Safety summary

What happened

On 6 December 2011, a Bombardier DHC-8-315 aircraft, registered VH-SBV and operated by QantasLink, was on a scheduled flight from Cairns to Weipa, Queensland. The aircraft was on descent with the power levers in the flight idle position and the first officer’s hand was on the power levers. When the aircraft encountered turbulence, the first officer inadvertently lifted one or both of the flight idle gate release triggers and moved the power levers below the flight idle gate. During the short time that the power levers were in the ground beta range, both propeller speeds increased uncontrollably by over 300 revolutions per minute (rpm). Realising the situation, the first officer immediately moved the power levers back above the flight idle gate and the propellers returned to the normal controlled operating rpm.

What the ATSB found

The aircraft design included features to reduce the likelihood of the power levers being moved below flight idle and into the ground beta mode during flight. However, the ATSB found that many DHC-8-100, -200 and -300 series aircraft did not have a means of preventing inadvertent or intentional movement of power levers below the flight idle gate in flight, or a means to prevent such movement resulting in a loss of propeller speed control. This design limitation has been associated with several safety occurrences.

The ATSB also concluded that the beta warning horn sounded as designed; however, the pilots were not acutely aware of the purpose of the warning horn due to a lack of previous exposure to the sound.

What has been done as a result

The aircraft manufacturer has advised that it will be releasing a Service Bulletin modification to rectify the propeller speed control issue. That bulletin will be mandated by an Airworthiness Directive (AD) from the airworthiness authority of the State of Design (Canada) to ensure that the bulletin is incorporated into all the aircraft affected by the design issue worldwide, including those in Australia. In addition, the aircraft operator has introduced a series of actions to reduce the risk of such occurrences. The ATSB has released an extract from the cockpit voice recorder with the beta warning horn and the audible rise in propeller speed to all Australian operators of the aircraft type and it is also available here in an effort to increase awareness of the issue.

Safety message

Until appropriate modifications are made to DHC-8 aircraft, pilots and operators of DHC-8-100, -200 and -300 series aircraft should familiarise themselves with the circumstances surrounding this occurrence and take the appropriate steps to minimise the possibility of propeller overspeed due to ground beta selection in flight.

What happened

On 6 December 2011, a Rockwell International 114 (Commander), registered VH-SJF (SJF), made a planned refuelling stop at Meekatharra Aerodrome in Western Australia on a flight from Karratha to Perth. Immediately following the refuel, the pilot taxied for departure before an approaching storm cell arrived in the area.

Shortly after rotation at 0925 WST, the wind speed and direction changed suddenly, causing the aircraft to sink and drift off the runway. The pilot initially lowered the nose, but then raised the nose and applied power to clear a ditch and mound running parallel to the runway.

The pilot again lowered the nose, but as the aircraft was not developing sufficient lift to clear trees ahead, he cut the power and aimed for a gap in the trees. The left wing contacted a tree and spun the aircraft, causing serious damage. The pilot, who was the sole occupant, was uninjured.

Weather related issues accounted for 25% of local condition related safety factors identified in aviation investigations completed by the ATSB over the 2010-11 period.

An ATSB aviation research and analysis report published in 2010 found that private operations accounted for 44% of accidents in proportion to hours flown. Problems with a pilot's assessment and planning were evident in all of these accidents. The report recommended that private pilots make decisions pre-flight and that they set and stick to personnel minimums.

Wind direction and strength can change ahead of a storm cell. The Pilot's Handbook of Aeronautical Knowledge, published in 2008 by the Federal Aviation Authority (FAA), described the impact of windshear, specifically a microburst, on an aircraft taking off. The description in the Handbook matches the sudden change in wind and aircraft performance characteristics reported by the pilot.

What happened

On 5 December 2011, at about 1030 EDT a Taylorcraft model BC12-D aircraft, registered VH-PEE, was engaged in taxi trails as part of a pre-flight inspection for a flight scheduled late in the day. The pilot reported that, while using a grass runway, 26 km to the south-east of Gunnedah Aerodrome, NSW the aircraft was struck by a strong wind gust or Willy-willy and, on attempting to correct with engine power and right rudder, the aircraft veered off of the runway. He was unable to regain control, and the aircraft subsequently struck a fence on the northern side of the runway and flipped over, coming to rest inverted. There were no injuries to the pilot. The aircraft incurred serious damage which included damage to the propeller, one wing strut and the wing surfaces.

