Safety summary

What happened

On 16 July 2012 at about 0830 New Zealand Standard Time, an Airbus A320-232 aircraft, registered VH-VQA and operated by Jetstar Airways, was conducting an Area Navigation (Required Navigation Performance) approach to runway 05 at Queenstown, New Zealand. During the approach the aircraft descended below two segment minimum safe altitudes. Upon recognising the descent profile error, the crew climbed the aircraft to intercept the correct profile and continued the approach to land.

What the ATSB found

The ATSB found that, contrary to their intentions, the crew continued descent with the auto-flight system in open descent mode, which did not provide protection against infringing the instrument approach procedure’s segment minimum safe altitudes. The ATSB also found that the crew were not strictly adhering to the operator’s sterile flight deck procedures, which probably allowed the crew to become distracted.

The ATSB found that the operator’s procedures did not specifically draw the crew’s attention to unchanged auto-flight system modes during descent or prompt crew reconsideration of the most suitable descent mode at any point during descent. Additionally, the operator’s procedures allowed the crew to select the altitude to which they were cleared by air traffic control on the Flight Control Unit altitude selector, irrespective of intervening altitude constraints. This combination of procedures provided limited protection against descent through segment minimum safe altitudes.

What's been done as a result

Following this occurrence, the operator included additional guidance material in its Flight Crew Training Manual regarding mode awareness. It also included a warning on its Queenstown approach charts to state that managed descent was required beyond the initial approach fix.

Safety message

The ATSB reminds operators and flight crew of the importance of continuous attention to active and armed auto-flight system modes. Equally, the ATSB stresses the importance of continually monitoring descent profiles and an aircraft’s proximity to segment minimum safe altitudes, irrespective of any expectation that descent is being appropriately managed by the auto-flight system. For flight crew, this occurrence illustrates once again the fallibility of prospective memory and the potentially serious effects of pilot distraction. For operators, it highlights the importance to safe operations of robust management procedures for auto-flight systems.

What happened

On 19 August 2012 at about 1520 Eastern Standard Time, a Kawasaki Heavy Industries 369HS helicopter, registered VH-JWJ, was approaching a landing site at Konwack, Victoria. As the helicopter approached the intended landing site the ‘engine out’ caution light illuminated, accompanied by the low rotor revolutions per minute (RPM) horn and a loss of power.

The pilot immediately lowered the collective to enter autorotation, but then increased the position of the collective lever to clear a line of trees directly in his path. Clearing the trees, the pilot was able to maintain speed by keeping the nose of the helicopter down while descending. The right skid contacted the ground and was torn off, taking the tail boom with it. The aircraft skidded for about 80 m before coming to rest. The pilot was uninjured while the passenger sustained a minor head wound.

The cause of the reported power loss could not be determined. The accident highlights the value of restraints and helicopter safety helmets for both pilots and passengers.

Aviation Short Investigation Bulletin – Issue 14

What happened

On 5 August 2012, the pilot and flight nurse of a Raytheon B200 aircraft, registered VH-MSH, were tasked with transporting a patient from Port Macquarie to Sydney, New South Wales.

After departing Sydney, the pilot reported that he began to feel unwell, experiencing abdominal pain and nausea. When about 10 NM to the south-west of Williamtown Airport, his conditioned worsened. After donning his crew oxygen mask, the pilot’s health improved and a return to Sydney was commenced. During the descent, the pilot removed his oxygen mask and, soon after, he began to feel unwell again

The aircraft landed at Sydney and after shutdown the pilot became physically ill. The pilot recovered from the illness about 1 week later. It was determined that he most likely suffered viral gastroenteritis.

While pilots conduct a pre-flight inspection of their aircraft to determine airworthiness, this incident highlights the importance of pilots also assessing their own wellbeing. Tools such as the ‘I’m safe checklist’ allows pilots to determine if they are physically and mentally prepared for a flight.

Aviation Short Investigation Bulletin - Issue 13

What happened

On 9 August 2012 at 1235 Eastern Standard Time, a breakdown of separation occurred between a Raytheon Beech 200, registered VH-FDD (FDD) operating under the callsign FLYDOC 423, and a Raytheon Beech 350, operating under the callsign DINGO 008, near Cooktown, Queensland. An air traffic controller had issued clearance for FDD, tracking north, to climb to flight level (FL) 300. During the climb, the air traffic control system’s Short Term Conflict Alert (STCA) activated, when the aircraft were 10.1 NM horizontally and 200 ft vertically apart. The STCA alerted the controller to a pending breakdown of separation with the southbound aircraft, DINGO 008, maintaining FL270. The controller issued both flight crews with safety alerts and instructions that limited the severity of the separation breakdown. The aircraft passed 4.8 NM horizontally and 100 ft vertically of each other.

