On 25 December 2012, a Fokker 100 aircraft, registered XY-AGC, collided with terrain on approach to Heho Airport, Myanmar, fatally injuring one of the aircraft’s occupants and a motorist on the ground.

The Myanmar Accident Investigation Bureau (MAIB) is responsible for investigating this occurrence. As part of its investigation, the MAIB requested assistance from the Australian Transport Safety Bureau (ATSB) in the recovery and download of data from the aircraft’s Flight Data Recorder (FDR) and Cockpit Voice Recorder (CVR) units. In accordance with clause 5.23 of Annex 13 to the Convention on International Civil Aviation (ICAO Annex 13), the ATSB appointed an accredited representative to assist the MAIB and initiated an investigation under the Australian Transport Safety Investigation Act 2003.

Following receipt of the CVR and FDR units on 21 January 2013, both units were successfully downloaded in accordance with the relevant manufacturer’s instructions. The download and data recovery operations were overseen by representatives of the MAIB and an Accredited Representative from the Dutch Safety Board (DSB). During preparations for the download process, ATSB specialists found that the crash survivable memory units (CSMU’s) from the both recorders had suffered damage from fire exposure. The CSMU is the module which carries the solid state chips that contain the recorded information.  The CVR CSMU was dismantled and the data recovered using data retrieval techniques appropriate for an accident-damaged flight recorder. However, the FDR CSMU had sustained a significantly greater degree of thermal damage and required specialised data recovery techniques involving recovery and downloading of individual chips. The data recovered from the discrete chips was later compiled into a single coherent data file using a specialised utility provided by the recorder manufacturer.

The downloaded audio and flight data was examined and confirmed as containing detail from the accident flight. The recovered information, together with a selection of graphical and tabular presentations of the flight data was provided to MAIB representatives on 25 January 2013.

Fire-damaged flight data recorder as-received

Thermally-damaged flight data recorder crash-survivable memory unit

The MAIB investigation has now been finalised and in accordance with the provisions of ICAO Annex 13, a copy of the final investigation report was provided to the ATSB on 28 January 2014.

A copy of the final report may be requested through the contact details below:

Myanmar Accident Investigation Bureau
First Floor, DCA HQ Building (B)
Yangon 11021, Myanmar
Tel: 951 533162
Fax: 951 533016
Email: ddmaib@dca.gov.mm

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

On 15 November 2012, an amateur-built SeaRey amphibious aircraft, registered VH-RRZ, was being operated on a private flight with only the pilot on-board. When the aircraft failed to arrive at its destination, search and rescue authorities were notified, and the aircraft was subsequently located on 16 November, having collided with terrain approximately 76 nautical miles north of Weipa, Qld. The aircraft was destroyed by impact forces and the pilot had sustained fatal injuries.

The QLD Police Service (Northern Coronial Office) is investigating this occurrence. Following examination of the aircraft wreckage, QPS officers requested assistance from the Australian Transport Safety Bureau (ATSB) in the recovery of data from a GPS unit found at the accident site. To protect the information supplied by the QLD Police Service and any data recovered from the examined device, the ATSB initiated an external investigation under the provisions of the Transport Safety Investigation Act 2003.

The examination found that the GPS memory chip which contains the flight data was damaged and the data was therefore not able to be recovered. The GPS was returned to the QLD police.

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

On 25 December 2012, a Bombardier DHC-8-202 aircraft, registered as P2-PXI, sustained an engine failure during approach to Pt. Moresby Airport, Papua New Guinea (PNG). The aircraft continued the approach and landed safely, with no injuries reported.

As the incident occurred in PNG, the PNG Accident Investigation Commission (AIC) was responsible for investigating this occurrence. To assist its investigation, the AIC requested assistance from the Australian Transport Safety Bureau (ATSB) in the download of data from the aircraft’s Flight Data Recorder (FDR) and Cockpit Voice Recorder (CVR).

To facilitate the work, and in accordance with clause 5.23 of Annex 13 to the Convention on International Civil Aviation, the ATSB appointed an accredited representative to assist the PNG AIC and initiated an external aviation safety investigation under the Australian Transport Safety Investigation Act 2003.

Following receipt of the CVR and FDR units on 14 January 2013, both units were successfully downloaded in accordance with the relevant manufacturer’s instructions. The downloaded audio and flight data was examined and confirmed as containing detail from the occurrence flight, before being provided to AIC representatives on 16 January 2013, together with a selection of graphical and tabular presentations of the flight data.

