On 30 January 2013, a Fairchild SA 227AC, registered VH-UUO (UUO), departed Melbourne Airport, Victoria for Launceston Airport, Tasmania on a scheduled freight flight. The pilot was the only person on-board.

The pilot prepared a trim sheet to confirm the weight and balance information for the aircraft, then provided an uplift figure to the freight organisation that prepared a loading plan that they used to load the aircraft.

When the pilot approached the aircraft, the freight had been loaded with all cargo access doors closed and the cargo support strut (tail stand) removed. The pilot completed the pre-flight checks in the cockpit then, removed the wheel chocks and wing tip safety markers and placed them in the main cabin area.

During the take-off, the pilot reported that he needed more forward elevator trim than usual to climb out at a 10 degrees nose-up attitude. The pilot noticed that in straight and level flight, the aircraft had full nose-down trim and the aircraft was flying at a 50 nose-up attitude. When the autopilot was engaged, the pilot reported that the autopilot struggled to maintain straight and level flight and the aircraft ‘porpoised’.

The pilot conducted a normal landing at Launceston and checked the freight located in the nose locker. The pilot estimated that the nose locker contained 35 kg of freight when it should have contained about 100 kg. After off-loading the freight at Launceston, the aircraft was re-loaded for the next flight, to ensure that the aircraft was within the centre of gravity limits.

As a result of this occurrence, the operator has advised the ATSB that they are taking safety action including: develop a plan to provide training for all employees, establish an audit oversight program, establish standard operating procedures for all facets of operation and identify all managers and supervisors that require training or retraining including agents.

Aviation Short Investigation Bulletin Issue 20

On 24 February 2013, the pilot of a Cessna 206 aircraft, registered VH-TOC (TOC), was conducting a private flight from Lake Nash, Northern Territory, to Mount Isa, Queensland, when the aircraft’s avionics system failed. The pilot commenced the radio failure procedure by squawking the transponder code of 7600 and transmitting blind.

The pilot overflew the Mt Isa Airport to assess the wind conditions and rocked the aircraft’s wings to alert any ground personnel of the communication failure, he then joined the circuit.

At around the same time, the Mount Isa airport safety officer (ASO) was preparing to conduct a runway and lighting inspection. The ASO turned on the vehicle’s radio and lighting. The ASO then activated the pilot activated lighting (PAL) and aerodrome frequency response unit (AFRU) systems.

The ASO broadcast a call on the Mount Isa common traffic advisory frequency (CTAF), advising that the vehicle was entering the runway and conducted a lookout for aircraft. As no response was received or aircraft sighted, the inspection was commenced.

By this time, the pilot of TOC was on the base leg of the circuit for runway 34 and observed a vehicle near the runway 34 threshold. He assumed the vehicle and would exit the runway, leaving the runway clear for him to land. The pilot continued to transmit his intentions blind.

As the pilot commenced the flare, he noticed that the vehicle had not yet vacated the runway. As a result of the vehicle being on the runway, the pilot initiated a go-around.

The aircraft passed 200-300 ft above the vehicle. The ASO heard TOC pass overhead and vacated the runway. The pilot of TOC conducted a second circuit and landed without further incident.

Mount Isa Airport Pty. Ltd. had planned to place yellow and black chequered safety stickers on the side and rear of the vehicle. As a result of this occurrence, that action was immediately implemented.

The need to conduct a go-around may occur at any point in the approach and landing phase, however, the sooner a condition that warrants a go-around is recognised, the safer the manoeuvre will be.

Aviation Short Investigation Bulletin Issue 19

On 4 January 2013, a Boeing 737-800 registered VH-VUZ, departed Launceston, Tasmania on a scheduled passenger service to Melbourne, Victoria. During departure, the crew selected level change (LVL CHG) as the vertical auto-flight system mode, and a climb speed of 250 kts. The crew intended to switch from LVL CHG mode to vertical navigation (VNAV) mode later during the climb, but inadvertently overlooked that selection.

Had the crew switched to VNAV mode as intended, the aircraft would have accelerated during the climb in accordance with a programmed speed schedule. In LVL CHG mode however, the aircraft climbed at a constant speed of 250 kts until passing about flight level (FL) 260, when the auto-flight system sequenced automatically to continue the climb at a constant Mach 0.62 (which was the Mach Number corresponding to 250 kts when the changeover occurred).

