At about 1730 Western Standard Time on 25 February 2013, a Cessna 337F (337), registered VH‑JUP (JUP), JUP departed Onslow Western Australia for a 30-minute charter flight to Exmouth with three passengers. The front seat passenger and the pilot conversed for most of the flight.

On about 5 NM final for runway 20, the pilot of JUP commenced pre-landing actions by extending the first stage of flap. The pilot later reported that this was where she normally lowered the landing gear but could not recall why this step was missed.

About 1 NM from landing, the pilot conducted the final pre-landing checks. Again, the pilot could not recall why she had not checked that the undercarriage was down as part of the final pre-landing checks.

At 1800, the pilot commenced the flare about 3 ft above the runway and as the aircraft touched down on the bitumen, the pilot realised that the undercarriage had not been selected down.

The passengers and pilot exited the aircraft without injury. The fiberglass cargo pod fitted to the aircraft was damaged. The aircraft hull was undamaged; however, the rear propeller contacted the ground.

As a result of this occurrence, the pilot advised that from at least 5 NM final, she will ask the passengers not to speak to her, except to alert her to the presence of animals on the runway.

The sterile cockpit rule, where crew do not preform non-essential activities during critical phases of flight, including taxiing, take-off and landing, assists in ensuring that critical information is not missed or misinterpreted.

By explaining the sterile cockpit rule in their pre-flight brief, pilots can give passengers an awareness of the importance of minimising discussions, questions, and conversation during critical phases of flight.

Aviation Short Investigation Bulletin - Issue 18

At 1453 Eastern Daylight-saving Time on 16 February 2013, a Beech B200C, registered VH-VAE (VAE), was about 15 NM from Wangaratta on descent when the pilot observed a white glider with red markings approaching at the same level. The glider passed the left side of the aircraft with separation reducing to about 70 m at the same altitude. The pilot of VAE did not have an opportunity to take evasive action, nor did he observe the glider take evasive action. The pilot of VAE did not hear any broadcasts from the glider pilot on the area very high frequency (VHF).

Attempts to identify the glider were unsuccessful.

Early in 2012 and following a submission from the operator of VAE, the Civil Aviation Safety Authority (CASA) commenced a safety review into the level of risk from gliders in aircraft proximity (airprox) events in uncontrolled airspace. More recently, in response to discussions at a Regional Aviation Safety Forum and following advice from the ATSB of an increase in the number of airprox events across all categories of operations, CASA has established an Industry Airprox Working group to examine ways to reduce airprox events and enhance safety.

When operating outside controlled airspace, it is the pilot’s responsibility to maintain separation with other aircraft. For this, it is important that pilots utilise both alerted and un-alerted see-and-avoid principles. Un-alerted see-and-avoid relies entirely on the ability of the pilot to sight other aircraft. A traffic search in the absence of traffic information is less likely to be successful than a search where traffic information has been provided.

Aviation Short Investigation Bulletin - Issue 18

On 19 February 2013, at about 1000 Eastern Daylight-saving Time, an Ayres Thrush S2R-T34 aircraft, registered VH-HAH (HAH), struck power lines while conducting aerial agricultural spraying operations, about 7 km south-east of Condobolin aerodrome, New South Wales. The pilot was the only person on board. The aircraft sustained serious damage, while the pilot was uninjured.

The pilot was carrying out the final spray run (clean-up run), before returning to the airstrip. The pilot was flying from west to east, parallel to the main power line, which was located beside the field, outside of the area being sprayed. Another smaller power line with three wires ran diagonally across the field from the main power line. Once the pilot had run out of product, he pulled up to gain altitude, when he struck the smaller power line that ran diagonally across the field. Two of the wires were cut by the aircraft’s wire protection system and the third wrapped around the propeller hub arresting the aircraft and pulling it around in a half circle where it came to rest on the ground.

As a result of this occurrence, the electricity distribution company will install a marking system on the power line.

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. 

For this reason, the Aerial Agricultural Association of Australia recommends that an additional hazard check should be performed from a safe height prior to every change of direction or ‘clean up run’.  The extra safety check for wires is important, as the obstructions are new from the new direction of flight.

For further reading of suggested approaches to risk management for agricultural pilots see the Aerial Application Pilots Manual, available from the Aerial Agricultural Association of Australia (AAAA) at www.aerialag.com.au/Home.aspx.