Past studies have indicated that Willy-willies are unseen, unpredictable and can adversely affect light aircraft and helicopters when they are operating on or close to the ground. Pilots must be vigilant when operating in these areas and be prepared to react to mitigate the effects of Willy-willies and maintain control of the aircraft.

What happened

During the afternoon of 5 December 2011, an instructor and student were conducting emergency procedures training in the circuit at Moorabbin aerodrome, Victoria, in a Schweizer 269C-1 helicopter, registered VH-XTY. The flight was to include low-level autorotations to simulate an engine failure during the take-off and approach.

At about 1520 Eastern Daylight-saving Time, and at about 200 ft above ground level (AGL), the instructor initiated a practice engine failure after take-off. The exercise was to be conducted to a power termination.

The student entered autorotation and subsequently flared the helicopter to the instructor's satisfaction; however, the helicopter did not decelerate as expected. Realising that imminent ground contact would be excessive; the instructor took control, levelled the skids and attempted to arrest the descent. The helicopter impacted the ground heavily in a level attitude, moving forward and with the skids straight. The helicopter subsequently rolled onto its left side and was seriously damaged. The instructor received minor bruising and the student was uninjured.

While the reason for the accident could not be conclusively established, it is possible that low forward airspeed was a contributory factor.

As a result of this occurrence, the aircraft operator has advised the ATSB that they are reviewing their procedures for the conduct of low-level autorotations.

What happened

At 0940 Eastern Daylight-saving Time on 2 December 2011 the crew of a Fairchild Industries SA227 aircraft (Metroliner) registered VH-UUN (UUN) was rolling through to the turning node after landing on runway 26 at Portland aerodrome, Victoria when a Cessna Aircraft Company 172 (C172) registered VH-VSH (VSH) was observed on short final for the reciprocal runway. VSH subsequently conducted a go-around.

The crew of UUN were completing a scheduled flight from Hamilton to Portland, Victoria. VSH was on a solo Visual Flight Rules navigation training flight from Ballarat. Despite both aircraft making all required Common Traffic Advisory Frequency (CTAF) broadcasts, the pilots of UUN and VSH were not aware of each other prior to the incident. Neither aircraft was fitted with a Traffic Collision Avoidance System, nor was fitment required.

The crew of UUN and VSH reported their radios were serviceable and that the correct frequency was used for all required CTAF broadcasts.

This incident highlights the need for pilots to apply all available methods to maintain separation with other aircraft when operating outside controlled airspace. These methods include:

• utilisation of both alerted and un-alerted see-and-avoid principles,
• conducting a radio serviceability check when operating at a non-towered aerodrome equipped with an Aerodrome Frequency Response Unit, and
• use of on-board collision avoidance systems where fitted.

Where ground-based personnel could provide regular operators with advice on the presence of other airspace users, operators should formalise the use of such resources to ensure maximum benefit without detracting flight crew from their prime duties.

What happened

On 30 November 2011, a Cessna 210L aircraft, registered VH-SKQ, departed Derby for Kalumburu, Western Australia, on a passenger charter flight. There was one pilot and six passengers (including an infant) onboard.

On landing, the aircraft touched down about 400 m from the landing threshold. The pilot attempted to slow the aircraft using brakes, however there was no brake pressure available.

The aircraft ran off the end of the runway at about 40 kts, colliding with some large rocks. The aircraft was seriously damaged, however there were no injuries to the passengers or the pilot.

The pilot stated that the normal approach procedure was to check the brake pressure prior to lowering the landing gear during the descent, however this step was missed during the pre-landing checks. If a brake fault had been detected prior to touchdown, the pilot would have had more time to consider the options available.

It is important for operators, training organisations and individuals to consider scenarios like this one as training scenarios, so pilots can formulate a plan prior to an actual event occurring. The pilot had not received any training for a brake failure.

Aviation Short Investigation Bulletin - Issue 11

What happened

On 27 November 2011, a Robinson Helicopter R22 Beta II, registered VH-RKN, departed Kununurra, Western Australia on a private flight.  The pilot was the sole occupant of the helicopter.

