On 24 March 2013, a Vans RV-12 amateur-built aircraft collided with terrain shortly after take-off from Lismore Airport, New South Wales. The pilot was fatally injured.

The NSW police service was responsible for investigating the accident on behalf of the state Coroner. On 10 April 2013, investigating officers contacted the ATSB and requested assistance with the recovery of data from the aircraft’s Dynon Avionics Skyview system. The display unit and control module were subsequently sent to the ATSB for examination and an investigation was initiated under the provisions of the Transport Safety Investigation Act 2003.

The ATSB liaised with the manufacturer of the display unit and was able to successfully disassemble and download flight data stored on the unit. The flight data contained the accident flight, however the flight data ended moments before the aircraft collided with terrain. An archive file, containing the downloaded flight data is released as Appendix A to this report and contains four comma-separated value (.csv) files. Attention is directed to the Data Limitations section of the main report, should any analysis of the recorded information be undertaken.

The ATSB report and the associated data were prepared by the ATSB to assist the NSW police investigation. The ATSB report, including the referenced data files, has been released under section 25 of the Transport Safety Investigation Act 2003 (the Act). Per section 27(1) of the Act, this report and the appended data files are not admissible in evidence in any civil or criminal proceedings. The device containing the original data was returned to the NSW Police Service on 13 November 2013.

On 17 April 2013, the crew of a Piper PA31-350 aircraft, registered VH‑EDV (EDV), were conducting a flight from Flinders Island, Tasmania to Moorabbin Airport, Victoria under instrument flight rules (IFR). During the descent to Moorabbin, the aircraft entered visual meteorological conditions, and the crew advised that they intended to track visually via the visual flight rules (VFR) reporting point at Carrum to Moorabbin. 

At about the same time, a Cessna R172K, registered VH‑JQQ (JQQ), was in transit via the VFR Coastal Route for the Tyabb, Victoria area. To remain in gliding distance of the coast, the pilot of the single-engine aircraft JQQ, elected to cross the coastline at Ricketts Point. With a clearance obtained from Moorabbin Tower, JQQ transited the western edge of the Moorabbin control zone flying about 1.5 NM off the coast, from Ricketts Point to Carrum at 1,500 ft.

EDV called Moorabbin Tower at Carrum, at about 1,500 ft on a descent profile to arrive at the entry of Moorabbin control zone at the required altitude of 1,000 ft. 

Less than a minute later, at about 1022, just over 5 NM south-west of Moorabbin, the pilot of JQQ saw EDV on a reciprocal track and the ICUS pilot in EDV saw the lights of JQQ. EDV commenced a descending turn to the right, as JQQ commenced a climb to the right, resulting in JQQ passing over EDV with about 200 ft vertical separation.

As a result of this occurrence, the operator of JQQ has advised the Australian Transport Safety Bureau (ATSB) that they are looking at the safest route to track from Westgate Bridge to Tyabb and have initiated consultation with Moorabbin Tower to determine the correct altitude for this leg.

This incident highlights the importance of good flight planning and preparation, in particular complying with tracking instructions for VFR routes. It also highlights the importance of being aware of other aircraft potentially operating in the area, particularly around VFR approach points. 

Aviation Short investigation Bulletin Issue 21

What happened

On 8 March 2013, during climb after departure from Tyabb aerodrome, Victoria, the pilot and sole occupant of a Jabiru J430 aircraft, registered VH-TJP, reported the onset of vibration through the airframe. As a precaution, the pilot began to turn the aircraft back towards Tyabb. During the turn, the propeller separated from the aircraft, necessitating a forced landing upon tidal flats at the western edge of Westernport Bay. The pilot was not injured and was able to disembark the aircraft safely.

What the ATSB found

The ATSB investigation found that most of the cap screws connecting the propeller mounting flange to the engine crankshaft had failed by bending fatigue fracture – principally due to repeated relative movement between the mounted components. This movement was traced to a combination of an ineffective, multi-step torqueing method and the relaxation of tension within the crank–flange joint due to the compression of multiple layers of paint within the joint. It was also found that there were some anomalies within the maintenance documentation that related to these areas.