Contact details for the PNG Accident Investigation Commission are available at: www.aic.gov.pg/contact.html

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

On 14 December 2012, an Airbus A320 operated on a scheduled passenger flight from Hobart, Tasmania to Melbourne, Victoria, without the runway lights being activated for the taxi and take-off roll.

Outside tower hours, Hobart Airport operated as a non-towered uncontrolled airport, operating on a common traffic advisory frequency (CTAF). When operating as a CTAF, the runway lighting was controlled by a pilot activated lighting (PAL) system that was combined with an aerodrome frequency response unit. Two pilot activated lighting systems exist at Australian airports, Pilot Activated Lighting (PAL) and Aerodrome Frequency Response Unit plus PAL (AFRU+PAL). Hobart Airport is equipped with the ARFU+PAL type installation. The two systems differ in their activation methods.

A number of situational factors were associated with the crew not activating the runway lights prior to departure. Defining a specific place for PAL tasks in the crew’s sequence of procedures, and incorporating this into a pre-taxi checklist, could potentially ensure more reliability in performing these tasks.

Aviation Short Investigation Bulletin Issue 19

On 15 December 2012, four DH-82A (Tiger Moth) aircraft departed runway 12 at Luskintyre airport, NSW, for a practice formation flight. The pilot flying VH-DDA (DDA), the formation lead aircraft, applied full power for take-off. Passing through about 50 ft above ground level, the pilot flying noted that the aircraft was not climbing as expected and, realising that full power was not selected, applied full power by moving the throttle fully forward and lowered the nose of the aircraft slightly to gain speed.

As there was insufficient distance remaining to land on the runway, and it had become evident that a forced landing was imminent, the instructing pilot input a slight left bank so that the left wing of DDA took the main force of the impact. The aircraft landed and struck a tree before coming to rest. Both pilots were able to undo their four-point harnesses and exit the aircraft without assistance, although the pilot flying received serious facial injuries.

While both pilots reported that they had not reduced engine power after take-off, the accident was a result of decreasing airspeed and the aircraft being unable to recover following the reapplication of full power. The ATSB could not resolve this ambiguity.

The positive aspects of wearing full restraint harnesses, evacuating the aircraft quickly and extinguishing the fire ensured neither pilot experienced further injuries.

Comprehensive pre-flight briefings are important for all flights to ensure each crew member is aware of their respective roles as well as normal and non-normal operations.

Aviation Short Investigation Bulletin – Issue 17

What happened

On 17 December 2012, a Cessna 182A aircraft registered VH-SGB, impacted with electrical powerlines that ran alongside a parachute drop zone at Burrum River, Queensland. The pilot was planning to attend a Christmas function at the drop zone and was flying to an airstrip located about 1.5 km to the north. After contacting the powerlines, the aircraft was seen to climb and continue to fly for approximately 500 m before the right wing separated from the aircraft. The aircraft subsequently impacted the ground and the pilot was fatally injured.

What the ATSB found

The powerlines that the aircraft impacted were at a height of approximately 9 m (30 ft) above ground level (AGL) and ran perpendicular to the aircraft’s flight path. The relevant cable marking standards did not require the powerlines to be marked. Weather conditions were fine, and there was no emergency broadcast from the pilot prior to the impact with the powerlines. No pre-existing defects with the aircraft could be identified.

No operational reason for the pilot to fly at a height below 500 ft AGL could be identified by the investigation.

Safety message

A minimum height of 500 ft AGL for flight over non-populated areas is promulgated for very long standing safety reasons. Pilots who choose to fly below this height without an operational reason to do so are exposing themselves, and any passengers that may be on board, to an increased risk of striking powerlines, many of which are difficult to see from the cockpit of an aircraft in flight. The circumstances of this accident highlight that risk.

On 4 December 2012, at about 1618 Western Standard Time, a Qantas Airways Boeing 737‑838 aircraft, registered VH‑VZL, was taking off on runway 06 at Perth Airport, Western Australia on a flight to Canberra, Australian Capital Territory.

During the take-off run, approaching the take-off reference speeds, the airspeed stopped increasing and did not start increasing again for several seconds. The captain noticed that the wind vector on the navigation display was showing a tailwind of about 20-25 kt. The captain disconnected the auto-throttle and ‘fire-walled’ the thrust levers. During the initial climb, the first officer performed a windshear escape manoeuvre.

While there was some cumulonimbus cloud activity about 20–30 NM north of the airport, there were no indications of an impending wind change before take-off.