Whilst manoeuvring for a landing the low rotor RPM light and horn activated.  The pilot was unable to recover the rotor RPM nor arrest the rate of descent and the helicopter landed heavily and sustained serious damage, however the pilot was uninjured.

Robinson Helicopter Company has identified low rotor RPM as a significant factor in helicopter accidents.  The training requirements in regard to low rotor RPM avoidance and recovery procedures is under review by the Civil Aviation Safety Authority.

Safety summary

What happened

On 8 October 2011, the flight crew of an Airbus A380-800, registered VH-OQE, was preparing for departure from Los Angeles International Airport, United States of America.

Prior to take-off, the captain changed the departure runway that was entered in the aircraft's flight management system. The procedure for completing that task was not followed exactly, resulting in the take-off speeds not being displayed on the flight instruments.

During the take-off roll, the flight crew, becoming aware that the take-off speeds were not displayed, called out the speeds from their notes instead and proceeded with the take-off.

What the ATSB found

The ATSB found that the captain was distracted from initially updating the runway change in the aircraft's navigation systems prior to the aircraft taxiing for the runway. Twice prior to take-off the aircraft's systems displayed a message to check take-off data. The first officer cleared the first message on the understanding that the take-off data would be checked and in the second instance, believing that it had been checked. There were no other warnings in place to alert the crew that they were commencing the take-off without the take-off speeds in the aircraft's navigation systems.

What has been done as a result

Qantas has advised that the aircraft manufacturer has updated the aircraft's warning systems as part of a planned upgrade program. This upgrade will issue a warning if take-off is commenced without the take-off speeds having been entered into the aircraft's systems. They also advised that their standard operating procedures have been updated to avoid any misinterpretation regarding the required actions in the case of a runway change.

Safety message

This incident highlights the problem of distraction during critical stages of flight preparation. It also highlights the importance of good flight crew communication to ensure a shared understanding of the aircraft's systems status.

What happened

On 17 September 2011, the first electrical engineer on board the passenger/ro-ro ship Spirit of Tasmania I fell through an opening in a catwalk between two of the ship's main engines. He fell about 2 m to the deck below, amputating the top of his left middle finger, fracturing his left ring finger and injuring his right shoulder and buttock. He was treated on board and later taken to hospital.

Safety summary

What happened

On 23 November 2011, a loss of separation occurred 6 km north of Cairns, Queensland, between a Cessna Aircraft Company 402C (C402), registered VH-TFK, and a Cessna Aircraft Company T210N (C210), registered VH-PDP.

The C402 was conducting an instrument landing system (ILS) approach for runway 15 and was 1.8 NM (3.3 km) from the airport when the pilot initiated a missed approach from a height of 1,000 ft in instrument meteorological conditions. At the time the C210 was on the same ILS approach and was 6.4 NM (11.9 km) behind the C402. About 1 minute after the pilot of the C402 turned left to establish the aircraft on the missed approach track, the distance between the two aircraft reduced below the required air traffic control separation (ATC) standard.

What the ATSB found

The Australian Transport Safety Bureau identified that a local ATC procedure, published in part to assist ATC in separation management during a missed approach event, was not clear and subject to varying interpretation. This resulted in the spacing between the two aircraft being closer than intended at the point when the pilot of the C402 commenced the missed approach.

The local ATC procedure did not fully consider all operational aspects that may lead a pilot to initiate a missed approach in instrument meteorological conditions above the procedure-defined minimum cloud base height.

What has been done as a result

In response to this occurrence, Airservices has initiated a number of safety actions including amending the local procedure to assist with the clarity and intent, changing the Cairns local instructions to enforce minimum flow (distance) spacing and updating controller missed approach procedures refresher training. This updated training will increase controller awareness of separation assurance issues relating to consecutive approaches and ensure that due consideration is given by controllers to the broad mix of aircraft types using straight-in approaches.

Safety message

This occurrence reinforces the need for all local procedures, in particular those that assist controllers in separation management, to be unambiguous and to encompass all possible operational circumstances. The importance of effective radar navigation guidance when positioning an aircraft for an approach is also highlighted.