The controller had not identified the conflict before the STCA activation, but their knowledge and application of effective compromised separation recovery techniques was integral to resolving the issue, following their recognition of the situation.

This incident highlights the importance for controllers to effectively balance their professional desire to promptly facilitate pilot requests with the overriding requirement to provide a safe and efficient air traffic control service.

The prompt and effective controller reaction to re-establish the appropriate separation standard highlights the benefit of and importance of regular compromised separation recovery training as an integral defence.

Aviation Short Investigation Bulletin - Issue 13

On 6 July 2012, a Bell Helicopter B206L1/C30P, registered P2-HCY, impacted terrain about 130 km south-south-east of Mount Hagen, Papua New Guinea (PNG). The pilot and two passengers on board the aircraft were fatally injured.

The PNG Accident Investigation Commission (AIC) is investigating this accident in accordance with its obligations under Annex 13 to the Convention on International Civil Aviation (Annex 13).

On 20 July 2012, the AIC requested Australian Transport Safety Bureau (ATSB) assistance in terms of investigator support and technical advice. In accordance with paragraphs 5.23 and 5.24 of Annex 13 (Aircraft Accident and Incident Investigation) to the Convention on International Civil Aviation, the ATSB appointed an Accredited Representative and an Advisor to the Accredited Representative (ATSB investigators). These investigators assisted the AIC with engineering expertise for the airframe and engine examination as part of an External Investigation under the provisions of the Australian Transport Safety Investigation Act 2003.

The wreckage was transported to Port Moresby by the AIC for examination by the team of two ATSB investigators, along with AIC investigators and representatives from the airframe and engine manufacturers. After examination of the wreckage, several instruments and the engine and its associated components were sent to Australia for a detailed examination under the control of the ATSB. Support and information was provided to the AIC during the course of the investigation and the ATSB's Engineering Group Report was provided to the AIC in July 2013.

The PNG AIC is responsible for and will administer the release of the final investigation report into this accident. Any enquiries in respect of the ongoing AIC investigation should, in the first instance, be directed to:

Mr David Inau
Chief Executive Officer
Papua New Guinea Accident Investigation Commission
Telephone: +675 311 2406

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

The Air Accident Investigation Bureau (AAIB) of Mongolia is investigating a runway excursion that occurred at Oyut Domestic Airport, Mongolia on 30 March 2012 and involved a Fokker 50 aircraft, operating as Aero Mongolia Airlines flight Ju 8257. The aircraft exited to the right of the runway and its nosewheel and propeller struck a frangible, stake-mounted runway edge light as the pilot manoeuvred the aircraft back onto the runway. The aircraft was substantially damaged and there were no injuries to passengers or crew.

The investigation is being carried out in accordance Mongolia's obligations as the State of Occurrence under Annex 13 to the Convention on International Civil Aviation. On 11 May 2012, the AAIB requested Australian Transport Safety Bureau (ATSB) assistance by providing investigator support to obtain relevant technical information and verify the correct lighting installation. In accordance with paragraph 5.23 of Annex 13, the ATSB appointed an Accredited Representative to assist the AAIB. To facilitate this support, the ATSB commenced an investigation under the Transport Safety Investigation Act 2003. The ATSB coordinated with the Australian aerodrome lighting manufacturer for technical information and diagrams, which were provided to the AAIB.

The AAIB of Mongolia is responsible for releasing the final investigation report on this occurrence. Any enquiries in respect of the AAIB investigation and report should, in the first instance, be directed to the:

Air Accident Investigation Bureau

Ministry of Road, Transportation, Construction and Urban Development of Mongolia
Chinggis Khaan International Airport
Ulaanbaatar 34 Mongolia

Telephone: +976 9595 3339
E-mail: aaib@aaib.gov.mn

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

What happened

On 19 July 2012, at about 1629 Eastern Standard Time, the pilot of a Cessna 172S aircraft, registered VH-EOP (EOP), received an air traffic control (ATC) clearance to land on runway 35 Right at Moorabbin Airport, Victoria.

Several seconds later, the pilot reported observing another Cessna 172S aircraft, registered VH‑EWE (EWE), pass overhead from his right, about 10-20 metres in front. In response, he reduced engine power and raised the nose of the aircraft slightly to slow the aircraft and increase separation. The pilot then advised ATC, who immediately instructed the pilot of EWE to conduct a go-around.

