What happened

On 2 September 2012, the pilot of a Cessna 172S aircraft, registered VH-EOP, was returning to Moorabbin Airport, Victoria, after having conducted a navigation training flight.

During the landing, the pilot attempted to initiate the hold-off by applying rearward pressure on the control column. The pilot reported that the column was ‘stuck’ and would not move. An excessive rate of sink occurred, resulting in a hard landing. After bouncing twice, the pilot applied left rudder and the aircraft veered off the runway, coming to rest on a grassed area. The aircraft sustained substantial damage.

Aviation Short Investigation Bulletin - Issue 13

What happened

On 4 September 2012, the pilot of a Piper PA-28 aircraft, registered VH-SFK (SFK), was conducting solo touch-and-go circuits at Bankstown Airport, New South Wales.  After landing on the fourth solo circuit, when the pilot applied full power for take-off, SFK veered suddenly to the left onto the grass. The pilot reduced the throttle setting to the idle position and applied the brakes, however the aircraft collided with the airport perimeter fence. The aircraft sustained substantial damage and the pilot sustained minor injuries.

Aviation Short Investigation Bulletin – Issue 14

What happened

On 31 August 2012, at about 1230 Eastern Standard Time, a Piper Seneca aircraft, registered VH-BTW (BTW) departed Hobart Airport, Tasmania for Bankstown Airport, New South Wales on a private flight under the instrument flight rules.  The pilot was the only person on board.    

Both engines stopped during cruise at 9,000 ft above mean sea level and 19 kilometres south of Nowra, New South Wales.  The pilot ascertained that the fuel selector for the right engine was in the cross-feed position and consequently both engines were drawing fuel from the left wing tank which was empty.  The pilot repositioned the fuel selector, was able to restart both engines and continued to Bankstown Airport. 

On landing at Bankstown, the aircraft had a significant lateral imbalance, as the left wing tank was empty and the right wing tank was almost full.  As a result, the aircraft departed the runway after landing.  The pilot regained control and the aircraft taxied to the parking area without further incident.  The aircraft was not damaged and the pilot was not injured.   

The incident highlights the importance of checklists in capturing errors made before and during flight and the need to conduct them diligently during all stages of flight. 

Aviation Short Investigation Bulletin – Issue 14

What happened

On 27 August 2012, at about 1330 Eastern Standard Time a Piper PA-28 aircraft, registered VH-BZE, departed Moorabbin Airport on a private flight to Colac, Victoria. The pilot was the only person on board. The pilot decided to return to Moorabbin due to the severity of the turbulence being experienced.  

While turning onto final for runway 35L at Moorabbin, VH-BZE drifted through the runway centreline. The pilot was having difficulty controlling the aircraft and requested a late change in runway to 35R. At the same time, a Cessna 172 aircraft, registered VH-EPB with an instructor and student on board, was established on finals for runway 35R. The two aircraft came within close proximity of each other.

This investigation is a reminder that personal minimums, when set, provide a safety buffer between the skills required for a flight and the skills available through training, experience, currency, and proficiency.

Aviation Short Investigation Bulletin – Issue 14

What happened

On 21 August 2012, at about 1430 Eastern Standard Time, an Aero Commander 500S registered VH-YJS (YJS) departed Charleville Airport, Queensland for Brisbane Airport via, Roma, Dalby and Toowoomba on a freight only charter flight under the IFR. The pilot was the only person on board.

During the landing roll the landing gear was inadvertently retracted and the lower fuselage contacted the runway.  The pilot exited the aircraft without injury however the lower fuselage of the aircraft was damaged. 

A manual safe pin was incorporated as a design feature to prevent inadvertent retraction of the landing gear. However operation of the gear lever and safe pin together had become an automatic response by the pilot and the effectiveness of the safe pin as a countermeasure reduced. Pilots are reminded to positively identify any control lever before actioning. 

Aviation Short Investigation Bulletin – Issue 14

What happened

On 22 August 2012, a Skippers Aviation Fairchild SA227-DC aircraft, registered VH-WBQ, was being operated on a charter passenger flight from Perth to Granny Smith aerodrome, Western Australia.

The aircraft arrived at the aerodrome and joined the circuit. When on downwind, the landing gear was extended, with the crew confirming that the three green down-locked lights were illuminated. The crew again confirmed, on a number of occasions, that the landing gear was extended.

During the landing flare, the left wing suddenly dropped. The first officer immediately applied right aileron in an attempt to counteract the wing drop and the aircraft touched down. After shutdown, the crew inspected the aircraft and determined that the left propeller had contacted the ground.