Aviation Short Investigation Bulletin - Issue 18

Safety summary

What happened

On 17 February 2013, ore train 9614S was departing Spencer Junction en route to Whyalla, South Australia. While the train was traversing 38A points at the northern end of Spencer Junction, the driver noticed a change in the train’s dynamic behaviour and immediately reduced the throttle. The train then quickly came to a stop due to the automatic application of the electronically controlled pneumatic train brake. Upon inspection of the train, the second driver discovered five ore wagons were derailed.

What the ATSB found

The ATSB’s investigation found that the leading edge of the right hand 38A point blade was worn and damaged. The blade damage had created a ramping angle, allowing the lead wheel of the ore wagon to “ride up” the blade and derail. The derailed wheels then impacted and damaged the concrete sleepers, which ultimately failed to maintain track gauge and allowed further wagons to derail. During the derailment sequence, a rupture to the train’s electronic control pneumatic pipe initiated the application of the train brake.

The ATSB found that the Australian Rail Track Corporation’s inspection and maintenance regime, following two similar derailments at the same location, had not been sufficient to identify and remediate the deteriorating condition of the 38A points, and ultimately contributed to the derailment.

What's been done as a result

In the months leading up to this derailment, Genesee Wyoming Australia (GWA) and the Australian Rail Track Corporation (ARTC) had agreed to a rail upgrade programme which included a new turnout incorporating 38A points, using 60 kg rail laid on concrete bearers. At the time of this derailment, a new turnout had been prepared, but had not yet been installed. Upgrade works have since been completed.

Following installation of the upgraded infrastructure, more frequent monitoring for wear rates of the point blade(s) was undertaken. After several months of condition monitoring it became evident that track performance and wear rates could be managed as specified in the Code of Practice and the normal inspection schedule was reinstated.

Safety message

Track infrastructure owners and maintainers should consider the associated increase in wear on track infrastructure when there is an increase in the volume of rail vehicles being operated. The high dynamic forces that may be exerted from rail vehicles, specifically those that bear a heavy axle load, will accelerate the rate of wear on track infrastructure.

In these circumstances, increased inspection and maintenance of track components should be considered until it can be established that resulting wear rates can be adequately managed in accordance with the established standards.

On 17 February 2013, an Enstrom 480B helicopter, registered VH-VDC (VDC), was engaged in agricultural spraying operations, near Trida, Victoria. On the final load of chemical to be applied to the paddock the Global Positioning System (GPS) lost reception during the application run. The pilot immediately aborted the run and climbed to about 400 ft above ground level and attempted to resolve the issue with the GPS. 

Once the GPS regained reception, the pilot commenced a left turn at about 50 knots indicated airspeed to return to the paddock and recommence the application run. The pilot then heard a loud bang and felt a shudder through the airframe. 

The pilot performed a run on landing in the nearest clearing, he had difficulty in maintaining yaw control, because the tail rotor control cables had lost tension. The pilot was able to exit the helicopter without injury, however, the helicopter was substantially damaged.  

The ATSB was advised by the owner of the wire, that wire struck was marked with five marker discs. However, the pilot of VDC advised that the wire was unmarked at the time of the wirestrike. The ATSB was unable to independently confirm that the maker discs were still in place at the time of the wirestrike.

As a result of the occurrence the owner of the wire has advised the ATSB that the broken cable was replaced to restore electricity supply as soon as possible and was replaced without new markers installed. However, arrangements are being made to install markers on the line. 

Wirestrikes pose an on-going problem to aerial agricultural operations. Despite the advantages of marking a wire, not all wires are marked, and it is simply not feasible to mark all wires. It is important that pilots and operators raise any concerns they may have about the visibility of a wire with the wire owner. Electricity distribution and transmission companies may install aerial markers on wires upon request. Landowners can request to have wires on their property marked and pilots who have a need to fly low-level near powerlines can also request wires to be fitted with markers.

Aviation Short Investigation Bulletin Issue 20

Safety summary

What happened

On the afternoon of 8 February 2013, the 42 m Cayman Islands registered motor yacht Calliope departed from the Sydney Superyacht Marina in Rozelle Bay for a cruise around the harbour.