The flight instructor in EWE reported that he was not aware of EOP operating in the circuit until after the incident occurred.

While research has shown that when searching for traffic, alerted see-and-avoid is eight times more effective than unalerted see-and-avoid, pilots should be mindful that the absence of a traffic broadcast does not necessarily mean the absence of traffic. Pilots should remain vigilant and employ both unalerted and alerted see-and-avoid principles to ensure the greatest level of traffic awareness is achieved.

Aviation Short Investigation Bulletin - Issue 13

At about 1802 on 1 August 2012, XPT passenger train ST23 (Sydney to Melbourne) reported loss of air shortly after traversing a level crossing between Longwood and Seymour in Victoria. Initial advice indicated that the coupler between the lead locomotive and adjoining passenger car had failed which led to the brake line and other service connections being damaged.

On 1 August 2012, the ATSB commenced an investigation into a separation of train ST23 at 1802 Eastern Standard Time on 1 August 2012 near Seymour, Victoria. Examination of the information collected during the investigation identified that the occurrence had significant similarities to the investigation of the partial separation of train ST24 near Broadmeadows on 11 August 2011 (RO-2011-012). 

Accordingly the ATSB decided to examine the Seymour occurrence as part of the Broadmeadows investigation (RO-2011-012) and therefore investigation RO-2012-008 was discontinued.

What happened

On 9 June 2012, a Robinson R44 helicopter, registered VH-CYH, departed Thursday Island to Dauan Island, Queensland, on a charter passenger flight. During the flight, the alternator light illuminated on two separate occasions, each time it was reset.

When at Dauan Island, the pilot attempted to start the engine for the return ferry flight, without success. After consultation with the operator, external batteries were used to start the helicopter.

About 10 minutes after departing, the alternator light illuminated and was again reset. This happened again several times in quick succession before the pilot then isolated all non-essential electrical systems. The pilot elected to fly to Moa Island because he had passed the point of no return to Dauan Island.

About 10 minutes later, the engine governor failed, the pilot switched the governor off. As a precaution, the pilot descended the helicopter to 500 ft above the water.

Over the next 10 minutes, the pilot adjusted the throttle manually to manage the engine and rotor RPM which would stabilize for a few minutes and then indicate a reduction. This was coupled with a gradually increasing vibration and grinding noise. At about 300 ft above the water, the pilot deployed the emergency ‘pop-out’ floats. The pilot was concerned about the increase in engine noise and vibration and elected to descend and commence a hover taxi. Soon after, the throttle was not able to be adjusted further, and he elected to ditch the helicopter.

The pilot contacted the helicopter operator, who initiated a search and rescue operation by contacting the Rescue and Coordination Centre Australia. At about 1845, a search and rescue helicopter arrived and transported the pilot to Horn Island. The pilot was uninjured.

The accident highlights the importance of wearing a life jacket equipped with flares and a PLB among other safety items; a nominated realistic SARTIME; a thorough knowledge of an aircraft’s systems; and the benefits of helicopter underwater escape training.

Aviation Short Investigation Bulletin – Issue 15

What happened

On 6 July 2012, a Gippsland Aeronautics GA-8 Airvan aircraft, registered VH-FCK, departed Tennant Creek on a night training flight to Alice Springs, Northern Territory.

When in the cruise, the crew noticed that the engine oil pressure indication was dropping and, as a result, they began planning for a diversion to the Ti Tree aeroplane landing area (ALA). Soon after, the engine oil pressure light illuminated, necessitating an immediate landing. The crew then diverted to the ALA and attempted to activate the runway pilot activated lighting (PAL), without success.

When abeam the township of Ti Tree, the engine began to run rough and subsequently failed.  The crew then noticed a vehicle travelling on a road to the north of the town. They elected to abandon the landing at the unlit ALA, and following the vehicle’s lights, carried out a successful landing onto the Stuart Highway, 4 km north of the township.

The engine was removed from the aircraft and the assessment at the time of writing this report was that the failure was a result of a No. 6 connecting rod, big end cap bolt failure.

One of the greatest concerns for pilots operating single-engine aircraft is the prospect of a total power loss at night. Should such an event occur, it is crucial that pilots are mentally prepared to act immediately. This incident demonstrates how responding to an adverse situation promptly can result in a positive outcome.

Aviation Short Investigation Bulletin - Issue 12