What happened

On 22 September 2011, at about 1317 hours Western Standard Time (WST), a Cessna Aircraft model U206G (C206), registered VH-SHZ, departed Kalumburru Aerodrome, Western Australia (WA) with the pilot and six passengers on the return leg of a charter flight returning to Wyndham, WA. Following climb-out and in level flight at 5,500 ft above mean sea level (AMSL), the engine shutdown without warning. At the time of the engine shutdown, the right-wing fuel tank was selected and the right fuel quantity gauge indicated less that ¼ tank.

The pilot actioned emergency procedures including switching fuel tanks, and, at about 2,000 ft above mean sea level, the engine restarted. The flight continued on uneventfully and the aircraft landed at Wyndham. Post-flight inspection revealed that the pilot had not properly secured the right-wing fuel tank filler cap following refuelling that morning, resulting in fuel venting from the right tank.

What happened

On 25 September 2011, the pilot of a Cessna Aircraft Company 182, registered VH-MST (MST) was inbound to Toowoomba, Queensland (Qld) from Roma, Qld.  At the same time, a Schempp-Hirth Ventus 2c glider, registered VH-ULZ (ULZ) was competing in the Qld State Soaring championships and thermalling west of Toowoomba on track for Jimbour.

Whilst on descent through 4,000 ft the pilot of MST sighted a glider between 300 m and 500 m in front and at the same level.  The glider was heading directly for MST and the pilot was required to take evasive action. 

The distance between the two aircraft was estimated at 100m horizontally.

The incident highlights the need for pilots to apply the principles of 'see-and-avoid' in combination with an active listening watch on the appropriate radio frequency. Furthermore, simply having a radio is no guarantee of safety. It is imperative that pilots broadcast their position and intentions, for the performance of the more effective 'alerted see-and-avoid'.

What happened

On 27 September 2011, a flight instructor and student pilot of a Piper Aircraft Corporation PA 28 151 (Warrior) aircraft, registered VH-CIX (CIX), were conducting circuits at Mangalore Airport, Victoria. After completing a stop-and-go on runway 05 and climbing to 1,500 ft above mean sea level (AMSL), the aircraft was turned onto crosswind. When the turn was completed, the instructor of CIX observed a Piper Aircraft Corporation PA-44-180 (Seminole) aircraft, registered VH-KHG (KHG), on downwind, about 30 to 45 m to the right and at the same height. The instructor of CIX immediately assumed control of the aircraft, reducing the engine power to idle and descending about 200 ft.

The flight instructor and student pilot on KHG had joined downwind for runway 05 from a practice instrument approach to the Mangalore runway 23 very high frequency (VHF) omnidirectional radio range (VOR)¹. Soon after, the instructor sighted CIX off to his left flying straight and level, established on a slightly earlier than normal crosswind leg. CIX then passed in front of KHG, about 100 to 200 ft below and 100 m in front.

As CIX was straight and level and established on crosswind when first sighted by KHG, it is likely that the pilots of KHG did not sight CIX until after the airprox² had occurred and CIX had descended.

CIX and KHG were both operated by the same operator. As a result of this serious incident, the operator conducted an internal investigation into the incident and advised the ATSB that they had introduced a procedure whereby, when the wind conditions favoured a take-off towards the north or north-east, aircraft joining the circuit from a practice instrument approach were to descend to an overfly height of 2,000 ft AMSL and join the circuit from the non-active side of the circuit.

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1.      A ground-based navigation aid that emits a signal that can be received by appropriately equipped aircraft and represented as the aircraft's bearing (called a 'radial') to or from that aid.
2.      An occurrence in which two or more aircraft come into such close proximity that a threat to the safety of the aircraft exists, or may exist, in airspace where separation is a pilot responsibility.

What happened

At 0835 Eastern Standard Time on 26 September 2011, a flight instructor and student pilot in a Cessna Aircraft Company 152, registered VH-HCE, was operating at Bankstown Airport, New South Wales, on a training flight.

After a series of simulated rejected take-offs, the aircraft departed runway 11 to conduct circuits. After completion of the second touch and go, at a height of approximately 200 ft, the engine gradually lost power. The instructor resumed control, and with minimal runway remaining, and engine power further reducing, identified a suitable grassed landing area. The instructor declared a MAYDAY to air traffic control and positioned the aircraft for an emergency landing.

After the main wheels contacted the ground, and just prior to nose wheel contact, the engine power suddenly increased. The instructor reduced the throttle to idle and continued with the landing. As the nose wheel contacted the ground it detached, the aircraft nosed over and slid a short distance before coming to rest inverted. The instructor and student vacated the aircraft with no injuries.

A subsequent inspection identified a quantity of water in the right fuel tank that probably entered the tank via the right fuel cap receptacle following a period of heavy rain. Immediately following the accident, the operator conducted a fleet check, identifying an additional aircraft with water contamination in the fuel.