As climb then continued above FL 260 at a constant Mach 0.62, airspeed gradually reduced. The unintended vertical auto-flight mode and the gradual airspeed reduction went unnoticed by the crew until the aircraft was approaching FL 350, when a ‘buffet alert’ caution appeared on the Control Display Unit and the auto-flight system made a small reduction in aircraft pitch attitude. At that moment, the crew noted that the airspeed had reduced to near the top of the amber bar on the airspeed indicator, representing the aircraft minimum manoeuvre airspeed.

In responding to recognition of the minimum manoeuvre airspeed condition, the crew reduced the aircraft pitch attitude to the point that the aircraft entered a shallow descent. Soon after, the crew was able to establish an accelerated climb to the intended cruising level of FL 360. Recorded data indicates that that aircraft reached a minimum speed of 201 kts, about 6 kts below the minimum manoeuvre airspeed at that moment.

The occurrence highlights the importance of consistent attention to auto-flight system modes and aircraft energy state. Since this occurrence, the operator has introduced a procedure requiring the announcement of flight mode annunciation changes. The operator also included mode awareness briefings during a 2013 recurrent training program.

Aviation Short Investigations Bulletin - Issue 30

What happened

On 15 February 2013, the crew of a Super Puma helicopter (VH-BHK) was returning to Barrow Island after conducting some night deck landing practice to an offshore vessel. At about halfway the helicopter entered cloud with severe turbulence and lightning. The crew steered away from Barrow Island and descended to the lowest safe altitude to try and escape the conditions, but after 10 minutes turned back towards the island.

With insufficient fuel to divert to a suitable night landing alternate or to safely conduct a published instrument approach, the crew of the twin-engine helicopter were compelled to shut down an engine to conserve fuel and to descend below the lowest safe altitude in instrument meteorological conditions. The crew eventually descended to 250 ft over water and visual contact was made with lights in vicinity of the island. To minimise distraction and conserve fuel, the crew did not restart the engine and landed in winds gusting to 50 kt. Fuel remaining was 300 lb (170 L), which was less than the stipulated fixed reserve.

What the ATSB found

The ATSB found that the crew departed Barrow Island for the night training flight with sufficient fuel to return and land with standard reserves intact as allowed by the aerodrome forecast, but encountered unforecast severe weather on the return sector that prevented a routine visual or instrument approach.

The validity of the Barrow Island aerodrome forecast had been extended to cover the duration of the flight, but the forecast did not include any reference to severe weather, and was not amended when the adverse trend became evident because the forecaster on duty at the time was unaware of the extended validity.

What's been done as a result

The Bureau of Meteorology compiled a report of the meteorological aspects of the occurrence which recommended the development of a handover checklist to be followed by all forecasters, including the handover of any non-routine forecasts. The report also recommended that all forecasters read the report and sign a reading register to indicate understanding of the importance of handing over critical information.

Safety message

Although a flight plan notification was not required and might not have made a difference in this occurrence, the non-submittal of an instrument flight rules notification to air traffic services was a missed opportunity to receive directed weather hazard alerts and reduce weather-related risk.

On 22 February 2013, VH-TGY (TGY) and VH‑TZJ (TZJ), departed a private airstrip near Bourke for Rumleigh, New South Wales. Both aircraft were to conduct aerial application (spraying) operations, which was supported by two ground personnel (mixers).

TGY landed at the Rumleigh and the mixers loaded the aircraft’s hopper. TGY departed and commenced spraying operations. Shortly after, TZJ landed at Rumleigh and was loaded. As the take‑off run on the south-eastern runway was commenced, TZJ’s fire-bombing door unexpectedly released and the 2,700 L load was jettisoned onto the ground, contaminating the runway.

About 15 minutes after, TGY landed on the north-west runway. When approaching the runway end, the pilot observed mud spraying up from the aircraft’s wheels. The aircraft then commenced sliding and turning to the left. When the left wheel contacted dry ground, the aircraft swung further left and tipped forward, resulting in the propeller contacting the ground. The aircraft then tipped backwards, and the tail wheel assembly detached. TGY sustained substantial damage.