Before take-off, both pilots checked the windsocks, which showed that headwind conditions existed. Late in the take-off run, a significant wind change occurred, and the aircraft began to experience tailwind conditions of about 20 kt. As the performance calculations had assumed nil wind for take-off, the aircraft failed to achieve the predicted take-off performance.

This incident serves as a reminder to pilots that significant wind changes can occur during take-off, can be difficult to predict, and can occur in the absence of thunderstorm activity. The wind conditions at each end of a runway may differ significantly so that headwind conditions can exist at one end and tailwind conditions at the other end.

Although it did not assist in this case, it is important to monitor the available windsocks before take-off as it is the final opportunity to detect wind changes before the take-off roll begins.

Aviation Short Investigation Bulletin - Issue 18

On 9 December 2012, at about 1245 Eastern Daylight –saving Time, a Piper PA-39 aircraft, registered VH-RMA (RMA), departed on a private flight from Tamworth via Griffith, New South Wales, for Bacchus Marsh, Victoria. The pilot, the sole person on board, was ferrying the aircraft for a pre-purchase engineering inspection.

About 75 NM from Griffith, he prepared for a descent from 4,500 ft above mean sea level (AMSL) to 2,500 ft AMSL. He noticed an uncommanded decrease in the left engine revolutions per minute (RPM). He moved the left propeller lever to the maximum position, however, the RPM failed to respond, and the aircraft continued to descend.

The pilot initiated the emergency checklist for the left engine; however, the engine was unresponsive. To utilise all available power, he commenced the emergency checklist for the right engine. Almost immediately, the right engine began to vibrate severely, with a noticeable loss of power, and an increased rate of descent.

The pilot looked for a suitable forced landing area and broadcast his intentions. During the round-out, he decided to extend the landing gear. The propellers contacted the ground, and the aircraft skidded to a halt. The pilot was uninjured, and the aircraft sustained serious damage.

The reason for the reported performance loss on either engine could not be determined.

The Australian ‘Tribe’ of the International Comanche Society maintain a website for pilots who fly or maintain an interest in Comanche aircraft such as RMA. This keeps readers up to date with Civil Aviation Safety Authority (CASA) airworthiness directives, and any other maintenance issues for the Comanche series of aircraft. They also conduct pilot proficiency programs on the type. Further information is available at www.comancheflyer.com.au.

Aviation Short Investigation Bulletin - Issue 18

On 9 December 2012 at about 1700 Eastern Standard Time, a Robinson R22 helicopter, registered VH-HTD, departed a fishing camp situated on the mouth of the Normandy River, Queensland, on a private flight. The pilot was the only person on board. 

The pilot was tracking north-west along the coastline at about 600 ft above ground level (AGL) when he sighted an object in the water, about 100 m from the coast. The pilot turned the helicopter towards the object and descended to have a closer look. 

As the pilot approached the object, he initiated a flare to reduce the airspeed and rate of descent.  During the flare, the tail rotor contacted the water, and the helicopter began to rotate to the right about the yaw axis.  The pilot closed the throttle, and the helicopter settled into the water and rolled over to the right. The pilot exited through the passenger door without injury and swam to shore. 

Robinson Helicopter Company issued Safety Notice SN-19 in regard to the hazards of low-level flight over water, particularly the lack of depth perception. Even choppy water with its constantly varying surface may interfere with normal depth perception and cause a pilot to misjudge their height above water.

Aviation Short Investigation Bulletin - Issue 16

What happened

On 9 December 2012, the pilot of a Robinson R44 Raven I helicopter, registered VH-WOH, was conducting aerial spraying activities on a property near Mudgee, New South Wales. Following the completion of a number of spray runs, the helicopter failed to return to the refilling station, and a search was commenced. The helicopter was found about 450 m up a hill from the refilling station, having collided steeply with terrain. The pilot was fatally injured.

What the ATSB found

Analysis of the recovered global positioning system data identified that immediately before the accident the helicopter was climbing up a hill when the speed decreased below about 10 kt (19 km/h). The ATSB found that at the time of the accident the helicopter was over its maximum allowable weight, was too heavy to hover out-of-ground effect and as the speed decreased, the power required exceeded that available from the engine resulting in a probable reduction in main rotor RPM (overpitch) and a descent. The time between this point and the first contact with a tree was insufficient for the pilot to complete a recovery action. The ATSB also found that the spray system on the helicopter had not been installed by an approved aircraft maintenance engineer.

Safety message

This accident highlights the dangers of operating helicopters overweight, especially when performance is critical, such as when low flying or conducting aerial spraying operations. The use of manufacturer’s performance data will assist pilots in avoiding the circumstances associated with this accident.