Safety summary

What happened

On 6 February 2012, the flight crew of an Airbus A320-232, registered VH-JQX, commenced take-off from runway 16R at Sydney Airport, New South Wales. The flight crew consisted of a training captain and a captain under training, who was occupying the left seat and conducting the duties of the captain.

During the take-off, one of the thrust levers was inadvertently moved forward of the required detent, which resulted in a thrust setting reversion to manual mode. The training captain identified the issue and initially made the required standard calls to the captain under training to indicate the issue with the thrust lever.

The training captain then made a call to indicate that the take-off should continue, with maximum thrust selected, and the captain under training began rotating the aircraft below the required rotation speed. At about that time the training captain increased the thrust levers to the maximum thrust setting. After noting the aircraft’s airspeed was below the required rotation speed, the captain under training discontinued the rotation until a suitable airspeed was achieved prior to commencing the climb.

What the ATSB found

The ATSB found that the captain under training misunderstood the command from the training captain, which led to the early rotation. The training captain recognised the thrust lever asymmetry situation, however the captain under training did not, and this resulted in a miscommunication that was not resolved effectively between the crew.

In addition, the captain under training was transitioning from another aircraft type to the A320 and the manual thrust mode on the A320 was consistent with his experience of a normal take-off on the previous aircraft type. This created a level of confusion for the captain under training and made it more difficult for him to recognise the thrust lever asymmetry situation. A situation where one thrust lever is in the detent and the other is not, is indicated to the crew on the flight mode annunciator panel and is only displayed above 100 ft.

What has been done as a result

Jetstar have advised that they have incorporated a module into simulator training for all pilots covering incorrect thrust settings at take-off. They have also released a communication to pilots on the responsibilities of the pilot in command during operational events.

Safety message

This incident highlights the importance of good flight crew communication to ensure a shared understanding of the aircraft’s system status.

What happened

On 22 November 2011, during pre-flight performance calculations at Melbourne Airport, the crew of a Qantas Airways Boeing B737-476 aircraft, registered VH-TJL, inadvertently used the full-length runway 16 distance to calculate the take-off performance figures despite planning a runway 16/taxiway Echo intersection departure. Neither crew identified the error, which produced inappropriately high take-off reference speeds. During the take-off run the crew realised there was inaccuracy in the figures and elected to continue the take-off, rotating the aircraft below the calculated rotation speed (V_R). The error was attributed to the Electronic Flight Bag (EFB) menu structure defaulting to the full runway length.

As a result of this incident, Qantas Airlines advised that they have modified the EFB to require a positive selection of the runway length. The application of correct operating data is a foundational and critical element of flight safety, but errors in the calculation, entry and checking of data are not uncommon. The ATSB has published a research report that addresses the issue.

What happened

At 1310 Western Standard Time on 25 January 2012, a Bombardier Inc DHC-8-202 (Dash 8), registered VH-ZZI (ZZI), was on descent into Broome Airport. At about 17 NM, the flight crew of ZZI advised Broome Tower that they were descending in response to a Traffic Collision Avoidance System (TCAS) Resolution Advisory (RA) alert.

The first officer on ZZI sighted a Pilatus Aircraft Ltd PC-12/45 (PC12) about 1 NM ahead and reported that it passed about 200 to 300 ft to the right and slightly above them.

The traffic was identified as a PC-12, registered VH-MWO (MWO), that had departed Broome Airport at 1300. The pilot of MWO only became aware of the breakdown of separation after ZZI reported a TCAS Traffic Alert (TA), at which time he observed the Dash 8 on his TCAS, behind and on a reciprocal heading. The pilot did not recall hearing a TCAS audible alert.

Both aircraft were operating under Instrument Flight Rules (IFR) and were within airspace controlled by Broome Tower which utilised procedural separation.

The pilot of MWO had not selected automatic direction finding (ADF) as one of the active navigation aids in the aircraft's Electronic Flight Instrumentation System (EFIS). As a result, upon programming new information into the EFIS after departure, MWO unintentionally deviated from the desired outbound track and conflicted with the inbound track of ZZI.

Following the incident, the operator of MWO checked all aircraft in its fleet to ensure that the audio level of the TCAS could be heard above engine noise and radio traffic. MWO was the only aircraft that required the audio level to be increased.

This incident highlights the need for pilots to cross check aircraft navigation performance to ensure accurate track keeping particularly when operating in a procedural separation environment. The incident also highlighted the need to comply promptly with TCAS advisory alerts.

Safety summary

What happened

At about 1710 on 27 January 2012, a De Havilland Aircraft Pty Ltd DH-82A Tiger Moth aircraft, registered VH-GVA, took off from Maryborough Airport, Victoria, with two people on board.