The pilot of TZJ had attempted to contact the pilot of TGY on a number of occasions, but due to an unserviceable radio in TZJ, the broadcasts were not heard. The mixers elected not to contact TGY as they were of the understanding that he had been advised of the contamination by the pilot of TZJ.

A reliable communications system can assist with improving the overall efficiency and safety of an operation. This incident highlights the impact ineffective two-way communications can have on aircraft operations, and in that case, the need to consider alternative means for warning pilots of potential ground hazards.

Aviation Short Investigation Bulletin - Issue 19

Section 21 (2) of the Transport Safety Investigation Act 2003 (TSI Act) empowers the Australian Transport Safety Bureau (ATSB) to discontinue an investigation into a transport safety matter at any time. Section 21 (3) of the TSI Act requires the ATSB to publish a statement setting out the reasons for discontinuing an investigation.

At 1625 on 26 February 2013, the Rescue Coordination Centre (RCC) Australia was advised that Mellum Trader was in need of assistance. The ship had been drifting to the northwest of Broome, Western Australia, while the master waited for the port to re-open following the passing of Cyclone Rusty. However, the cargo had shifted as a result of the ship’s movement in the extreme weather conditions and the ship was now listing heavily.

Air and surface assistance was tasked to the area and the master altered course to minimise the effect of the weather on the ship. When the weather abated, the ship resumed its passage to Broome where it berthed on 1 March.

During the course of the investigation, the ATSB looked at several areas which may have had an influence on the incident, its outcome or have ongoing safety implications. These included:

• tropical cyclone avoidance
• guidance material and management support/resources
• cargo lashing and securing plans and arrangements
• ship stability and ballasting
• passage planning and record keeping
• actions of the master and crew
• effectiveness of the emergency response.

Analysis in these and other areas of investigation revealed no underlying safety issues. Accordingly, the ATSB decided that there was limited potential to enhance transport safety by continuing this investigation, and has elected to discontinue it.

On 23 February 2013, a Robinson R44 Raven I helicopter, registered VH-HGF, was engaged in agricultural operations in a paddock near Clarks Hill, Victoria. The pilot was the only person on board.

As the helicopter approached the paddock from the south, at 50 kt and at spray height, the pilot remembered a wire that extended halfway across the southern boundary of the paddock to a pump house. The pilot judged that it was too late to attempt to pull up over the wire and attempted to avoid the wire by flying underneath it. The vertical stabiliser contacted the wire and the tail rotor gearbox separated from the tail boom. The pilot was able to exit the helicopter with minor injuries however the helicopter was substantially damaged.

The practice within the aerial agricultural industry is to extensively pre-plan an application task that takes into account the specific hazards affecting an application. Any change from the previously planned application runs, including an unplanned change of direction has the potential to affect a pilot’s awareness of the relative position of previously known power lines and other hazards.

Aviation Short Investigation Bulletin Issue 19

On 12 February 2013, a Skywest Airlines ATR72 aircraft, registered VH-FVH (FVH), departed Sydney on a scheduled passenger service to Port Macquarie, New South Wales, under the instrument flight rules (IFR). The crew planned to enter the Port Macquarie non-directional (radio) beacon (NDB) holding pattern at 3,600 ft and then conduct an NDB approach to runway 21.

When inbound to Port Macquarie, the crew heard a taxi call from the crew of an Eastern Australia Airlines Bombardier DHC-8-315 aircraft, registered VH-TQZ (TQZ), operating an IFR scheduled passenger service from Port Macquarie to Sydney.

The crews of both FVH and TQZ discussed their respective positions and intentions and the crew of TQZ stated that they would advise FVH when they were about to take-off.

When lined up on runway 03, the crew of TQZ observed FVH on the aircraft’s traffic alert and collision avoidance system (TCAS), positioned directly overhead the airport and turning outbound in the holding pattern. The crew of TQZ broadcast a call advising FVH they were about to commence the take-off run and intended to conduct a left turn at 600 ft.

