Safety summary

What happened

On 24 December 2011 an Agusta Westland AW139 helicopter departed Bankstown Airport in response to an emergency personal locator beacon in the Budderoo National Park, about 16 km west-south-west of Wollongong Airport, New South Wales. On board the helicopter were a pilot, an air crewman, two paramedics and a doctor.

On locating the emergency beacon, the crew identified a seriously injured person on a rock ledge near the bottom of a waterfall. They assessed that it would not be possible to winch emergency personnel directly to the patient. In response, the crew landed at a nearby clear area and devised a plan to access and retrieve the patient. During the retrieval, the patient and one of the paramedics hit rocks at the base of the waterfall. The paramedic died from the impact. The patient was subsequently transported to hospital for treatment.

What the ATSB found

The Australian Transport Safety Bureau (ATSB) identified that, due to reduced light, the paramedic and patient were accidentally pulled from the rock ledge as the helicopter was manoeuvred in preparation to lift them out using its winch.

The ATSB also identified several safety issues relating to training and use of the helicopter’s lighting and radios. A number of organisational issues that could adversely influence the way crews act in similar circumstances were also identified.

What has been done as a result

In response to this accident, the Ambulance Service of New South Wales and the helicopter operator took safety action in respect of the operating scope applied to retrieval operations and procedures used by helicopter emergency crews. In addition, paramedics, in their role as ambulance rescue crewmen, are now required to conduct annual night winching currency training. Finally, proactive safety action was taken by these parties in the areas of general crew training and operational risk assessment.

Safety message

This accident highlights the dangers associated with modifying established procedures in order to complete a difficult, and potentially not previously experienced, rescue task. Specifically, the use of procedures that are neither documented nor trained for by crews makes it difficult to identify hazards and manage the related risks.

What happened

At about 1500 Eastern Daylight-saving Time, on 17 December 2011, a Cessna 172R aircraft, registered VH-LWX (LWX), landed on runway 13L at Moorabbin Airport. On board were a student pilot and instructor. The student was the handling pilot, and the instructor was the pilot in command.

On vacating the runway, LWX was issued a clearance by air traffic services to taxi back to base via taxiway C, but to hold short of runway 13R. The pilot read back the requirement to hold short of runway 13R. The holding point on taxiway C was appropriately marked; however, LWX did not stop at the holding point, but continued across the runway, resulting in a runway incursion.

At the time of the incursion, a Cessna 172S, registered VH-EOR (EOR), with two persons on board, had just touched down to land on runway 13R. On seeing LWX cross the runway, the pilot of EOR applied full power, commenced a go-around, and passed overhead LWX. EOR subsequently completed a circuit and landed safely. There were no injuries or damage to either aircraft.

The pilot in command of LWX reported that he had been distracted by discussions with his student. The quick action by the pilot of EOR demonstrated the need for landing aircraft to keep a good lookout. The incident also highlights the need to avoid distractions when operating on or near an aerodrome.

What happened

About 1045, Eastern Standard Time, 25 December 2011, a Cirrus Aircraft Company SR22 aircraft, registered VH-MMG, with the pilot and two passengers onboard, was on final approach from the south to land on runway 02 at Warnervale aerodrome, New South Wales. Just prior to the runway threshold, at about 30 ft above ground level, the stall warning sounded. The pilot immediately applied full engine power, but the aircraft continued to descend rapidly landing on soft ground short of the bitumen runway.

The aircraft sustained minor damage. All of the occupants exited the aircraft safely with no injuries reported.

As a result of this incident, the pilot advised that in future he would be adopting a steeper approach to runway 02. He would also increase the approach airspeed when landing into headwinds greater than 10 kts.

This serious incident demonstrates the importance of establishing wind direction and strength using all available references, including those on the ground while on approach. Ground references could better position the pilot to adjust the aircraft approach profile and airspeed to suit the weather conditions.

The incident also highlights the unexpected nature of wind gusts and the need to identify an appropriate touchdown point on the runway that provides an adequate safety margin.

