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

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

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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