Safety summary

What happened

On 30 March 2012, Airservices Australia was unable to resolve two short-notice controller absences for night shift coverage of the Kimberley and Cable airspace sectors, located over north-western Australia. A contingency plan was activated, and a Temporary Restricted Area (TRA) initiated for that airspace from 0015 to 0515 Eastern Standard Time on 31 March.

Two aircraft separately entered the TRA without the knowledge of Airservices personnel. An Airbus A330 registered PK-GPA, on a flight from Denpasar, Indonesia to Melbourne, Victoria, was detected at 0500 when the flight crew contacted a Melbourne Centre controller because their aircraft was at the Brisbane/Melbourne Flight Information Region (FIR) boundary after transiting the TRA. The second aircraft, an A330 registered PK-GPO, on a flight from Denpasar to Sydney, New South Wales, was detected at 0641, when the crew contacted Melbourne Centre at the FIR boundary. The aircraft had been operating in controlled airspace for 86 minutes, without the knowledge of any controllers. The minimum standards for separation from other aircraft were met, but both situations constituted losses of assurance that separation would be maintained.

What the ATSB found

Overall, Airservices had many risk controls in place to manage the situation where it was unable to provide the published air traffic services (ATS) and had to activate a TRA. In this case, a TRA had to be activated at short notice in airspace adjacent to an international ATS provider, and a range of actions by operational personnel did not conform to expectations. Airservices’ risk controls were not robust enough to effectively manage this situation and ensure they would be made aware of all aircraft that were operating within the TRA.

The ATSB concluded that a number of procedures and processes were not fulfilled on the night of the occurrence and identified four safety issues: Airservices’ process for ensuring that all aircraft operating in the TRA were known to ATS; selection and preparation of personnel for the Contingency Response Manager role; the contingency plan testing and review process; and the absence of a defined process for recording the actual hours worked by Air Traffic Control Line Managers.

What's been done as a result

Airservices has revised its contingency plan documentation and procedures. In addition, its updated Fatigue Risk Management Requirements have addressed the recording and monitoring of the actual hours worked by Air Traffic Control Line Managers.

The ATSB is not satisfied that Airservices has adequately addressed the identified safety issues regarding processes for managing a Temporary Restricted Area to ensure that all aircraft were known to air traffic services and contingency plan testing and review effectiveness. As a result, the ATSB has made formal recommendations to Airservices.

The operator of the A330 aircraft, Garuda International, specified that, as the use of procedures associated with TRA activation was an infrequent requirement and not practiced in daily operations, it would ensure the procedures were reviewed as part of check and training programs.

Safety message

The occurrence provides a timely reminder to all organisations operating in high reliability systems of the importance of having multiple risk controls in place to effectively manage rare combinations of events during abnormal situations, and to regularly review the effectiveness of these controls.

On 7 January 2012, while operating in the vicinity of Carterton, New Zealand, a Cameron Balloons A-210 hot-air balloon, registered ZK-XXF, contacted power lines and caught fire before colliding with terrain.  The 11 occupants were fatally injured.

The Transport Accident Investigation Commission (TAIC) of New Zealand is responsible for the investigation of this occurrence.  On 14 March 2012, the TAIC formally requested the assistance of the Australian Transport Safety Bureau (ATSB) in the recovery of data from a damaged GPS receiver found at the accident site.

The ATSB successfully recovered the accident data from the GPS receiver. This data and a technical report have been sent to the TAIC of New Zealand to assist its ongoing investigation. The TAIC is responsible for releasing a final investigation report regarding this occurrence.

• TAIC website: www.taic.org.nz

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

Safety summary

What happened

At about 0910, on 11 April 2012, an Ayres Corporation S2R-G10 Thrush aircraft, registered VH-WDD, collided with terrain in a fallow wheat field about 36 km north-west of Moree, New South Wales while on a ferry flight from St George, Queensland to Moree. The owner-pilot was fatally injured, and the aircraft was destroyed by impact forces and an intense fuel-fed fire.

What the ATSB found

The ATSB found that the aircraft departed controlled flight, and the pilot was unable to recover before impact with the ground. On the basis of the evidence available to the ATSB, it was not possible to determine with any certainty the reasons for the loss of control.

There was no evidence of any mechanical fault with the aircraft that could have contributed to the accident. A number of other possible factors could not, however, be completely discounted: pilot incapacitation; aircraft handling, such as to avoid a bird or flock of birds or other deliberate manoeuvring by the pilot; or a mechanical problem which could not be identified during the post-accident site and aircraft examinations.

Although it did not contribute to the accident, an issue was identified with the potential to affect the safety of agricultural operations in S2R-G10 Thrush aircraft in Australia. The aircraft’s permitted load-carrying capability, based on its published maximum take-off weight, was very low in comparison with other agricultural aircraft types. The aircraft type’s operational history indicated that it could be operated at higher loads, but the absence of a more practical published weight limit increased the risk of pilots flying at weights where the aircraft had not been fully tested for safety.

