivability of aircraft occupants. Pilots should take care to ensure that all cargo is adequately restrained to prevent movement during flight and improve survivability in the event of an accident.
On 30 March 2012, a Europa XS amateur-built aircraft collided with terrain shortly after takeoff from Caboolture Airfield, Queensland. The pilot, who was the sole occupant, was fatally injured.
The Australian Transport Safety Bureau (ATSB) did not investigate the accident, which was investigated by the Queensland Police Service (QPS) on behalf of the Queensland Coroner. On 20 June 2013, the Queensland Coroner requested ATSB assistance with the review of the coroner’s investigation and advice of any potential additional lines of enquiry or other expert review before the matter proceeded to inquest.
To facilitate this support, the ATSB initiated an external investigation under the provisions of the Transport Safety Investigation Act 2003. A report on the results of the ATSB’s review of the coroner’s investigation was provided to the Queensland Coroner on 6 September 2013.
Any enquiries as to the planning for, or conduct of the Coroner’s Inquest into this accident should be directed to the Queensland Coroner’s Office at:
Queensland Courts Office of the State Coroner Brisbane Magistrates Court 363 George Street Brisbane QUEENSLAND 4000