As Calliope transited the Glebe Island Bridge, it was off course and veered towards the bridge structure. To minimise any damage to the vessel, the crew attempted to walk a fender between the yacht’s hull and any possible points of contact. During this process, a crew member, leaning over the side of the yacht positioning the fender, was caught between the yacht and one of the bridge mounted fenders. The crew member was pulled over the yacht’s side and into the water.

The crew member was retrieved from the water shortly afterwards but died as a result of the injuries he had sustained.

What the ATSB found

The ATSB found that a passage plan for the voyage had not been completed and, therefore, the risks associated with the voyage were not appropriately assessed or communicated to the crew. It was also determined that the yacht’s master could not reference any navigational aids from his conning position in front of the navigational bridge. Hence, he was not in a position to properly monitor the yacht’s progress.

The ATSB also concluded that while Calliope was in voluntary compliance with elements of the Large Commercial Yacht Code (a United Kingdom instrument which had been adopted by the Cayman Islands), the yacht did not have to comply with these requirements because it was deemed to be a pleasure yacht. Similarly, the yacht did not have to carry a pilot while operating in Sydney Harbour because it was considered to be a recreational craft.

What's been done as a result

Calliope’s management company has advised that the ship’s safety management system procedures have been updated to require the completion of a passage plan for all voyages. Procedures for transiting bridge openings will be also be issued. A specialist consultant will also be engaged to conduct on board audits of the safety management system.

The Cayman Islands Shipping Registry has advised that the effectiveness of the Large Commercial Yacht Code in meeting the fundamental requirements of a documented safety management system will be raised with the United Kingdom as the authors, publishers and custodians of the Code.

The harbour master for the Port of Sydney has highlighted the details of this accident as part of a review of the NSW Marine Safety Act.

Safety message

Flag States and port administrations should consider the risks associated with operating a vessel when determining regulatory compliance requirements, rather than making such determinations based on the vessel’s mode (commercial or private) of operation.

What happened

On 15 February 2013, the crew of a Eurocopter Helicopter MBB‑BK117 B-2 (BK117), registered VH-VSA, were conducting a trauma recovery flight from Port Pirie to Adelaide Hospital, South Australia. After reaching the cruise altitude of 5,000 ft above mean sea level, the crew observed fluctuations of the hydraulic system pressure gauges. Shortly after, the helicopter sustained an uncommanded and violent nose-up pitch and rolled left before descending. The pilot regained control at about 800 ft above ground level. Control checks by the pilot confirmed normal control had resumed and the pilot flew the helicopter back to Port Pirie Aerodrome. No injuries were reported by the occupants and the helicopter sustained minor damage.

What the ATSB found

The ATSB did not find any mechanical or system faults that could account for the hydraulic system pressure fluctuations. The ATSB found that the helicopter was being operated at a weight, density altitude and airspeed, and in meteorological conditions that were conducive to the onset of retreating blade stall. The uncommanded and violent nose-up pitch and left roll were consistent with the onset of that condition. The pilot’s instinctive action of pushing the cyclic control forward delayed recovery from the stall.

What's been done as a result

The operator issued an urgent Immediate Safety Notification advising all company BK117 pilots of the conditions conducive to retreating blade stall and the correct actions to recover from that condition.

Safety message

This incident highlights the importance of pilot awareness of the factors conducive to retreating blade stall, including high all-up weight, high density altitude, high airspeed, manoeuvres that increase flight loads and flight in turbulence. Similarly, the importance of initially reducing collective pitch to optimise recovery is emphasised as incorrect recovery actions can result in loss of control of the helicopter.

Safety summary

What happened

On 12 February 2013, intermodal freight train 3MC1 derailed at Locksley, near Seymour in Victoria. The train consisted of two locomotives (GL107 leading and GL101 trailing) hauling 33 wagons having a trailing mass of 921.1 t and an overall train length of 885.5 m. There were no injuries but the last eight wagons derailed and about 800 m of track was damaged.

What the ATSB found

The ATSB determined that the derailment of freight train 3MC1 at Locksley was most likely the result of a track misalignment at the 127.768 km mark on the West Line of the interstate mainline. Hot weather in the period preceding the derailment, and trains travelling along the track, probably caused a redistribution of longitudinal rail stresses in a northerly direction towards the derailment site. The track structure near the derailment site probably had a reduced capacity to withstand lateral forces, due to track quality (ballast contamination). This, coupled with maintenance activities close to the derailment site, most likely initiated a redistribution of longitudinal forces towards the 127.768 km mark and increased the likelihood of a track buckling event.

