What happened

On 9 August 2011, a Piper Aircraft Corp PA-44-180 aircraft, registered VH-FRI departed Bankstown for Coffs Harbour, New South Wales, on a private instrument flight rules (IFR) flight. About 30 NM to the north-west of Port Macquarie, the pilot decided to divert to Port Macquarie aerodrome due to a build-up of cloud above the forecast freezing level along the intended flight path.

While the pilot was examining arrival charts for the approach into Port Macquarie, he inadvertently entered cloud. The electronic flight instrument system (EFIS) screen went blank, some of the analogue instruments became fixed in position and the autopilot disconnected.

The pilot followed the standby attitude indicator and set an attitude and power setting to estimate an appropriate rate of descent.
The pilot broadcast a PAN call and requested assistance from Air Traffic Control. The controller acknowledged the PAN call and confirmed the aircraft's position. The aircraft then tracked away from Port Macquarie aerodrome. The controller queried the pilot's intentions, but did not inform the pilot of the aircraft's changed flight direction.

The pilot again asked for assistance, and the controller suggested a heading change. A short time later, the pilot became visual with the ground and was able to navigate the aircraft to Port Macquarie. He noticed that there was light icing on the leading edge of the wings.
Subsequent engineering tests revealed that the pitot heat had only one of two heating elements fitted. A second element was subsequently fitted.

The operator has directed their contract maintenance organisations to ensure that both heating elements are fitted and serviceable prior to certifying the aeroplane airworthy. An undertaking to educate flight crew on the correct technique for checking that both heating elements are operating when conducting a pitot heat check was also made.

Safety summary

What happened

On 11 August 2011, a scheduled Melbourne to Sydney Express Passenger Train (XPT) partially separated as it passed over a dip in the track near Broadmeadows, Victoria. The train suffered a total loss of power and was unable to continue its journey.

What the ATSB found

The ATSB found that the tail pin in the draft gear between the lead power car and first carriage failed as a result of a brittle overstress fracture that was initiated by fatigue cracking. Recent routine ultrasonic testing had not detected the presence of the fatigue crack and post incident material testing established that the mechanical properties of the tail pin were below the required standard.

Following this incident, the ultrasonic testing procedure was revised to improve the detection of smaller cracks in the tail pin. However, the separation of another XPT near Seymour, Victoria, on 1 August 2012 in similar circumstances highlighted the fact that the ultrasonic testing regime was still not detecting all small fatigue cracks in critical areas of the tail pin.

This investigation did not examine how the track irregularities near Broadmeadow may have contributed to the partial separation of train ST24, why the track condition deteriorated significantly in the 6 weeks between when it was last rehabilitated and the day of the partial separation or why the inspection and maintenance regimes in place at the time did not detect the deterioration in track conditions. These issues will be considered as part of the broader safety issue investigation RI-2011-015 Safety of rail operations on the interstate rail line between Melbourne and Sydney.

What's been done as a result

A new batch of tail pins has been manufactured to an upgraded standard which includes improved quality control and acceptance testing and RailCorp, the operator of the XPT fleet, is currently in the process of fitting these new tail pins. RailCorp has also further revised the tail pin inspection regime with the aim of improving its effectiveness.

Safety message

It is important that components are fit for purpose and meet the appropriate requirements for service and that inspection regimes are effective in providing assurance of continuing equipment reliability.
 

What happened

On 12 August 2010, at about 1402 Eastern Standard Time, the pilot of a Piper PA-28-161 (Warrior II) aircraft registered VH-BZE (BZE) was cleared by the Surface Movement Controller (SMC) to taxi to holding point Alpha 2 (A2) for a departure from runway 13R, on a private navigational flight from Moorabbin Airport, Victoria. Following line up checks, the pilot was issued a takeoff clearance for runway 13R. Another aircraft, VH-PVL, that had recently landed on runway 13R was cleared to cross runways 22, 17L and 17R during taxi. The pilot of BZE inadvertently began a take-off roll on runway 17R instead of runway 13R, which resulted in a runway incursion. The aircraft came within 100 m of each other before BZE exited at the first taxiway and returned to the apron. There were no injuries to the occupants and nil damage to either aircraft.

The pilot of BZE became disorientated at holding point A2 as it was a combined entry to both runway 13R and 17R. Information regarding potential runway conflict areas (hotspots) was available for the airport on the Airservices Australia (Airservices) website, but this was not common knowledge to all airport users.