The aircraft operator examined the aircraft and believed that there was uncommanded retraction of the left landing gear on, or just after touchdown. The reason for the uncommanded retraction could not be determined.

Aviation Short Investigation Bulletin – Issue 14

What happened

On 23 August 2012 at 1733 Central Standard Time, a Cessna 210N, registered VH-WPD, departed Numbulwar for Urapunga, Northern Territory, on a charter passenger flight with the pilot and two passengers on-board. The pilot reported intermittent sun glare during descent to Urapunga, when at 3 NM for runway 28. On late final the sun glare on the windscreen greatly restricting visibility. During the flare, the pilot identified a runway edge marker in line with the nose of the aircraft. The pilot manoeuvered the aircraft back in line with the centre of the runway and the aircraft continued to float down above the runway.

The sun glare increasingly restricted visibility during the landing. The aircraft touched down and the pilot applied heavy braking in short bursts. The aircraft departed the end of the runway and travelled through two fences before coming to a stop. The pilot and two passengers evacuated the aircraft. The pilot received minor injuries and the two passengers were uninjured.

The operator has indicated that during pilot training greater emphasis will be placed on go-around procedures and identify situations when it would be used; particularly during training increase awareness to consider the planning of circuit entry and ensure a backup is considered if conditions are not what was expected; and go-around procedures are practiced during in command under supervision (ICUS) training.

The accident highlights the importance of the identification of approach and landing hazards, decision making when a hazard becomes evident, recognition of a destabilised approach and being go-around prepared and go-around minded.

Aviation Short Investigation Bulletin - Issue 16

Safety summary

What happened

On 21 August 2012, Genesee and Wyoming Australia (GWA) freight train 2AD1 was en route from Adelaide, South Australia, to Katherine, Northern Territory, when the train crew exceeded the limit of their train authority at Tarcoola, South Australia.

The train authority authorised the crew to travel to Northgate, which is located on the railway line branching to the north from Tarcoola. However, the crew did not take the line to Northgate and the train continued through Tarcoola, travelling west for about 2.6 km toward Perth before stopping.

What the ATSB found

The ATSB investigation found that the driver of train 2AD1 was a trainee who was unfamiliar with the route and had not completed the minimum competencies required by GWA to enable him to operate the train. The qualified supervising driver had allowed the trainee to take control of the train and had subsequently fallen asleep.

Following the occurrence, the supervising driver returned a positive test for amphetamine and methamphetamine, which he had consumed while off-duty. These drugs probably contributed to him falling asleep during the shift.

The ATSB found that the supervising driver’s performance was being managed in accordance with GWA’s drug and alcohol management program as a result of a previous positive drug test and that the company’s drug and alcohol policy/processes were effective in managing drugs and alcohol in the workplace.

The ATSB further found that the company’s safety management system procedures did not provide supervising and trainee drivers with sufficient guidance and direction in relation to their supervisory and permitted driving roles.

The report also notes that the actions of a crew member travelling in the crew van in alerting the locomotive crew and operating the emergency brake handle significantly reduced the distance that train 2AD1 travelled before it stopped.

What's been done as a result

GWA has introduced a ‘Category Card’ to enhance the classification system for trainee locomotive drivers. The card specifies any operational restrictions placed on trainees and instructs the supervisor/mentor driver of the level of oversight that must be exercised for each classification level. GWA has notified all drivers of changes to the classification system and has taken steps to clarify the responsibilities of drivers supervising a trainee.

While GWA had a robust alcohol and drug-testing program in place, the organisation has taken further action by introducing screening en route and at off-train resting locations and increasing the frequency of random screening at existing locations.

Safety message

This incident emphasises the need for rail transport operators to implement robust procedures that systematically manage the supervision, training and assessment of trainee drivers. It also highlights the risks associated with the use of amphetamines or methamphetamines and the impact that recreational drug use can have on safe rail operations.

What happened

The ATSB was advised of two aircraft proximity events at Ballarat Airport, Victoria on 4 August 2012, which occurred within a short period of time. Both incidents were witnessed by an observer on the ground.

The first incident involved VH-VSD and VH-VTA, who were observed passing in close proximity overhead the airport, on reciprocal headings.

About 20 minutes later, a second incident occurred overhead, when VH-PKH was observed to pass below VH-VTJ. Airservices Australia surveillance data indicated that the distance between the aircraft reduced to 0.1 NM laterally and 100 ft vertically.

These incidents highlight the importance of pilots effectively broadcasting and actively listen to the radio, and maintaining a vigilant lookout at all times, to enhance traffic and situation awareness. This is particularly important when operating in a high traffic density environment.

Aviation Short Investigation Bulletin – Issue 14