What's been done as a result

Australian Rail Track Corporation track maintenance staff have been provided with additional training on the consequences of multiple track disturbances altering the stress free temperature of rail track. The training will provide an enhanced level of compliance with the requirements of procedure ETM-06-06 (Managing Track Stability - Concrete Sleepered Track).

Following the derailment and subsequent reinstatement of the track the Australian Rail Track Corporation undertook stress free temperature testing at ten sites near the ‘Point of Derailment’. Tests established that the rail stress free temperature was within specified tolerances.

The Australian Rail Track Corporation has implemented a ballast remediation program on the Melbourne – Sydney rail corridor. This work will continue as programmed until completed, following which further works will be undertaken at sites having identified formation weakness.

Safety message

Track managers must consider the potential impact of track disturbing maintenance activities on lateral track stability, particularly in areas having poor ballast quality and during periods when temperatures are significantly higher than the rail neutral temperature.

On 9 February 2013, a Cessna 150F, registered VH-ICE (ICE), landed on the 11^th fairway of the Mt Broughton Golf Club, New South Wales after the initial leg of a return flight from Robertson. The pilot was the only person on-board and had been authorised and pre-arranged with the Golf Club to use the fairway as a landing area.

After landing to the south, the pilot backtracked along the landing area to conduct a short field take-off in the same direction.

The pilot reported that the aircraft accelerated as normal, however during the take-off run he realised the aircraft would not clear the trees at the end of the landing area and elected to reject the take-off. The left wing impacted a tree; the aircraft turned over and came to rest inverted. The pilot was uninjured, and the aircraft sustained substantial damage.

An insurance assessor attended the accident site and reviewed the landing area. The assessor determined that the effective available take-off length of the landing area was 1,180 ft. Based on performance charts in the approved Cessna 150F owner’s manual, the take-off distance required by the unmodified Cessna 150 F was 1,583 ft. There was no available performance data that took into account the installation of the 160 hp engine.

This accident highlights the importance of following the published performance data for your aircraft and knowing the performance requirements, physical characteristics and dimensions of the landing area that you are intending to take-off and land on. Other factors, such as environmental conditions, may affect the usable landing area length needed for a safe take off, landing or rejected take-off.

Aviation Short Investigation Bulletin Issue 19

On 7 February 2013 at about 1655 Eastern Daylight-saving Time a Eurocopter AS350 B2 helicopter, registered VH-EWM (EWM) was conducting water-bombing operations near Hobart, Tasmania, when it collided with terrain. The pilot, the sole person on board, suffered minor injuries and the helicopter sustained substantial damage.

The spot fire EWM was working on was not particularly large but was on a downhill slope and in a gully. The pilot reported that the overall wind was north-north-westerly, but the fire created a localised westerly in-draft, within the gully. The pilot slowed EWM in preparation of making a water drop. Approaching the hover at about 80 ft above ground level, and immediately following the loss of translational lift (TL), the helicopter suddenly commenced an uncommanded left yaw and descent. Without any warnings or alarms, the helicopter rotated rapidly 2-3 times to the left. The pilot raised the collective to decrease the rate of descent and countered the yaw with anti-torque pedal input; however, the rate of yaw increased. The pilot reported that “in a very short period of time” the helicopter was in the trees. The pilot received minor injuries, and the helicopter was substantially damaged.

As the ATSB did not attend the accident site, or examine the helicopter, the reason for the accident could not be conclusively established.  The described behaviour of the helicopter by the pilot was consistent with Loss of tail rotor Effectiveness (LTE). In this condition of flight, the tail rotor loses aerodynamic efficiency. Factors which contribute are:

• Low airspeed
• High power
• An adverse relative wind

Water-bombing helicopters operate at very low altitudes, in very challenging and often rapidly changing conditions. Any sudden onset of an abnormal condition of flight presents negligible time for recovery.

Eurocopter circulated Service Letter No 1673-67-04 in 2005 regarding the yaw axis control features for all helicopters under certain flight conditions.

Aviation Short Investigation Bulletin Issue 20