When on downwind, approaching 3,000 ft in IMC, the captain of TQZ observed an aircraft on the TCAS, above. The captain identified the aircraft as FVH and instructed the first officer to stop the climb and turn the aircraft to the right. Shortly after, the crew received a TCAS traffic advisory (TA) and then an initial resolution advisory (RA) to descend, followed shortly after by an RA to ‘adjust vertical speed’. At the same time, while also in IMC, the crew of FVH also reported receiving a TCAS TA and then a TCAS RA to climb. The captain of FVH immediately responded and climbed the aircraft.  Both flights continued without further incident.

It is essential that pilots monitor their surroundings and have an awareness of traffic disposition. It is important to know where the traffic is and where it will be in relation to you, so that potential issues can be identified and actioned, before they escalate. This is particularly important when operating at non-towered aerodromes, where aircraft separation is pilot responsibility.

Aviation Short Investigation Bulletin - Issue 23

On 23 February 2013, a Cessna 210M, registered VH‑PBV (PBV), was returning to Broome Airport, Western Australia, from Lombadina with a pilot and four passengers on board. The weather on the day was windy and wet with thunderstorms and rain moving through the area, requiring the pilot of PBV to alter the aircraft’s flight plan and flight path.

The aircraft tracked to a position north of the airport, in order to land on runway 10. The pilot reported selecting the landing gear down as part of his landing checks, and a passenger later reported that he heard what he believed to be the landing gear being lowered.

The air traffic controller (controller) cleared PBV to land when the pilot reported turning base and advised the pilot of an 18-knot crosswind. Just prior to PBV crossing the runway threshold, the controller sighted the aircraft on short final and conducted a final scan of the runway to ensure it was still clear

Shortly before landing the pilot completed his final checks, but did not look out the window to visually check that the landing gear was down. However, he did observe a green light, indicating that the landing gear was down and locked. To compensate for the crosswind, the pilot operated the aircraft at a slightly higher throttle setting, until flaring to land. PBV then landed on the runway with the landing gear retracted and skidded about 300 to 350 m down the runway on the underbelly. The controller activated the airfield emergency response.

The pilot later reported that the landing gear warning horn had not activated.

Following the accident, an assessment conducted by an insurance assessor found that the pilot had failed to extend the landing gear prior to landing. The assessor noted that the micro switch that activated the landing gear warning horn was set for a throttle setting lower than that used by the pilot during the landing.

Bad weather and changed plans can distract attention away from a pilot’s primary function – to safely fly the aircraft. However, the failure of the gear warning horn to activate removed a defence against landing with the landing gear retracted.

Aviation Short Investigation Bulletin Issue 20

Safety summary

What happened

At about 1320 on 12 February 2013, the 1250 Swan Hill to Melbourne passenger train collided with the rear corner of a semi-trailer on the B. McCann Road level crossing near Lake Charm, in northern Victoria.  The semi-trailer was travelling towards the Murray Valley Highway having taken on a load of gypsum at a nearby mine.

As a result of the collision there were minor injuries to one train passenger and to the drivers of the train and truck.  The truck’s trailer was destroyed and there was minor damage to the front of the locomotive.

What the ATSB found

The ATSB found that the truck driver’s view of the track was restricted due to the acute road-to-rail interface angle and the resulting limited opportunity to observe the train through the truck cabin’s passenger-side window.  When the truck driver stopped to look for trains, his view along the track to the north was probably no more than 220 m and insufficient to observe the approaching train.

An embankment in the crossing’s northwest quadrant also affected sighting and vegetation either side of the road approach meant that the installed give-way protection was inconsistent with the available sighting distances. 

In the three years prior to the incident, the risk profile of the crossing had changed significantly due to a large increase in truck movements associated with a greater demand for gypsum from the mine.  The safety interface management of the crossing by V/Line and the Gannawarra Shire did not identify this changing risk profile and did not involve consultation with a key stakeholder, the mine owner.

What's been done as a result

The operator of the gypsum mine has undertaken to re-align the road approaches to the crossing to address the acute road-to-rail interface angle, and to reduce the incline of the road on the approaches.

Safety message

This incident highlights the need for rail and road authorities to be proactive in addressing identified sighting deficiencies at level crossings and to monitor the risk profile of crossings.

The occurrence also highlights the need to involve all key stakeholders in road-rail interface safety management processes.