What happened

At 0840 Eastern Standard Time on 6 July 2012, during mustering operations near Miranda Downs aeroplane landing area, Queensland, the right skid of a Robinson R22 Beta, registered VH-STK (STK), struck a tree and the helicopter collided with terrain. The pilot, the only occupant, was seriously injured and the helicopter sustained substantial damage.

The operator conducted an investigation into the accident and, using Global Positioning System (GPS) data, determined that STK had climbed to about 2,500 ft above sea level before commencing a left spiral descent. Bureau of Meteorology data, obtained by the operator, indicated that the temperature was 14.7° C and the dew point 1.3° C. The operator determined that the combination of temperature and dew point would indicate a moderate carburettor icing risk at cruise power and a serious icing risk at descent power.

As a result of this occurrence, the aircraft operator has advised the ATSB that they have reminded their pilots of documentation in relation to carburettor icing and auto-rotations.

Pilots are reminded to maintain awareness of the weather conditions that are conducive to carburettor ice formation and closely monitor aircraft performance during times when the risk exists.

Aviation Short Investigation Bulletin - Issue 13

Safety summary

What happened

On 11 July 2012, the pilot of a Piper Seneca I, registered VH-LCK, was conducting a freight-carrying flight between Broome and Port Hedland, Western Australia. The flight was conducted at night under the instrument flight rules. Witnesses who heard or saw the aircraft take-off reported hearing unusual noises from the engines during the climb. Other witnesses closer to the accident site reported hearing the engine sound suddenly cut out before the aircraft banked left and descended steeply towards the ground. The aircraft wreckage was located amongst sand dunes, about 880 m beyond the upwind runway threshold. The aircraft was destroyed, and the pilot sustained fatal injuries.

What the ATSB found

The take-off towards the ocean was conducted in dark night conditions with limited external visual cues. An on-board global positioning system (GPS) recorded a reducing ground speed as the aircraft approached and passed overhead the upwind runway threshold, but without a significant increase in climb performance. That reduction in ground speed occurred about the same time witnesses heard unusual noises from the aircraft’s engines.

In the absence of any identified environmental, airframe or structural factors, the witness reports and GPS data were consistent with the aircraft’s performance being affected by a reduction in engine power. Following the likely loss of engine power, the aircraft speed reduced significantly, resulting in uncontrolled flight, a steep descent and collision with terrain.

Although not identified as a factor contributing to this occurrence, post-accident examination of the aircraft’s fuel selector valves found the internal seals had deteriorated and allowed fuel to flow to the engines when the valves were in the OFF position. A review of the aircraft manufacturer’s maintenance instructions revealed this type of internal leakage may not be evident during routine maintenance, although a non-scheduled valve leak procedure was available.

What's been done as a result

The aircraft manufacturer has been advised that their maintenance instructions may not identify deteriorated fuel selector internal seals during routine maintenance. Airworthiness bulletin AWB 28-105, published by the Civil Aviation Safety Authority, recommended that owners and operators of Piper Seneca, and other aircraft fitted with similar fuel selector valves, regularly check their function.

Safety message

This accident highlights the need for pilots to closely monitor their aircraft’s airspeed and initial climb performance during take-off. The need for prompt identification of any performance degradation and optimisation of the aircraft’s available climb performance is emphasised. The accident also highlights the elevated risk associated with dark night conditions, which increase pilot workload, particularly in the case of abnormal aircraft operations.

The investigation also identified the potential for inadvertent operation of the engine magneto switches due to their close proximity to the landing and taxi lights and auxiliary fuel pumps, potentially increasing risk if these switches are operated at a critical stage of flight.

The Air Accident Investigation Department (AAID) of the Ministry of Transport and Communication of the Republic of Kazakhstan is investigating a loss of separation that occurred in Kazakhstan airspace on 26 May 2012. One of the aircraft involved in the occurrence was an Australian-operated Boeing Company 747, registered VH-OJI, which was en route from Singapore to Frankfurt, Germany.