What has been done as a result

In June 2012, Statewide Aviation, the Australian distributor for Ayres aircraft, in consultation with the Civil Aviation Safety Authority, commenced developing a Supplemental Type Certificate (STC) for some Ayres Thrush variants. This STC would permit an increase in the aircraft's maximum take-off weight, and is expected to be available to Thrush owners in October 2013.

Safety message

Although the investigation did not determine why the aircraft departed controlled flight, the potential for the operation of the emergency cut-off lever in Garrett-engined Thrush aircraft to prevent significant control difficulties in the event of a serious engine or propeller problem was highlighted.

On 29 August 2011, the Papua New Guinea Accident Investigation Commission (AIC) requested technical assistance from the Australian Transport Safety Bureau (ATSB), in the recovery of information from the global positioning system (GPS) and several engine and flight instruments from a MBB BO-105 aircraft that impacted terrain 5 km south of Timini, Morobe Provence, Papua New Guinea, on 8 August 2011. The pilot and two passengers on-board the aircraft were fatally injured in the accident.
 
The AIC is responsible for investigating this occurrence. In accordance with clause 5.23 of Annex 13 to the Convention on International Civil Aviation, the ATSB appointed an accredited representative to assist the AIC and initiated an investigation under the Australian Transport Safety Investigation Act 2003.
 
Examination of the GPS was commenced with the intent of downloading the GPS data, however the data was unrecoverable due to the absence of the memory device (chip) containing the GPS data for the accident flight. The flight and engine instruments were examined for evidence of indicating pointer contact marks on the instrument face. Support and information was provided to the AIC during the course of the investigation and the ATSB's Technical Analysis Reports were provided to the AIC.
 
The AIC of Papua New Guinea is responsible for releasing the final investigation report on this occurrence.
 
Contact details for the PNG AIC are:

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.

What happened

At 1400 Eastern Daylight-saving Time on 23 March 2012, as a Vans RV-10 registered VH-PGX (PGX) became airborne at about 65 kts, the pilot of PGX observed another aircraft enter runway 22 at Taree, NSW and turn right for the threshold of runway 04. PGX passed directly overhead the other aircraft at about 300 ft.

The other aircraft was identified as a Regional Express, SAAB Aircraft Co 340B registered VH-ZLH (ZLH). After the incident, the captain of ZLH established contact with PGX and neither aircraft experienced problems communicating with the other.

As a result of the incident, the operator of ZLH will amend procedures to more clearly define radio procedures for both flight crew and ground staff at those Common Traffic Advisory Frequency aerodromes without an Aerodrome Frequency Response Unit.

This incident highlighted the need for pilots to apply all available methods to maintain separation with other aircraft when operating outside controlled airspace. These methods include the utilisation of both alerted and un-alerted see-and-avoid principles, the use of on-board collision avoidance systems where fitted and all available aircraft lighting.

What happened

The pilot of a Piper PA‑34 aircraft, registered VH-FEJ (FEJ), submitted a flight plan from Archerfield to Cairns via Townsville, Queensland. Prior to departure, air traffic control (ATC) at Archerfield updated the flight plan from visual flight rules (VFR) to instrument flight rules (IFR) at the pilot’s request.

The updated flight plan was transmitted via a change message to the various ATC agencies responsible for the aircraft. Townsville ATC, operated by the Department of Defence, utilised computer printed flight progress strips (strips) and the strip for FEJ was printed prior to the change message being processed, indicating that FEJ was a VFR flight.

When the pilot of FEJ contacted Townsville Approach, he requested a runway 01 instrument landing system approach. The Approach controller cleared the aircraft to track direct to the initial approach fix and, once the aircraft was within 36 NM, cleared the pilot of FEJ to descend to 4,000 ft.

Shortly after, the Approach controller became concerned about FEJ maintaining visual meteorological conditions given the weather in the area and queried the pilot on the aircraft’s flight category. On being advised that FEJ was an IFR flight and in cloud, the Approach controller immediately instructed the pilot to stop the descent at 5,500 ft. By the time the pilot was able to arrest the aircraft’s descent, FEJ had reached 5,200 ft. Though FEJ did not descend below the lowest safe altitude on the aircraft’s track, terrain clearance on track was not assured until FEJ climbed back to 5,500 ft. Shortly after, the pilot became visual and FEJ landed without further incident.

As a result of this occurrence, the Department of Defence has advised the ATSB that controllers are now required to check flight progress strips thoroughly prior to passing them to Approach, ensuring that the data was correct.

Aviation Short investigation Bulletin Issue 21

What happened

On 28 February 2012, an Airbus A340-313X aircraft, Portuguese registered CS-TQM (TQM), was operating on a chartered service from Sydney, New South Wales to Darwin Airport, Northern Territory.

