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 

Telephone: (07) 3239 6193
Facsimile: (07) 3239 0176
Email: state.coroner@justice.qld.gov.au
Web: www.courts.qld.gov.au

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

On 13 September 2013, the flight instructor and student pilot of a Robinson R22 helicopter, registered VH-ONT, were preparing for a dual training flight from Armidale, New South Wales.

Prior to take-off, the instructor explained the purpose of the fuel mixture control guard, the use of the carburettor heat, and took the student through the start-up checklist.

At about 1515 Eastern Standard Time, the helicopter departed, with the instructor operating the controls. During the climb, at about 300 ft above ground level (AGL), the instructor handed control of the helicopter over to the student. When maintaining 1,200 ft AGL, the instructor discussed with the student on how to enter a descent. After confirming that they would reduce the engine power, the instructor asked the student to pull the carburettor heat on.

The instructor looked outside to check for traffic and the engine then stopped. The instructor immediately initiated an autorotation and lowered the collective. He observed that the fuel mixture control was in the idle cut-off position. The student had removed the fuel mixture control guard, inadvertently pulled the fuel mixture control instead of the carburettor heat control and then replaced the guard. The instructor asked the student to push the fuel mixture control back in and he broadcast a ‘MAYDAY’ call.

The instructor selected a paddock and focused on the autorotation. Prior to the landing flare, the low rotor revolutions per minute (RRPM) horn sounded. The helicopter landed and ran on the ground on its skids, before rolling onto its side due to the slope of the paddock. Both occupants sustained minor injuries and the helicopter was substantially damaged.

This accident highlights the benefit of pilots positively identifying the control to be manipulated, prior to performing the action.

Aviation Short Investigation Bulletin - Issue 24

On 12 September 2013, at about 0956 Eastern Standard Time, a Cessna 185 aircraft, registered VH-OZA (OZA), departed Moruya, New South Wales for a parachute drop overhead the airport.

At about 1013, the crew of a Regional Express Saab 340B aircraft, registered VH-ZLJ (ZLJ), broadcast a call advising they were taxiing for runway 36 at Moruya, for a scheduled passenger service to Merimbula. In response, the pilot of OZA broadcast a call advising of his intention to conduct a parachute drop overhead.

At about 1018, the crew of ZLJ broadcast that they had entered, and were rolling on runway 36, and intended to conduct a right turn after take‑off, with a departure track of 178° (True).

Soon after, the parachute drop was completed. 

At about 1021, the crew of ZLJ asked the pilot of OZA to confirm that the drop had been completed. At that time, ZLJ was climbing through 3,500 ft and tracking to overhead the airport. The crew then questioned the altitude, time and position the parachutists had been dropped. The pilot of OZA advised that they had been dropped about 0.4 NM to the west of the airport, about 30 seconds previously.

The crew of ZLJ immediately turned the aircraft left. They continued to parallel their intended departure track overwater until about 10 NM to the south of the airport. The flight continued without further incident.

As a result of this occurrence, the operator of OZA has advised the ATSB that they have distributed a letter to all company pilots detailing the incident and highlighting the importance of not becoming complacent with procedures.

This incident highlights the impact complacency and time pressures can have on aircraft operations. It is important that pilots remain vigilant and alert, and be mindful that the even the most routine tasks must be conducted with care and concentration. Furthermore, when time pressures do occur, it is a useful strategy for pilots to take the time to re-evaluate the task and their priority.

Aviation Short Investigation Bulletin - Issue 24

Safety summary

What happened

On 7 September 2013 at about 0925, V/Line passenger train 8205 travelling to Warrnambool, Victoria collided with a northbound road vehicle (rigid truck and dog trailer combination) at the Pettavel Road level crossing in Mount Moriac, located about 20 km west of Geelong. Vehicular traffic across the Pettavel Road level crossing was controlled by warning and Stop signs (passive controls).

Five passengers, the locomotive driver and a conductor sustained minor injuries in the collision. The truck driver was not physically injured.

The collision destroyed the road vehicle trailer and caused significant damage to the locomotive and approximately 75 m of track infrastructure.

What the ATSB found

The ATSB found that the driver of the truck did not come to a stop at the railway crossing Stop sign and proceeded into the level crossing and the path of the train. It is possible that the truck driver’s attention to the driving task was compromised and he did not look for trains. It is also possible that the driver noticed the train and misjudged its speed, believing that he could get through the crossing before the arrival of the train.

When at the Stop sign south of the crossing—the direction the truck driver approached the crossing—there was adequate sighting to the east, the direction from which the train approached.

The investigation also found that location of the warning signage and the Railway Crossing Ahead sign on the approach to the level crossing was not in accordance with Australian Standard AS 1742.7-2007, Manual of uniform traffic control devices, Part 7: Railway crossings. These non-compliances with the standard were not contributory to this incident.