As a result of this occurrence, the aircraft operator advised the ATSB that they were taking the following safety actions:

• Instructor training on fuel system in Cessna aircraft type operated by the company;
• Student information sessions on water contamination incidents; and
• Compulsory instructor training.

This accident highlights that following periods of heavy rain, extra vigilance is needed during pre-flight checks to ensure that fuel is free of contamination.

What happened

On 20 September 2011, a Eurocopter AS.350B3 helicopter, registered VH-HTV (HTV), was returning to the Mount Coot-tha helicopter landing site (HLS), Queensland, at about 2,000 ft.

When 1 NM to the west of the HLS, descending through about 1,500 ft, the pilot received an alert from the helicopter's traffic and collision alert device (TCAD) indicating an aircraft was about 400 to 500 ft below.

The pilot was unable to sight the conflicting aircraft, so the descent was continued. Shortly after, a second alert was received from the TCAD indicating the aircraft was now 200 ft below. The pilot immediately stopped the descent and observed a Cessna Aircraft Company 180 aircraft, registered VH-UPF (UPF), below the helicopter tracking outbound from Archerfield, Queensland at 1,000 ft.

A review of Airservices Australia radar data indicated that the distance between HTV and UPF reduced to about 0.1 NM laterally and 200 ft vertically.

This serious incident highlights the benefits of onboard collision avoidance systems in assisting pilots with traffic awareness; and the need for pilots to regularly review documentation to remain up to date with procedures.

Safety summary

What happened

On 12 September 2011 at about 1000, the pilot of a Cessna 210N aircraft, registered VH-JHF, was conducting low-level aerial survey operations near Bourke Aerodrome, New South Wales. After encountering a brief turbulence event, the pilot had difficulty in making elevator control inputs and in maintaining height. The aircraft subsequently landed safely. There were no injuries.

What the ATSB found

The ATSB found that the reported elevator control input difficulties resulted directly from the fracture of the aircraft’s two horizontal stabiliser rear attachment brackets. The forward spar of the horizontal stabiliser was also extensively cracked. The fractures and cracking were all consistent with metal fatigue and, as such, were typical of the damage sustained by aircraft as they age and move beyond the manufacturer’s originally intended design life. Many manufacturers have addressed the growing potential for this type of damage by introducing supplemental inspections to the principal aircraft maintenance requirements.

The Australian Civil Aviation Regulations 1988 (CAR) were being misinterpreted by some class B aircraft registration holders, to the extent that they believed that their aircraft was exempt from the manufacturer’s supplemental inspections when their aircraft was maintained using the CASA maintenance schedule. While the CASA maintenance schedule did not make any specific reference to the incorporation of the manufacturer’s supplemental inspections, it was a CAR requirement that all aircraft be maintained in accordance with approved maintenance data that, by definition, included those inspections.

What's been done as a result

As a result of this occurrence, on 19 September 2011 the Civil Aviation Safety Authority (CASA) issued Airworthiness Bulletin AWB 55-001 issue 2; highlighting the failure of horizontal stabilisers on Cessna 200 series aircraft. The AWB made recommendations on the maintenance schedule and inspection of the stabiliser in order to ensure the structural integrity of the area.

CASA also published a series of Discussion Papers in December 2012, detailing a range of options for developing updated continuing airworthiness regulations for all aircraft not used in regular public transport operations. This included options for reform of maintenance program requirements for non-RPT aircraft – to bring the regulations up to date with modern technology and current international standards and practice.

The outcomes from the discussion papers were unresolved at the time of writing and therefore the Australian Transport Safety Bureau has recommended that CASA proceed with its program of regulatory reform to ensure that all aircraft involved in general aviation operations are maintained using the most appropriate maintenance schedule for the aircraft type, and to also ensure that the provisions of CAR Schedule 5 are clarified in relation to the incorporation of all relevant supplemental inspections specified for the aircraft type.

Safety message

This occurrence highlights the importance of comprehensive, periodic maintenance inspections and the role of supplemental inspections in maintaining ageing airframes. The ATSB strongly encourages registration holders of class B aircraft to review their aircraft’s maintenance schedule to determine if it is the most appropriate for their aircraft and to ensure that it adequately provides for the continuing airworthiness of the aircraft.

What happened

On 12 September 2011 a Vincent Airlines operated Raytheon Aircraft Company 1900D, registered VH-VAQ, departed Darwin Airport, Northern Territory on a local training flight. Onboard was a check captain, a check captain under training and a first officer (FO).

The purpose of the flight was to conduct a proficiency check in preparation for the FO to be checked to line operations. After take-off, at about 80 ft above ground level (AGL), the check captain announced, "simulating engine failure" and reduced the power on the left engine, setting above zero thrust. The FO recalled feeling pressure from the left rudder pedal under his foot and he instinctively pressed the left rudder pedal. He doesn't recall carrying out any actions to identify the failed engine.