After attempting to analyse the origin of the worsening vibration in the aircraft, the pilot correctly followed emergency procedures both before and after the propeller loss. The over-water return decision limited the risks associated with the forced landing, and the pilot effectively maintained control of the aircraft throughout the descent and landing.

What's been done as a result

In July 2011, the manufacturer had improved the strength and reliability of the crank–flange joint by adding positive-location dowels in all new-production engines. However, that modification was not extended to earlier design assemblies, which included VH-TJP. The current (revised) issue of the Engine Overhaul Manual has an added, strong recommendation for inclusion of these dowels at the next full overhaul or at bulk strip of engines manufactured prior to July 2011. Furthermore, in addition to the earlier requirement for no paint on mating faces or where screw heads bear, a broad requirement was introduced to ensure that no paint, thread-locking compound or contaminants remain in the propeller flange joint. The fastener torqueing method has been amended to a single-step process in which the required torque is to be obtained dynamically while the fastener is being turned.

Finally, the manufacturer’s Propeller Flange Attachment Service Bulletin now refers maintainers directly to the engine overhaul manual for installation procedures – removing the variability that previously existed between documents.

Safety message

A potentially serious accident was avoided by the pilot’s adherence to emergency procedures and maintaining control of the aircraft after a significant mechanical failure.

Regarding the mechanical assembly, the ATSB encourages manufacturers and maintainers to consider older and legacy operating assemblies when designs are optimised or improved to enhance safety and reliability.

On 11 April 2013, a Piper PA-24-260, registered VH-DRB (DRB), departed Albany Airport, Western Australia, to conduct an annual aeroplane flight review, with the pilot and testing officer on board.

After conducting the aerial work component of the flight review, DRB returned to the circuit and did two touch and go circuits on runway 14. On take-off the testing officer informed the pilot that the circuit would be at low-level for a full stop landing. On early downwind, the testing officer asked the pilot if a glide approach could be made for runway 23 and the decision was made to conduct a practice forced landing on runway 23. The pilot moved the throttle lever to reduce engine power and extended the flaps to slow the aircraft. On final, the testing officer thought she saw the pilot move his hand to the landing gear selector. The aircraft subsequently landed with the landing gear retracted just past the intersection with runway 14/32, skidded and then came to a stop. The pilot and testing officer were not injured and the aircraft sustained minor damage.

As the landing for runway 23 was initiated during a low-level circuit and on early downwind, the pilot reported that he was not following his normal pre-landing sequence.

The approach appeared a little fast, however, the pilot reasoned that it was because the aircraft type normally floated a little on landing and there was a slight crosswind that may have had a small tailwind component.

The testing officer also reported the approach looked a little fast and reasoned that was because the runway has a slight down slope, there may have been a small tailwind component and it was similar to the speed of the prior flapless landing.

This accident highlights that when practicing emergency procedures the defences that are usually in place, such as having a normal place in the circuit to put the gear down, audible alarms and checklist items can be missed or go un-actioned.

Aviation Short Investigation Bulletin Issue 20

Shortly after take-off, as the landing gear retracted, the crew heard a loud bang. The crew detected a potential issue with the landing gear and began troubleshooting the problem. The crew noted that the red landing gear transit warning light had remained illuminated. They cycled the landing gear on several occasions, which resulted in the green main landing gear down indicator lights illuminating, but not the nose landing gear (NLG) light. The transit light also remained illuminated. 

The aircraft arrived at Toowoomba, Queensland and a pass over the runway confirmed that the NLG had extended but was not in the locked position. The crew then referenced the wheels up landing procedure and formulated a plan.

During the subsequent landing, the aircraft’s nose lowered and slid along the runway. The aircraft came to a stop and the crew exited.

An examination of the aircraft determined that the rod end on the NLG forward retract rod assembly had separated from the plunger tube on the NLG plunger assembly. The affected components were further examined by the aircraft manufacturer who determined that copper braze had not been placed inside the plunger tube before the rod end had been inserted during the manufacturing process, which was conducted by an external supplier. 

As a result of this occurrence, the aircraft manufacturer released a Mandatory Service Bulletin for the inspection, and if necessary, replacement of the affected plunger assemblies. They further advised the ATSB that the manufacture of the plunger assembly will now be conducted in‑house, and that they are reviewing all braze process specifications and other brazed components manufactured by the external supplier.