What's been done as a result

V/Line has made a submission to the Railway Crossing Project Delivery (RCPD) Committee1 to consider the upgrade of the Pettavel Road level crossing from passive to active warning protection devices.

Surf Coast Shire Council has relocated the signage to comply with the requirements of the Australian Standard AS 1742.7-2007, Manual of uniform traffic control devices, Part 7: Railway crossings.

Safety message

Road vehicle drivers, especially of heavy vehicles, using railway level crossings equipped with passive controls need to be vigilant, observe road-warning signs, obey road rules and look out for trains.

On 6 September 2013, at about 1545 Eastern Standard Time, the pilot of a Beech A36 aircraft, registered VH‑FFY, taxied for a private flight from the Caloundra aeroplane landing area (ALA) to Archerfield, Queensland.

The pilot reported that, during the take-off run, all engine indications were normal. When at about 200 ft above ground level (AGL), the pilot detected a burning smell and observed smoke entering the cockpit from the pilot foot-well. The engine continued to produce power. At about 300 ft AGL, as the area was heavily forested, the pilot commenced a turn back to the runway for landing.

The pilot opened the left side storm window to draw the smoke out of the cockpit and reduced power. The engine then began to run rough. The pilot elected to conduct a forced landing and selected a suitable paddock. The pilot shut down the engine and prepared the aircraft for landing.

During the landing roll, the nose landing gear separated from the aircraft due to the uneven terrain and the propeller subsequently contacted the ground. One passenger sustained minor injuries.

After the accident, the exhaust tailpipe from the turbocharger assembly was found on the runway at Caloundra. An engineering inspection revealed that the tailpipe had separated at a weld joint.

As a result of this occurrence, the turbo-normalizing system manufacturer has advised the ATSB that the requirement to complete the circumferential weld will be highlighted in the installation instructions. The tailpipe supplied will also be clearly marked as supplied tack-welded, with additional instructions showing the requirement to perform the circumferential weld prior to flight. 

Aviation Short Investigation Bulletin - Issue 24

On 24 July 2013, an Airbus Industrie A320 aircraft, registered VH-FNP (FNP) was being operated on a scheduled passenger flight from Perth to Newman, Western Australia.

Prior to reaching the top-of –descent point, the crew conducted a full approach briefing. This included the decision to use Flap Full for the visual approach.

Newman had a lot of aircraft movements both into and out of the airport that day. The pilot in command (pilot monitoring) focussed on maintaining separation for FNP, while the first officer (pilot flying) maintained the aircraft on the approach.

The crew reported the aircraft was on the correct glidepath and at the correct approach speed. This is confirmed by the flight data recorder (FDR) information.

By 500 ft above ground level (AGL) the landing gear had been extended and Flap 3 selected. As the visual approach had been programmed into the flight management guidance system, the crew expected to receive the automatically generated 500 ft AGL call.

At about 231 ft radio height the crew received a ground proximity warning system (GPWS) warning “TOO LOW FLAP”. Full flap was selected at about 185 ft and the aircraft landed shortly after.

Virgin Australia Regional Airlines (VARA) have initiated two safety actions in regard to the requirement to maintain track during go-around procedures and further training for the crew.

A United States Navy/National Aeronautics and Space Administration research report Cockpit Interruptions and Distractions: A Line Observation Study targets some of the actions that pilots take, when forced to make decisions, outside their well-practiced sequences.

Aviation Short Investigation Bulletin - Issue 26

On 8 September 2013, the pilot and passenger of a De Havilland DH‑82A aircraft, registered VH‑BJE (BJE), were conducting a local scenic flight from the Redcliffe aeroplane landing area (ALA).

At about 1615 Eastern Standard Time, the pilot broadcast a taxi call on the common traffic advisory frequency (CTAF) and commenced taxiing via the eastern-most taxiway toward runway 07. The pilot then reported broadcasting a call advising that he was entering and backtracking runway 07. The aircraft was backtracked on the grass on the southern side of the sealed runway.

At the same time, the pilot of a Piper PA‑36 aircraft, registered VH‑SEN (SEN), broadcast a taxi call on the CTAF and taxied from the eastern taxiway behind BJE, then turned onto the sealed taxiway to runway 07. When SEN arrived at the intersection between the western taxiway and runway 07, the pilot reported that he broadcast his intention to line up after an aircraft on final had landed.

The pilot of BJE taxied off the flight strip, outside the gable markers, to allow the aircraft on final to land and vacate the runway. He then reported broadcasting a lining up and rolling call and lined up on the grass to the right of the sealed runway.