What happened

On 7 August 2011, a Cessna Aircraft 172, registered VH-WYG (WYG), departed Bankstown, New South Wales, for a student solo-navigation exercise. WYG entered Sydney controlled airspace without a clearance, which subsequently resulted in a breakdown of separation with a departing Boeing 747 aircraft, registered N171UA. Air Traffic Services (ATS) alerted the crew of N171UA to the traffic, and issued instructions for N171UA to conduct an avoidance turn away from WYG.

When the pilot of WYG contacted ATS for an airways clearance to conduct the Sydney Harbour scenic route, he was informed that he had been radar-identified as having entered controlled airspace without a clearance. The pilot then remained outside controlled airspace and subsequently elected to terminate the navigation exercise and return to Bankstown via the Lane of Entry.

The pilot reported that inclement weather had influenced his en-route track decision making during the flight.

This incident highlights the importance of both weather avoidance, and awareness of proximity to controlled airspace.

Abstract

On 30 April 2011, the owner-pilot of a Robinson Helicopter Co. R44 helicopter, registered VH-ETT, was conducting a local flight from a private property located near Kilmore Gap, Victoria. During low-level manoeuvring at low speed around a dam, the pilot lost directional control and landed heavily in the water. The helicopter was seriously damaged; the pilot and passenger sustained minor injuries.

The investigation found that the helicopter was probably serviceable, and that the loss of directional control was likely to be a result of a loss of tail rotor effectiveness.

The emergency locator transmitter (ELT) activated on impact and prompted an effective search and rescue (SAR) response through a broadcast on the 121.5 MHz frequency. However, the 406 MHz transmission that was monitored by the SAR agency did not trigger an alert or provide identification information. As a result, there was no assurance of an immediate and effective response from the SAR agency.

The investigation found that the ELT could be programmed with identification information either directly or (if fitted) by input from a component (dongle) in the ELT wiring connector. In this occurrence, the ELT had been inadvertently reprogrammed with incorrect information from the dongle.

A minor safety issue was identified in that there were only subtle cues to distinguish programmable dongles from the standard-type wiring connector. There was also variability in the conduct of post-installation ELT testing.

In response, on 6 June 2011, the Civil Aviation Safety Authority (CASA) published Airworthiness Bulletin 25-018 to alert maintenance organisations to the risk of programming dongles transferring potentially invalid details to the memory of ELTs. CASA advised that an article in Flight Safety Australia would also highlight the issue.

The helicopter manufacturer advised that they were introducing measures to increase awareness of programming dongles in their new helicopters.

What happened

On 28 July 2011, the crew of an Embraer EMB-120 ER Brasilia, registered VH-TWZ, were conducting an instrument approach at Perth, Western Australia in frontal weather conditions that included significant thunderstorm activity. At a time of high workload, the crew's situation awareness was compromised, resulting in the aircraft flight path being above the desired descent profile. An appropriate decision was made to discontinue the approach, but during the go-around the crew did not conform to the published missed approach procedure.

As a result of the incident, the operator advised the ATSB that it had taken the following safety actions:

• simulator retraining was conducted for the flight crew with specific focus on instrument flying skills and go around procedures
• a proficiency assessment was made after the retraining
• random monitoring of crews' ongoing performance from the jump seat during normal line operations was conducted
• incorporated aspects of the incident into recurrent simulator training for all EMB-120 ER crews
• a procedure to define removal from line, retraining and return to line has been developed for inclusion in the next edition of the Training and Checking Manual

This incident highlights the need for flight crews to be fully prepared for the go-around when it is required. As a go-around is not a regular occurrence, its preparation requires a complete knowledge of standard calls, sequence of actions, task sharing and cross-checking.

What happened

On 30 July 2011, a Virgin Australia Airlines, Embraer-Empresa Brasileira de Aeronáutica ERJ 190-100 IGW aircraft, registered VH-ZPA, was being operated on a scheduled passenger service from Sydney, New South Wales to Melbourne, Victoria.

The crew were assigned the LIZZI FIVE VICTOR standard arrival route for a visual approach to runway 34 at Melbourne by air traffic control, with a requirement to cross waypoint SHEED (overhead Essendon Airport) at or above 2,500 ft.

When about 3 NM before SHEED, the First Officer (FO) disconnected the autopilot as he believed he had visually identified SHEED (Essendon Airport) and passed overhead. Immediately after, the aircraft descended through 2,500 ft. The descent was continued with the aircraft actually crossing overhead SHEED at about 1,800 ft. Neither crew identified the error until receiving altitude alerts.

The operator conducted an investigation into the incident and identified that the crew's situation awareness had reduced, resulting in the aircraft being flown 700 ft below the required altitude restriction at SHEED.

This incident emphasises the impact reduced situation awareness can have, and the importance of monitoring not only the aircraft's state, but also the actions of other crew members.