While the crew were faced with an unfortunate situation, this accident highlighted the benefits of using time to your advantage. The crew took the time to formulate a strategy for the landing, assigned responsibilities to each crew member, and then rehearsed the plan. This ensured that they were well prepared and ended in a safe outcome.

 Aviation Short investigation Bulletin Issue 21

Safety summary

What happened

At about 2119 on 9 April 2013, freight train 331 derailed while travelling between Burnie and Boyer in Tasmania. The train travelled for about 2.5 km while derailed and came to a stop at Lowdina, about 48 km north of Hobart.

What the ATSB found

The ATSB investigation found that a large twist defect in the track near Lowdina caused the leading wheelset of the third wagon’s trailing bogie to unload and derail.

The investigation further found that it is likely that a previously undetected, small to medium sized twist defect, either at or near the derailment site, developed under the passage of train 331.

What's been done as a result

Prior to this incident, the network owner/manager (TasRail) had identified the need to renew the track infrastructure in the area of the derailment and anticipates that the track between Colebrook and Campania should be renewed by June 2014.

Safety message

Early detection and conscientious management of track defects is critical in maintaining safe rail operations.

On 5 April 2013, a Mitsubishi MU‑2B aircraft, registered N64MD, departed Honiara, Solomon Islands with two pilots on board. The purpose of the flight was to ferry the aircraft from Honiara to Essendon, Victoria, with an intermediate stop at Townsville, Queensland.

Shortly after take-off at Townsville, both pilots received a considerable amount of static in their headsets. Townsville Tower air traffic control (ATC) then instructed the crew to transfer to the Townsville Approach frequency. The pilot in command (PIC) read back the instruction; however, ATC advised that he was transmitting carrier wave only (no voice communications were heard).

About 5 minutes after the aircraft departed, Townsville ATC offered the crew the option of returning to Townsville. The PIC reported that they could hear the transmissions made by Townsville ATC but were unable to return to as the fuel quantity in each wing tip tank was in excess of the maximum landing limitation and the aircraft was carrying additional fuel in the ferry tank. The PIC was unable to advise Townsville ATC of this as the aircraft’s very high frequency (VHF) radios were now inoperable. Consequently, the PIC elected to continue the flight as per the submitted flight plan.

The PIC attempted to resolve the radio problem, but without success. Townsville ATC, Brisbane Centre ATC and Melbourne Centre ATC also continued attempts to establish communications with the crew.

When about 230 NM north of Essendon, Victoria communications with ATC were re-established. The crew were not in normal communications with ATC for about 3 hours and 35 minutes.

An examination of the radio determined that water leakage from a small access door had corroded two main radio isolator breakers/switches, which subsequently resulted in the radio failure.

It is important that ATC is made aware of any problems as soon as possible. This provides ATC with sufficient time to manage a situation, rather than having to react when an issue has developed into a major problem. In the event of a communications failure, it is important that pilots follow the appropriate procedure, and if communications cannot be re-established, consider utilising alternative methods such as mobile telephones.

Aviation Short investigation Bulletin Issue 21

What happened

On the morning of 1 April 2013, the pilot of a Cessna 210 was one of a group intending to fly various light aircraft under the visual flight rules from Bullo River homestead to Emkaytee, a private airstrip near Darwin, Northern Territory. Low cloud delayed all of the departures from Bullo River and the aviation forecasts and weather radar images accessed by the group via the internet indicated isolated thunderstorms, low cloud, and rain in the intended area of operation. Some improvement was forecast after 1130 local time.

By lunchtime the weather had lifted at Bullo River and the pilots observed that the weather radar images were indicating an improvement en route. All of the pilots departed between 1300 and 1500, some electing to track via the coast and the rest tracking as required more or less on the direct track. The pilot of the Cessna 210 departed at about 1415 with three passengers to track via the coast.

The pilots in the group were communicating by radio on a discrete frequency and the Cessna 210 pilot was heard to report at about 1510 that he was approaching Cape Ford and the weather ahead was gloomy, or words to that effect. That was the last radio transmission from the pilot.