What happened

On 20 December 2011, at about 1500 Eastern Standard Time, a Cessna Aircraft Company 188B Ag wagon, registered VH-SHM, collided with terrain after experiencing difficulty becoming airborne from a station property near St George, Queensland. The purpose of the flight was the aerial application of herbicide to control weeds on the property. The pilot was the sole occupant of the aircraft and sustained serious injuries.

The pilot was relatively new to the aerial application industry and inexperienced on the aircraft type. The aircraft had recently had a new propeller and hub fitted pursuant to an engineering order.

Approved Agricultural pilots are reminded of the importance of supervision of newly rated agricultural pilots. The accident also highlights the importance of pilots being aware of the maintenance that has been performed on an aircraft and the value of a test flight being performed by a pilot experienced with the aircraft type following maintenance.

Safety summary

What happened

At 0743 on 20 December 2011, an empty coal train collided with an excavator that was being used for scheduled maintenance of rail lines near the High Street Station at Maitland, NSW.

The excavator suffered extensive damage while the lead locomotive suffered minor damage and was able to continue on its journey after a crew change. Neither the train drivers nor the track workers were injured in the collision.

What the ATSB found

The ATSB found that the collision occurred despite the fact that the maintenance work being undertaken had been authorised and that safety measures designed to exclude rail traffic from the worksite had been put in place.

The ATSB further found that the network control officer did not confirm the location of the worksite before authorising access to the track for maintenance purposes, there were communication protocol omissions between network control and the worksite protection officer and a lack of coordination between interfacing network control officers.

What has been done as a result

The track manager has advised that it is reviewing the safe working rules and will include the issues identified by the ATSB in that review.

Safety message

The incident highlights the importance of ensuring the exact location of a given worksite is clearly understood by all concerned in providing protection and that communications between network control officers and worksite staff is effective.

Safety summary

What happened

On 15 December 2011, British Beech was berthed in Brisbane, Queensland, and its crew was taking on stores from a barge. During the return of a stores container from the ship to the barge, the container came free of its slings. It fell to the barge below, striking the master of the barge. The master was attended to by the barge crew and shore paramedics but he died from his injuries while being transported to hospital.

What the ATSB found

The ATSB found that the container had not been appropriately rigged on board the ship and the ship’s crew had not warned the barge crew of its return. The ship’s crew did not view the storing operation as dangerous and had, over time, removed identified safety barriers which would probably have prevented the accident. Compliance auditing processes had not identified and minimised such routine violations of the shipping company’s procedures.

The ATSB also found that the barge master had placed himself in a position of danger under the suspended load, and that the barge crew had not followed their company’s procedures for storing operations. The ATSB further found that the company had not adequately implemented compliance auditing or incident reporting schemes. As a result, the company had not acted on, or learnt from, previous less serious incidents.

What has been done to fix it

The method used for handling containers of this type in Brisbane has been altered so that the containers are top lifted and slings are no longer used.

The ship’s manager, BP Shipping, implemented a requirement to have the lifting point fixed and above the centre of gravity of loads. A thorough review of lifting and slinging processes, practices, procedures and equipment was conducted as well as a review of lifting and slinging job hazard analyses. A fleetwide review and training workshop for lifting and slinging was also completed.

The barge’s operator, Bowen Tug and Barge, undertook a review of its operations and work practices. On 1 July 2012, the company ceased ship storing operations and sold all associated vessels and equipment to another operator.

Safety message

Lifting operations, even when they are routine, involve inherent risks. Therefore, established procedures must be followed, reinforced and audited to ensure vigilance is maintained and complacency avoided. The basic precaution of standing well clear of suspended loads must always be taken.

What happened

While attempting a take-off from an improvised runway at about 1800 Eastern Daylight-saving Time on 15 December 2011, an Auster Aircraft Ltd J5F (Auster), registered VH-AFT (AFT), failed to climb sufficiently to clear a fence in a paddock 1 km south of Tyabb aeroplane landing area (ALA), Victoria. The aircraft was seriously damaged when it came to rest inverted. The owner-pilot, the only occupant, received minor injuries.