The check captain observed that the aircraft had diverged left of centreline and was in about a 15-200 left level turn. The check captain took over the role of pilot flying and called "taking over". The FO replied, "handing over" and released the controls. The check captain applied right rudder, reduced the roll to the left and increased the power on the left engine while simultaneously reducing the power slightly on the right engine. The aircraft was established in a climb and reconfigured for a normal two-engine departure.

Following the event, the FO believed that the upward pressure he felt from the left rudder pedal was due to the normal operation of the rudder boost system deflecting the right rudder during the simulated engine failure.

The operator has actively pursued the establishment of a Beech 1900 simulator in the Australasian region. The operator is hopeful that an appropriate simulator will become available shortly and will endeavour to use the simulator for non-normal training.

What happened

On 12 September 2011, a Robinson Helicopter Co. R44 Astro helicopter, registered VH-HBA, departed Heartbreak Hotel, Northern Territory, for a local scenic flight with one pilot and three passengers onboard.

The pilot conducted a thorough safety brief prior to departure. Shortly after take-off, and at about 1,500 ft above ground level, the engine fire warning light illuminated. The pilot commenced a descent to carry out a precautionary landing. Shortly before touchdown the engine oil pressure light illuminated, and the pilot observed a rapid loss of oil pressure. 

After landing, the pilot observed flames originating from under the engine cowling at the rear of the helicopter. All three passengers evacuated the helicopter. The helicopter was subsequently destroyed due to fire.

An engineering inspection could not determine the cause of the fire.

This incident highlights the importance of thorough pre-flight safety briefs. The brief assisted the passengers in being able to exit the helicopter quickly. The pilot also commented that emergency equipment stored under the seat was difficult to access in a fire. Future consideration would be given to placing this equipment in a more accessible location.

On 2 September 2011, a Howard Hughes Engineering Lightwing SP-2000 aircraft, registered 24-5040, was being operated on a private flight with the pilot and one passenger on-board. While operating to the north of Sydney Harbour, witnesses observed the aircraft descend and impact the water adjacent to the North Curl Curl shoreline. The aircraft was destroyed by the forces of the collision and one of the two occupants was fatally injured.

Recreational Aviation Australia (RA-Aus) is assisting the New South Wales Police Service with their investigation of this occurrence. Following recovery of the aircraft wreckage, RA-Aus officers requested assistance from the Australian Transport Safety Bureau (ATSB) in the recovery of data from some of the aircraft's electronic instrumentation systems and portable navigation devices. To facilitate this work, the ATSB initiated an investigation under the Transport Safety Investigation Act 2003.

In summary, four devices in total were examined by the ATSB. Raw data was successfully recovered from a portable GPS navigation unit and a fuel monitoring instrument, however ATSB analysis showed that neither data set contained usable information that was relevant to the accident flight. The data from both units was provided to RA-Aus on 26 October 2011 and the instrumentation returned on 2 April 2012.

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

Safety summary

What happened

On 3 September 2011, the pilot and one crewman of a Robinson Helicopter Company R44 helicopter, registered VH-HCA (HCA), departed an airstrip located near Kumarina roadhouse, approximately 150 km south of Newman, Western Australia. The crew were conducting low-level geophysical survey operations when the pilot was observed to have slumped forward in the seat. The crewman, who was seated behind the pilot, made unsuccessful attempts to rouse the pilot. The helicopter subsequently impacted terrain causing significant injuries to the crewman and pilot. After the impact the pilot regained consciousness but later succumbed to his injuries prior to the arrival of medical assistance.

What the ATSB found

The investigation found that, following the pilot’s probable incapacitation during flight, the helicopter’s descent could not be arrested before impacting terrain. It was likely that the incapacitation was of a similar nature to other previous unconsciousness events reported experienced by the pilot while not flying.

The pilot held a Class 1 Aviation Medical Certificate with no restrictions, despite inconsistencies in recorded information in the pilot’s aviation medical questionnaires, and one previous unconsciousness episode being recorded. If information about the pilot’s medical history had been accurately documented and included on the medical questionnaires, further medical tests may have been required and the results used to better assess the pilot’s current medical status.

What has been done as a result

The ATSB advised the Civil Aviation Safety Authority (CASA) of the reporting inconsistencies identified in the pilot’s aviation medical questionnaires. CASA confirmed that the medical section of the CASA website is currently being reviewed and guidance material pertaining to medical issue reporting requirements will be available on that site when that work is complete.

Safety message

In addition to the regular aviation medical assessments, should a pilot become aware of any condition that may affect their ability to safely carry out the privileges of a licence, the advice of a Designated Aviation Medical Examiner (DAME) should be sought. Additionally, all information documented on the pilot’s aviation medical assessment should be checked by the pilot for accuracy and completeness to allow for accurate assessment of medical status and potential risk to the safety of flight.