When the aircraft did not arrive at Emkaytee a search was initiated. Bodies and a small amount of wreckage were found on the southern shoreline of Anson Bay, about 10 km south-east of Cape Ford. There were no survivors.

What the ATSB found

During the flight from Bullo River to Emkaytee, the pilot continued to track along the planned coastal route towards a thunderstorm, probably encountering conditions such as low cloud, reduced visibility and turbulence, and as a result of one or more of those factors the aircraft descended and collided with water.

Safety message

Tracking visually via a coastal route in marginal weather conditions can be advantageous in terms of ease of navigation and absence of elevated terrain, but can also increase the risk of spatial disorientation in the context of drastically reduced visibility exacerbated by a lack of surface definition when over water.

In situations where significant weather is forecast or otherwise expected, pilots are encouraged to access the Bureau of Meteorology detailed weather briefings (via the phone number on the area forecast) to assist with understanding the conditions at the time as well as the immediate trend.

On 29 March 2013, at about 1000 Eastern Daylight-saving Time, a Piper PA-30 aircraft, registered VH-HPR (HPR), departed Bankstown Airport for Griffith Airport on a private flight. On board were the pilot and two passengers.

Following the take-off, the pilot selected the landing gear up. Passing through 400 ft, the tower advised that the landing gear was still down. The pilot responded that he would continue with the departure and hold at 2,000 ft to troubleshoot the problem. 

At 2,000 ft, the pilot engaged the autopilot and confirmed that the gear was selected up, but the gear down and locked light remained illuminated. The pilot checked the circuit breakers and could not see any that had tripped. The pilot then cycled the gear a number of times, however, the gear did not retract and the gear down and locked light remained illuminated. 

The pilot elected to return to Bankstown and was cleared for a straight in approach. On short finals, the tower advised HPR to ‘check wheels’, the pilot confirmed that the green down and locked light was still illuminated and that the gear selector was in the down position.

HPR touched down on the main wheels followed by the nose wheel, which collapsed when it contacted the ground, followed by the left main wheel and right main wheel. The pilot and passengers exited the aircraft without injury and the aircraft sustained substantial damage. 

Inspection of the aircraft by a licenced maintenance organisation was arranged by the insurer. The landing gear mechanism was visually inspected, and the worm drive was almost to the full retraction position, indicating the gear was retracted electrically.

The reason for this electrical retraction despite the gear selector being in the down position was not determined.

Aviation Short Investigation Bulletin Issue 20

On 9 September 2011, a Cessna 208B ‘Grand Caravan’ aircraft, registered PK-VVE, collided with terrain and was destroyed on a cargo flight from Wamena to Kenyam in the Pasema District of West Papua, Republic of Indonesia. The pilot and copilot, the only persons on board were fatally injured. 

As the accident took place in Indonesia, the Indonesian National Transportation Safety Committee (NTSC) is responsible for investigating this occurrence, consistent with Indonesia’s obligations as State of Occurrence under Annex 13 to the Convention on International Civil Aviation Aircraft Accident and Incident Investigation (Annex 13).

The pilot of the aircraft was an Australian citizen and, in accordance with the ‘special interest’ provisions of paragraph 5.27 of Annex 13, the Australian Transport Safety Bureau (ATSB) appointed an expert to the NTSC investigation. This allowed the ATSB to receive relevant factual information that was approved by the NTSC for public release and a copy of the NTSC’s final investigation report. 

The NTSC subsequently requested ATSB support in the analysis of the available recorded data from the flight and with finalising the draft investigation report. To facilitate this support, the ATSB appointed an accredited representative in accordance with paragraph 5.23 of Annex 13 and, in order to protect the information supplied by the NTSC, commenced an external investigation under the Transport Safety Investigation Act 2003. The ATSB completed its work as accredited representative in March 2013.

The National Transport Safety Committee of Indonesia is responsible for releasing the investigation report.

National Transportation Safety Committee
Ministry Of Transportation Republic Of Indonesia
Transportation Building 3^rd Floor
Jalan Medan Merdeka Timur No. 5
Jakarta Pusat 10110
Indonesia

Phone  :  +62 21 384 7601
Email    :  knkt@dephub.go.id

Website: http://knkt.dephub.go.id/knkt/ntsc_home/ntsc.htm

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