Safety summary

What happened

On 29 July 2011, at 0756 Eastern Standard Time, a loss of separation occurred between a Boeing Company 737-838 aircraft, registered VH-VZC (VZC), and a Boeing Company 737-8FE aircraft, registered VH-VOT (VOT), in the holding pattern at BLAKA, an IFR reporting point south-west of Brisbane, Queensland. The aircraft were inbound to Brisbane on the same air route, with a requirement to hold at BLAKA for sequencing.

The air traffic controller, who had been recently endorsed on the control position, did not identify that the sequence in which the two aircraft entered the holding pattern had changed, and twice assigned VOT descent through the flight level of VZC. The flight crew of VZC identified the confliction and queried the controller, who then took action to recover the compromised separation situation. Separation reduced to 3.9 NM (7.2 km) and 400 ft. The required separation standard was either 5 NM (9.3 km) or 1,000 ft.

What the ATSB found

The Australian Transport Safety Bureau (ATSB) identified that the controller received a reduced amount of on-the-job training, was allocated multiple training officers, and was required to intermittently staff another control position during and immediately following their training on the Gold Coast en route sector. As a result, the controller probably had not consolidated effective control techniques for the sector, particularly for high workload situations.

The ATSB also found that, even though the quality of the controller’s training had been affected by several factors, the controller’s planned on-the-job training period had been reduced from 6 weeks to 4 weeks. More importantly, there was no requirement for a systematic risk assessment to be conducted and documented when the planned amount of training for a controller was reduced.

What has been done to fix it

Airservices Australia advised that it would develop a training variation form to systematically assess risk associated with amendments to the planned length of controller training programs, and completion of the form required the involvement of the controller’s line manager and the Operational Training Manager. Airservices also indicated several other proposed enhancements to its controller training.  

Safety message

In order for the training of operational personnel to be managed safely and effectively, organisations should have a structured risk assessment process in place to evaluate proposed changes to a training program.

What happened

On 28 July 2011, a Jetstar Airways, Airbus A320-232 aircraft, registered VH-VQA, departed Newcastle, New South Wales on a scheduled passenger service to Melbourne, Victoria. The First Officer (FO) was designated as the pilot flying.

While on approach to runway 34 at Melbourne, at about 245 ft (radio altitude), the Captain realised that the landing checklist had not been completed. At the same time, the crew received a 'TOO LOW FLAP' aural and visual warning from the aircraft's enhanced ground proximity warning system (EGPWS). The Captain identified that the aircraft was not in the landing configuration, immediately called for a go-around which the FO initiated. Prior to establishing a positive rate of climb, the crew received a second 'TOO LOW FLAP' warning.

The operator conducted an investigation and determined that the following factors had contributed to the incident: incomplete approach brief, loss of situation awareness, improper coaching techniques and cognitive overload. As a result, the operator intends to:

• provide the Captain and FO with a remedial training and coaching program
• conduct a review of their command upgrade training to ensure it focuses on the development of a positive cockpit authority gradient, and the command of flight capabilities
• incorporate this incident into the command upgrade training course as a case study
• conduct a review of their recurrent human factors training.

Safety summary

What happened

On 28 July 2011, at around 1615 Central Standard Time, a Robinson R44 Raven II helicopter, registered VH-ZWC, departed Darwin Airport on a charter flight to Bamurru Plains, Northern Territory. Approximately 30 minutes into the flight, the aircraft lost main rotor drive and the pilot conducted an autorotative descent and landing. There were no reported injuries.

What the ATSB found

The ATSB’s investigation found that the loss of main rotor drive was associated with corrosion and subsequent fatigue failure of the main rotor gearbox gear carrier, as a result of water present in the main rotor gearbox.

What has been done as a result

The helicopter manufacturer has modified the design of the gear carrier to incorporate a metallic cadmium surface plating to improve the corrosion resistance of the assembly.

In May 2012, the Civil Aviation Safety Authority (CASA) released Airworthiness Bulletin 63-008, to raise awareness among operators and maintenance providers of Robinson R44 helicopters of the hazards associated with gearbox internal corrosion due to water ingress. The bulletin made several recommendations aimed at reducing the associated risks.

Safety message

Operators and maintainers of Robinson R44 helicopters are alerted to the potential for the ingress of water into the main rotor gearbox, and for the subsequent corrosion and possible fatigue cracking of componentry, which could lead to a loss of main rotor drive while in flight. Responsible persons are referred to the recommendations contained within CASA AWB 63-008, which are aimed at limiting the likelihood of water ingress and provide guidance on remedial action should water ingress be suspected.