On approach into Darwin, the crew noted heavy rainfall near the threshold of runway 29 and requested wind information from the Darwin tower air traffic controller. At that time, the windsock at the threshold was indicating 5 kts tailwind and the approach was continued. In the final stages of the approach, the rainfall increased significantly, and the aircraft deviated below the glideslope. On touchdown, the wind suddenly increased to an 18 kt tailwind, possibly due to a microburst, and the aircraft landed heavily.

Subsequent engineering inspection revealed a crack in the No. 1 engine rear attachment bolt retainer. Components from the left and right main landing were also replaced.

As a result of the incident, the operator has

• Introduced go-arounds from 50 ft and go-arounds from immediately after touchdown into simulator training sessions.
• Developed an awareness program to increase the go-around mind set among flight crew, including allowing First Officers to initiate a go-around without the need for consent from the Captain.

What happened

On Wednesday 21 March 2012 at 0530 Eastern Daylight-Savings Time an aerodrome reporting officer (ARO) reported a runway edge light outage at Williamtown Airport, New South Wales. A further inspection during daylight revealed a broken runway edge light and wheel marks in the grass adjacent to the runway. The evidence was consistent with an aircraft departing from the sealed operational readiness platform adjacent to the runway threshold onto the grass and colliding with the runway edge lighting.

The distance between the wheel marks was consistent with a Beechcraft Kingair aircraft. Air traffic control records show that no other aircraft with this wheel arrangement had operated between the runway inspections.

The pilot of a Beechcraft Kingair 350, recalled rejecting the take-off on departure from Williamtown Airport on the night of 19 March 2012 due to asymmetric power resulting in the aircraft deviating left of centreline. The pilot did not believe that the aircraft left the sealed runway area. A number of other Kingair aircraft operated at Williamtown during the considered period.

It was not possible to determine when the runway excursion occurred, however the wheel marks indicated that a Kingair may have inadvertently lined up on the runway edge lighting during take-off. A paper published by the ATSB, "Factors influencing misaligned take-off occurrence at night" highlighted the risk factors for a misaligned take-off.

Safety summary

What happened

On 12 February 2012, the flight crew of a Boeing 737 aircraft, registered VH-TJS and operated by Qantas Airways Limited, was conducting a scheduled passenger service from Sydney, New South Wales to Canberra, Australian Capital Territory. Due to scheduled maintenance the instrument landing system at Canberra was not available and the crew prepared for an alternate instrument approach that provided for lateral but not vertical flight path information. The flight was at night with rain showers and scattered cloud in the Canberra area.

Shortly after becoming established on the final approach course with the aircraft’s automatic flight system engaged, the flight crew descended below the minimum safe altitude for that stage of the approach. The crew identified the deviation and levelled the aircraft until the correct descent profile was intercepted, then continued the approach and landed. No enhanced ground proximity warning system alerts were generated, as the alerting thresholds were not exceeded.

What the ATSB found

The ATSB found that at the time of the occurrence the automatic flight system was in the level change mode rather than the vertical navigation mode specified by the operator for such approaches. While in that mode the flight crew had selected an altitude lower than the applicable minimum safe altitude, with the effect that unless the crew intervened, the aircraft would descend to that lower altitude. The flight crew then allowed the aircraft to continue descending in the level change automatic flight mode through the segment minimum safe altitude, reflecting a temporary loss of situation awareness.

Safety message

During those phases of flight when terrain clearance is unavoidably reduced, such as during departure and approach, situation awareness is particularly crucial. Any loss of vertical situation awareness increases the risk of controlled flight into terrain. This occurrence highlights the importance of crews effectively monitoring their aircraft’s flight profile to ensure that descent is not continued through an intermediate step-down altitude when conducting a non-precision approach.

Safety summary

What happened

On 19 March 2012, Pacific National ore train 4460S travelling on the interstate main line between Port Augusta and Port Pirie collided with an eastbound motor vehicle on the Port Flinders Causeway Road level crossing, about 10 km south of Port Germein in South Australia. The level crossing was controlled by passive approach warning signs and a ‘Stop’ sign at the crossing.

There were two occupants in the motor vehicle. The passenger was fatally injured and the driver suffered serious injuries. The crew of the train were physically unhurt.

What the ATSB found

The ATSB found that the driver of the road vehicle involved in the collision did not come to a complete stop at the railway crossing and entered the crossing in the path of the approaching ore train. The ATSB concluded that the motorist’s attentional resources might have been diverted during a critical period when they would normally have stopped to look for a train.

What's been done as a result

Minor corrective action was taken to replace a missing ‘Railway Crossing’ assembly which should have been situated on top of the ‘Stop’ sign on the western approach to the crossing. The absence of the ‘Railway Crossing’ assembly was not considered a factor that contributed to the collision as it was found that the motorist regularly used the crossing and the ‘Stop’ sign was still in place.

Safety message

The occurrence highlights the need for drivers of motor vehicles to be vigilant and obey road traffic signage.