Immediately after lift-off, the aircraft was observed to have a partial, intermittent power loss. The pilot continued the flight with the aircraft maintaining altitude or climbing slightly. At the upwind end of the runway, the aircraft made a climbing left turn before stalling and descending. The aircraft impacted the ground, and the occupants received fatal injuries.

The aircraft was seriously damaged by the accident forces and post-impact fire.

What the ATSB found

The partial engine power loss was probably a result of a partial blockage of the aircraft’s fuel cock. Although sufficient runway remained ahead to allow a safe landing, the flight was continued under limited power without gaining sufficient height to clear trees beyond the runway. Approaching the trees the aircraft climbed, lost airspeed, stalled and collided with terrain. There would have been a safer outcome had the pilot immediately landed the aircraft straight ahead.

Safety message

This accident illustrates several of the points made in the ATSB’s research report AR-2010-055, Managing partial power loss after take-off in single-engine aircraft. In particular, pilots are reminded that continued power in such circumstances is unpredictable, and risk can be reduced by conducting a controlled landing at the earliest opportunity.

What happened

At about 1605 on 26 January 2012, a fire broke out in the number one cargo hold of the general cargo ship BBC Baltic while it was discharging cargo in Port Hedland. At the time, workers from Cervan Marine, a local engineering company, were gas cutting in the cargo hold using an oxy-acetylene torch. The ship's crew assisted by the local emergency services fought the fire and, by 1625, had extinguished it. There were no injuries as a result of the incident and damage to the ship and its cargo was not serious.



In carrying out the hot work on board BBC Baltic, neither the ship's crew nor the Cervan Marine workers properly considered and mitigated the risk of fire. All the precautions listed on the ship's hot work permit were not taken nor was the permit completed properly. Similarly, all the measures listed on Cervan Marine's job safety analysis were not taken. Furthermore, a toolbox meeting was not held to discuss the work and risk, define roles and responsibilities, and the action to take in case of a fire. 



As a result of inadequate risk assessments, there was no fire watch, none of the ship's crew was at the hot work site and Cervan Marine's workers did not have a clear understanding of the action to take in case of a fire. Consequently, action to fight the cargo hold fire with a fire extinguisher and other fire-fighting equipment was not taken immediately, resulting in a larger fire that took longer to contain.

What happened

On 25 January 2012, at about 1600 Eastern Daylight-saving Time, a Schweitzer helicopter company 300C helicopter (300C), registered VH-FUJ departed an agricultural property near Scottsdale Tasmania. The pilot was returning to his home base of Devonport at the conclusion of the day's aerial spraying activities.  The pilot was the only person onboard.

Whist flying over heavily timbered country, the engine power reduced, and the helicopter collided with the tree canopy before coming to rest on the ground. 

The pilot was not injured and immediately exited the helicopter, which caught fire and was destroyed. The accident highlights the value of helicopter pilots wearing a helicopter safety helmet.

What happened

On 25 January 2012, a Virgin Australia Boeing Company 737-81D aircraft, registered VH-YFC, (YFC) was being operated on a scheduled passenger service from Brisbane to Sydney.

On descent into Sydney YFC encountered unexpected and severe turbulence which lasted about 3 to 5 seconds.  As a result, three unsecured cabin crew members sustained minor injuries. 

Turbulence is one of the leading causes of in flight injuries and due to the nature of their work cabin crew are 26 times more likely to be injured than passengers.  Measures likely to mitigate the risk of injury from unexpected turbulence include aircraft design and cabin crew training

What happened

On 23 January 2012, the pilot of a Robinson Helicopter Company R44 Raven II helicopter, registered VH-HYC (HYC), was conducting a routine gas pipeline inspection flight between Parramatta and Castle Hill, New South Wales.

When 1 NM (1.85 km) north of Parramatta, the pilot of HYC observed a Piper Aircraft Corporation PA-28-161, registered VH-TAK (TAK), tracking northbound from Bankstown, pass overhead, about 20 ft above. In response, the pilot of HYC immediately lowered the collective and commenced a descending right turn.

A review of Airservices Australia radar surveillance data indicated that the distance between HYC and TAK reduced to 0.2 NM (370 m) laterally, with both aircraft at the same altitude of 1,400 ft. The aircraft were operating in uncontrolled airspace and were not subject to air traffic control services.

This incident highlights the advantages of utilising two communication systems, if fitted, to enhance traffic awareness. It further emphasises the benefits of notifying the appropriate air traffic control authority if intending to conduct aerial work within a known area of high traffic levels, such as the Bankstown Lane of entry.