The pressure perceived by the pilot to get the aircraft back to Tyabb may have led him to make the decision to take-off in less than ideal circumstances. An earlier successful forced landing may also have contributed to the accident in that it boosted the pilot's confidence in his ability to retrieve the aircraft from the paddock.

This accident highlights the need for pilots to be aware that pressure can come about for a variety of reasons, and of the importance of understanding one's personal limitations. By making decisions pre-flight, being mindful of pressures and by setting and sticking to personnel minimums, pilots can reduce the risk of being involved in an accident.

Prior to conducting any unusual operation, a pilot should carefully consider all options and seek the most accurate information available. Threat and error management (TEM) training has the potential to provide significant safety benefits to the general aviation (GA) community.

What happened

At about 0349 Eastern Daylight-saving Time, the Melbourne aerodrome controller cleared an Emirates Airlines, Boeing Company 777-31H/ER aircraft registered A6-EGG for take-off on runway 16.

The crew believed that the runway lights were on a low setting and conducted the take-off. Once airborne the pilots advised the approach controller that they believed that the lights were on a low intensity. A subsequent check of the airport lighting system revealed that runway 16 lights were turned off.

Had the crew queried the status of the runway lights, the aerodrome controller would have been able to identify that they had not been turned on as believed and corrected the situation.

This incident highlights the potential hazards associated with skill based human error and the need for increased vigilance when working in isolation in a safety critical environment.

Airservices Australia, advised the ATSB that they were in the process of standardising the operation of runway lighting controls at Towers and would propagate a national ATC instruction pending the related change effective 28 June 2012.

Aviation Short Investigation Bulletin - Issue 11

What happened

On 9 December 2011 a S.O.C.A.T.A. Groupe Aerospatiale TBM 700 aircraft, registered VH-VSV (VSV) departed Bankstown airport, for a private flight to Merimbula, New South Wales. Onboard the aircraft was a pilot and one passenger.

The pilot was cleared to depart Bankstown control zone on a downwind departure from runway 11 left, however mistakenly conducted an upwind departure. The aircraft penetrated Sydney controlled airspace by 2.3 NM and came within 1.2 NM with no vertical separation of another aircraft on approach into Sydney Airport and a breakdown of separation occurred.

The controller at Bankstown tower then instructed the pilot of VSV to conduct a left turn and track back overhead Bankstown airport.

This incident highlights the importance of developing a technique to ensure a clearance is processed, understood and actioned correctly. It is also important to clarify a clearance if any ambiguity exists. Finally, pre-flight planning is essential to ensure safe flight. CASA has published a Visual Pilot Guide for Archerfield, Jandakot, Melbourne, Parafield and Sydney areas to provide detailed assistance for operating in these areas.

Safety summary

What happened

On 7 December 2011, the owner-pilot of a Cessna 210M, registered VH-WBZ, was conducting a private flight under the visual flight rules from Roma to Dysart in Queensland. Thunderstorms with associated cloud, rain and severe turbulence were forecast for the area. About 30 minutes into the flight the outer sections of the wings and parts of the tail separated. The aircraft collided with terrain, fatally injuring the pilot.

What the ATSB found

The ATSB established that the aircraft was structurally sound before the wing and tail sections separated. No aircraft system defects were identified. Ground-based weather radar showed thunderstorms in the vicinity of the accident site, and recorded engine data showed cruise power setting was maintained until recording ceased. Although the precise circumstances leading up to the accident were not known, a combination of aircraft airspeed with the effects of turbulence and/or control inputs generated stresses that exceeded the design limits of the aircraft structure.

Safety message

Airspeed is a critical factor in the stress sustained by an aircraft. Pilots need to be aware of the manoeuvring (V_A) speed for the aircraft weight, and to control the airspeed so as not to exceed that value when full control deflection is required, or severe turbulence or wind/gusts are encountered.

Severe turbulence and wind gusts are just some of the hazards prevalent in and around thunderstorms. This accident is a reminder to all pilots that, to minimise the risk of structural damage or loss of control, thunderstorms should be avoided.