The investigation is being carried out in accordance the Republic of Kazakhstan’s obligations as the State of Occurrence under Annex 13 to the Convention on International Civil Aviation (Annex 13). On 18 June 2012, the AAID requested Australian Transport Safety Bureau (ATSB) assistance with obtaining relevant technical and operational information from the aircraft operator. In accordance with paragraph 5.23 of Annex 13, the ATSB appointed an Accredited Representative to assist the AAID. To facilitate this support, the ATSB commenced an investigation under the Transport Safety Investigation Act 2003. The ATSB obtained aircraft and flight crew details from the aircraft operator and forwarded them to the AAID.

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

Air Accident Investigation Department
Ministry of Transport and Communication
47, Kabanbai batyr Avenue
010000 Astana
Republic of Kazakhstan

Telephone: +7 7172-242605
Fax: +7 7172-243165

______________

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

What happened

During track work, the Traffic Officer instructed the Track Machine Operator to travel beyond the limit of the Track Occupancy Authority that had been granted.

Safety message

This occurrence highlights potential for confusion around terminology used in Track Occupancy Authority notices. All track personnel and operators are reminded of the need to ensure they know the limits of their authority before moving vehicles.

What happened

On 29 June 2012, at about 1757 Eastern Standard Time, a Piper PA-31 Navajo aircraft, registered VH-LWW (LWW), took off from runway 05 at Mackay Airport on a charter flight to Emerald, Queensland.

At that time, an Airport Safety Officer (ASO) was conducting an airfield runway and lighting inspection in an airfield safety vehicle and moving in a north-westerly direction along runway 32. Despite an earlier air traffic control instruction to hold short of runway 05, the ASO was distracted by a telephone call and continued along runway 32, crossing runway 05. LWW passed over the airfield safety vehicle by an estimated vertical distance of 30 ft.

This incident highlights the importance of remaining vigilant during airside operations, and to be mindful of the potential distraction presented by portable communication devices.

Aviation Short Investigation Bulletin - Issue 13

What happened

On 21 June 2012, a breakdown of separation occurred between a Qantas Airways Boeing Company B737-438, registered VH-TJS (TJS) and a Sharp Aviation Fairchild SA227, registered VH-MYI (MYI) near Melbourne Airport, Victoria. After being radar vectored from the north-east and given an assigned heading of 230˚, TJS was cleared to conduct an instrument approach to runway 27 at Melbourne Airport. However, instead of intercepting the runway 27 localizer, TJS maintained the assigned heading and passed through the localizer by about 1 NM. As a result the separation between TJS and MYI reduced to less than the required standard of 3 NM.

Although the reason for the clearance deviation could not be positively identified, it was likely that a higher than usual workload resulted in the flight crew not arming the appropriate approach mode or observing the aircraft’s closure relative to the runway 27 localizer. The occurrence highlights the need for flight crews to closely monitor the aircraft flight path and be ready to take prompt action in the event of any deviation from the cleared route.

Aviation Short Investigation Bulletin - Issue 13

What happened

At 0557 Western Standard Time, an airport safety vehicle, Safety 2, entered runway 21 without a clearance during the operation of low visibility procedures. Prior to entering the runway, an air traffic controller used non-standard phraseology to instruct Safety 2 to conduct a runway visibility check.

In response to this incident, the Perth Airport Pty Ltd, the operator of Safety 2, has conducted a workshop for airport operations officers (AOOs) to reinforce the importance of seeking clarification of implied or unclear instructions from air traffic control (ATC). Training and procedures for AOOs are also being updated.

As a result of this incident, Airservices Australia will issue a Standardisation Directive to remind controllers of the importance of using standard phraseology for interaction with ground vehicles. In addition, they will review the industry communications document Airside Driver’s Guide to Runway Safety – Safe surface operations at controlled aerodromes to ensure that the document continues to be accurate and relevant for the promotion of runway safety performance.

This incident is a reminder that radio communications phraseology should be clear, concise and unambiguous. It is also a reminder to drivers of airport vehicle to seek clarification of ATC instructions, should there be any doubt as to the content or intent of the instruction.