Safety summary

What happened

On 18 January 2012at 2125 Eastern Daylight-saving Time, there was a loss of separation (LOS) between an Airbus A320, registered 9V-TAZ, and an Airbus A340, registered A6-EHH, 907 km NW of Karratha, Western Australia. The aircraft were under the air traffic control of Airservices Australia. The A320 was southbound at FL 350 and the A340 was heading west and cleared to operate in a ‘block’ level, anywhere between FL 340 and FL 360. The aircraft were estimated to cross waypoint TANEM within 2 minutes of each other. The relevant separation standards were 1,000 ft vertical separation or 15 minutes lateral separation at the same position. Controller 1, who approved the block level clearance, did not detect the traffic confliction prior to handing over to controller 2. After a short break, controller 2 handed back to controller 1, and the confliction was detected by controller 2 during the handover. Compromised separation recovery techniques were applied to re-establish vertical separation.

What the ATSB found

The two controllers were experiencing a high workload due to a range of factors, including traffic levels, weather diversions and the airspace configuration, and controller 1 had limited opportunity to consolidate their training and skills before being rostered onto more complex sectors and situations. The ATSB found that Airservices’ processes for monitoring and managing controller workloads did not ensure that newly-endorsed controllers had sufficient skills and techniques to manage the high workload situations to which they were exposed. In addition, Airservices had limited formal guidance regarding how to determine appropriate consolidation periods for en route controllers on one sector before they were transitioned to commence training on another sector. Further safety issues were also identified relating to the application of block level clearances, and the continuing absence of an automated air traffic conflict detection system available for conflictions involving aircraft that were not subject to radar or ADS-B surveillance services.

What's been done as a result

Airservices reported that changes had been made to the configuration, training and rostering arrangements for the airspace sectors involved in the occurrence. The commissioning of a radar in northern West Australia had reportedly alleviated controller workload in two of the airspace sectors, with enhanced surveillance of the majority of aircraft operating in that airspace expected with the mandate of automatic dependant surveillance- broadcast (ADS-B) effective in December 2013. A working group had also been established to determine a suitable workload model to monitor and forecast controller workload on a sector by sector basis. In addition, the first stage of a flight plan conflict function had also been deployed in Brisbane Upper Airspace, with further roll out planned in Melbourne Centre in 2014. The ATSB is not satisfied that Airservices has adequately addressed the identified safety issues regarding formal guidance for consolidation periods for newly-endorsed controllers and the limited formal guidance to controllers and pilots regarding the conditions in which it was safe and appropriate to use block levels. As a result, the ATSB has made formal recommendations to Airservices.

Safety message

Ideally the best way of managing workload is to reduce the level of work demands and distractions. If the work demands cannot be reduced, then another option is to ensure the controllers have the experience, skills and techniques to effectively manage their task demands. Overall, high workload can have significant effects on a controller’s performance, and it needs to be monitored and managed using a systemic approach, particularly for less experienced controllers but also controllers who have recently received a new endorsement. The instances of other recent loss of separation occurrences involving high workloads and newly-endorsed controllers on other sector indicates that this problem was not restricted to the sectors involved in this occurrence.

What happened

On 10 January 2012, a Dornier Werke GMBH 328-100 aircraft, registered VH-PPJ, landed at Horn Island Airport, Queensland, after having departed Cairns, Queensland to conduct a search and rescue operation with two flight crew and three technical crew onboard.

The aircraft touched down on the runway normally, at about 48 kts, the pilot flying released the power levers from the reverse thrust position, the right propeller moved to a ground idle position, but the left propeller remained in the reverse thrust position and the aircraft veered off the side of the runway.

The FO attempted to correct the deviation through rudder input; however, despite full right rudder, the aircraft continued to diverge left. At the same time, the nose-wheel weight-on-wheels sensor showed the nose wheel alternating between ground and air modes, resulting in the nose-wheel steering not being operational.

A subsequent engineering inspection found that the left power lever appeared not to spring as far forward as the right power lever when released from reverse thrust. The levers and shaft assembly were inspected and found to be serviceable. A lubrication of the springs in the reverse thrust system was carried out.

The operator reported that the thrust levers required positive handling to move from the reverse thrust to the ground idle position, rather than relying on the spring tension. The first officer did not recall receiving specific instruction on operating the power levers.

The operator advised the ATSB that it had conducted the following safety action: All crew have been alerted to potential difficulties with the operation of power levers; an external advisor has been recruited to review the safety system and check and training program; the organisation is assessing the ongoing introduction of simulator training.