At about the same time, the pilot of SEN also broadcast a call advising he was entering, lining up and rolling on runway 07. The pilot of BJE heard the pilot of SEN broadcast the call. He looked back and observed SEN lined up on the sealed runway. He immediately broadcast a call requesting the pilot of SEN delay his take-off as BJE was within the confines of the flight strip. The pilot of SEN had also observed BJE about 100 m ahead on the grass, to the right, and reported that he rejected the take-off and made a call to BJE requesting his intentions. The pilot of BJE then commenced a turn towards the gable markers.

Shortly after, SEN recommenced the take-off. When SEN passed BJE, the pilot of BJE reported that his aircraft was still within the flight strip and estimated that the aircraft came within 10-15 m of each other.

Aviation Short Investigation Bulletin - Issue 24

On 6 September 2013, at about 1220 Eastern Standard Time, a Piper PA-28R-200 aircraft, registered VH-MMU, was completing a private flight from White Cliffs, New South Wales, to Birdsville, Queensland. On board the aircraft were the pilot and a passenger.

As it was during the annual Birdsville horse race meeting, the pilot joined the circuit at Birdsville in accordance with the promulgated Airservices Australia Aeronautical Information Publication Supplement (AIP SUP).

The wind was fluctuating during the aircraft’s arrival, at times indicating 010 ° T at 10 kt, but close to landing it was 040 ° T at 10-15 kt. As there were restrictions on the use of runway 03, the pilot elected to fit in with traffic and use runway 32.

The approach to runway 32 placed the aircraft over raised ground and a high fence, where much of the crowd were situated. To remain at a safe altitude above the crowd, the passenger, a more experienced pilot, suggested that the pilot keep the aircraft at least 50 ft above the runway threshold, and flare soon after.

The pilot attempted to comply with this suggestion and prepared for the landing flare, but the passenger advised him that they were too high, and not to reduce the engine power until the aircraft was in a safer landing configuration. The pilot lowered the aircraft’s nose slightly and initiated the flare. The aircraft landed firmly on the main landing gear, then bounced once or twice.

Despite the pilot’s efforts, the aircraft veered to left of the runway and the left wheel subsequently struck a graded mound. The aircraft stopped abruptly. The pilot and his passenger sustained minor injuries, and the aircraft was substantially damaged.

It is important to be aware that the presence of others may influence your decision-making process. Their apparent ability does not mean that others can achieve the same outcome. To be competent, pilots must know, and fly within, their own personal limitations on that particular occasion.

Aviation Short Investigation Bulletin - Issue 24

On 30 August 2013, a Boeing 737 aircraft, registered ZK-NGI, was involved in a cabin depressurisation incident near Auckland, New Zealand.

An investigation into the circumstances of this incident is being conducted by the Transport Accident Investigation Commission (TAIC) of New Zealand. The TAIC investigation reference is 13-008 / AO‑2013-008.

TAIC requested assistance from the Australian Transport Safety Bureau (ATSB) in the download of the aircraft’s cockpit voice recorder (CVR). To facilitate this support and to provide the appropriate protections for the CVR information, the ATSB appointed an accredited representative in accordance with paragraph 5.23 of ICAO Annex 13 and commenced an investigation under the Australian Transport Safety Investigation Act 2003.

The CVR was hand-carried to the ATSB’s facilities in Canberra by a TAIC officer and was downloaded on 5 September 2013. The downloaded audio and a replay report were provided to TAIC.

TAIC is responsible for releasing the final investigation report regarding this incident.

• Transport Accident Investigation Commission of NZ www.taic.org.nz

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

On 3 September 2013, at about 1531 Central Standard Time, a Cessna 441 aircraft, registered VH‑SMO, departed Adelaide on a charter flight to the Honeymoon aeroplane landing area (ALA), South Australia.

While en route, the pilot determined that the wind conditions were favourable for a straight‑in‑approach to runway 01 at Honeymoon.

During the descent, the pilot selected the first stage of flap. The pilot reported that normally he would lower the landing gear and confirm that it had been extended, but on this occasion, he could not recall performing this action.

The pilot then selected the second stage of flap and established the aircraft on a 5 NM final to runway 01. When about 500 ft above ground level (AGL), the pilot commenced his pre-landing checklist. After selecting full flap, the first item on the checklist, the pilot looked at the windsock to confirm the wind and observed 4-5 emus on the right side of the airstrip. He watched them run away from the airstrip and then continued the approach, but inadvertently omitted to complete the remaining checklist items, which included confirming the landing gear had been extended. The aircraft subsequently landed with the landing gear retracted.

This incident highlights the impact distractions can have of aircraft operations, particularly during a critical phase of flight.

Aviation Short Investigation Bulletin - Issue 24