Aviation Short Investigation Bulletin - Issue 13

On 21 June 2012, after a review of the initial Airservices Australia report of the occurrence, the Australian Transport Safety Bureau (ATSB) initiated an investigation into a breakdown of separation (BOS) between two aircraft near Melbourne Airport, Victoria on 20 June 2012.

A preliminary examination of the occurrence showed that the BOS involved an Airbus A320 aircraft (A320) that was inbound to Melbourne Airport from the north and a Bombardier Inc BD-700 aircraft (Bombardier) that had departed from runway 34 at Melbourne and was tracking to the north-west. The ATSB also reviewed information from the involved Melbourne Approach Departures controller, the relevant air traffic control automatic voice recordings, weather information from the Bureau of Meteorology and the respective aircrafts flight tracks on Webtrack recordings (see Airservices WebTrak). 

The preliminary investigation determined that the controller had planned for a lesser rate of closure between the two aircraft than eventuated, with the actual rate of closure being affected by the ambient conditions and a slower acceleration by the Bombardier than anticipated by the controller. No avoiding action was necessary by either crew. The controller became aware of the infringement of the 3NM (5.6km) separation standard when advised by the crew of the A320 that they had received a Traffic Alert and Collision Avoidance System traffic advisory on passing behind the Bombardier. Shortly after, the lateral and vertical distance between the two aircraft increased and a separation standard was re-established.

The preliminary investigation showed that the potential for any systemic issues to have contributed to the occurrence was low and that it was unlikely that any safety issues would be identified through further investigation. On that basis, the ATSB decided to discontinue its investigation, as provided for in Section 21 (2) of the Transport Safety Investigation Act 2003.

What happened

On 19 June 2012, at about 0815 Eastern Standard Time, a Cessna Aircraft Company 182P aircraft, registered VH-WTS, departed Mayvale Station, about 53 km east-north-east from Cunnamulla, Queensland. Shortly after becoming airborne, the pilot recalled the aircraft losing airspeed and then clipping a tree during the subsequent forced landing. The aircraft collided with the ground and came to rest inverted.

The pilot, the only occupant, was seriously injured and the aircraft was destroyed. The pilot was wearing a seat belt at the time, but had not used the shoulder harness. The pilot and aircraft were located about 3 hours after the accident following a search. The aircraft’s Emergency Locator Transmitter (ELT) had not activated and the pilot’s personal ELT was inaccessible.

The day before the accident flight, the pilot refuelled the aircraft from drum stock kept as an emergency fuel supply. The pilot did not test the drum fuel for water or contamination. Following the accident, a considerable amount of water was found in a number of fuel samples taken from the aircraft, and in a sample taken from the drum.

This accident highlights a number of safety messages, including that:

• pre-flight checks, including checking samples from all fuel drain points, are a vital barrier in reducing the likelihood of power loss after takeoff;
• aviation fuel stored in drums should be checked before use for water and other contaminants;
• aircraft occupants should fasten available restraints, both seat belt and shoulder harness, where provided, for takeoff and landing;
• pilots are encouraged to leave a flight note with a responsible person as discussed in the Aeronautical Information Publication (AIP); and
• survival equipment should be carried on the person so that it is readily available when most needed.

Aviation Short Investigation Bulletin - Issue 12

What happened

On 19 June 2012 at about 1645 Central Standard Time, a Eurocopter AS-350BA helicopter, registered VH-HEB (HEB), was en-route from Ceduna to Border Village, South Australia when abnormal fumes were detected in the cockpit. The pilot conducted an emergency landing. Once on the ground, the passenger exited the aircraft and noticed smoke and fire emanating from the aft cargo compartment. The pilot and passenger left the vicinity of the helicopter, which was subsequently destroyed as a result of the fire. This accident highlights the importance of having appropriate practices and procedures in place for the transport of dangerous goods and conducting remote area operations.

Aviation Short Investigation Bulletin – Issue 14