Abstract

On the evening of 27 July 2011, the owner-pilot of a Robinson Helicopter Co. R22 helicopter, registered VH-YOL, was conducting a local flight from Big Rock Dam to Brooking Springs homestead near Fitzroy Crossing, Western Australia. The pilot was reported missing, and the wreckage of the helicopter was located the following day, 14 km north-west of Fitzroy Crossing township. The helicopter was seriously damaged, and the pilot sustained fatal injuries.

The pilot was attempting to fly visually at low level on a dark night in an area that did not contain any local ground lighting. About halfway into the flight, the pilot inadvertently allowed the helicopter to develop a high rate of descent, resulting in a collision with terrain.

The investigation found that the pilot was operating at night without the appropriate training or qualification in a helicopter that was not suitably equipped. An examination of the helicopter found no evidence of any pre-existent defects or anomalies.

No organisational or systemic issues were identified that might adversely affect the future safety of aviation operations. However, the accident highlighted the significant risk to non‑night-qualified pilots of spatial disorientation and subsequent collision with terrain when attempting visual operations at night.

Safety summary

What happened

At 2019 Eastern Standard Time on 24 July 2011, a Thai Airways International Boeing Company 777-3D7 aircraft, registered HS-TKD, was conducting a runway 34 VOR approach to Melbourne Airport, Victoria. During the approach, the tower controller observed that the aircraft was lower than required and asked the flight crew to check their altitude. The tower controller subsequently instructed the crew to conduct a go-around. However, while the crew did arrest the aircraft’s descent, there was a delay of about 50 seconds before they initiated the go-around and commenced a climb to the required altitude.

What the ATSB found

The ATSB established that the pilot in command may not have fully understood some aspects of the aircraft’s automated flight control systems and probably experienced ‘automation surprise’ when the aircraft pitched up to capture the VOR approach path. As a result, the remainder of the approach was conducted using the autopilot’s flight level change mode. In that mode the aircraft’s rate of descent is unrestricted and therefore may be significantly higher than that required for an instrument approach. In addition, the flight crew inadvertently selected a lower than stipulated descent altitude, resulting in descent below the specified segment minimum safe altitude for that stage of the approach and the approach not being managed in accordance with the prescribed procedure.

What has been done as a result

In response to this occurrence, Thai Airways International issued a notice to flight crews that emphasized the importance of constant angle non-precision approaches and adherence to the segment minimum safe altitudes. Other actions included a review of the training in support of non-precision approaches and the provision of additional information relating to the use of the aircraft’s autopilot flight director system.

Safety message

This occurrence highlights the risks inherent in the conduct of non-precision approaches and reinforces the need for flight crews to closely monitor the aircraft’s flight path to ensure it complies with the prescribed procedure.

Modern air transport aircraft are equipped with ever increasing levels of automation that, when used appropriately, can greatly reduce flight crew workload. While flight crews retain the option of flying the aircraft manually, the use of automation is generally preferred and often provides increased levels of safety and efficiency. To effectively manage the aircraft and flight path, however, flight crews need to maintain a thorough understanding of the relevant automatic flight systems. Worldwide, errors associated with the use and management of automatic flight systems have been identified as causal factors in more than 20% of approach and landing accidents.

What happened

On 19 July 2011, a Virgin Australia operated Boeing Company 737-81D aircraft, registered VH-YFE, departed Brisbane on a scheduled passenger service to Mackay, Queensland. The First Officer (FO) was designated as the pilot flying for the flight.

While conducting a high-speed descent into Mackay, the aircraft became low on profile and descended below the 8,500 ft lower limit of the control area (CTA) step. The aircraft departed Class C and entered Class G airspace for 2.9 NM and 32 seconds, before re-entering Class C. A clearance to depart, or re-enter Class C airspace was not obtained from ATC.

The Captain realised that they were low on profile and advised the FO, who reduced the aircraft's rate of descent. The flight continued without further incident. No other aircraft were affected during the event.

The operator conducted an investigation and determined that the crew's situation awareness of the aircraft's descent profile and proximity to the CTA steps had reduced.

This incident highlights the effect reduced situation awareness can have on aircraft operations and the importance of using all available resources, including instruments and charts, to assist with monitoring the descent profile.

Safety summary

What happened

At 0900 Eastern Standard Time on 22 July 2011, a Bell 206L helicopter, registered VH-CIV, with a pilot and one passenger, departed from Rosehill, New South Wales on a private flight to the Sydney Adventist Hospital near South Turramurra. As the aircraft neared the destination, the pilot encountered low cloud and rain in the area. Shortly thereafter, witnesses observed the helicopter descending rapidly, with the tail section separated. The helicopter subsequently collided with terrain, fatally injuring both occupants.

What the ATSB found

The ATSB found it was likely that during manoeuvring in the area of low cloud and rain, the pilot inadvertently flew into reduced visibility conditions, leading to the onset of disorientation and a loss of control of the helicopter.

What has been done as a result

There were no systemic safety issues identified as a result of the ATSB investigation and no specific safety actions taken. An ATSB research report released in July 2011 addressing avoidable accidents is relevant to the circumstances found during the investigation of this accident.

Safety message

The hazards associated with visual flight into conditions of limited visibility are significant. The ATSB has investigated a number of accidents associated with visual flight rules (VFR) flight into instrument meteorological conditions (IMC), and has published several research reports into the factors that can contribute to this type of accident. The Civil Aviation Safety Authority (CASA) also maintains a library of advisory materials aimed at assisting pilots in decision-making before and during visual flights in conditions where continued visibility cannot be assured.

Pilots and operators are encouraged to familiarise themselves with guidance material on safe visual flight operations, and use this to develop appropriate strategies for planning and in-flight decision making if reduced visibility conditions are encountered.

Although no definitive conclusion could be made with respect to the extent to which any external pressures may have affected the pilot’s decision making, the accident does serve as a reminder to pilots of the need to manage pressures and external factors in the planning and conduct of any flight.

What happened

On 21 July 2011, at 1630 Central Standard Time, the crew of a Super Puma helicopter, registered VH-LAG (LAG), was taxiing in the vicinity of two parked aircraft on the apron at Port Keats Airport, Northern Territory when the main rotor blades contacted a light pole. As the main rotor disintegrated, the helicopter was propelled towards the pole and rolled onto its left side. The aircraft was seriously damaged including significant disruption to the cockpit area.

The two crew members and three of the four passengers sustained minor injuries. Three bystanders also sustained minor injuries and one of the parked aircraft and four parked vehicles were damaged by flying debris.  

As a result of this accident, the helicopter operator conducted an internal investigation that produced a number of recommendations addressing operations to remote airfields, obstacle separation standards and emergency management. 

On 24 June 2011, a Super Petrel amphibious aircraft, registered 24-7654, was being operated on a private flight with the pilot and one passenger on-board. While operating over Lake Jindabyne, New South Wales (NSW), witnesses observed the aircraft to depart from controlled flight and impact the lake surface. The aircraft was destroyed by the forces of the collision and the two occupants were fatally injured.

The NSW Police Service are investigating this occurrence. Following recovery of the aircraft wreckage, officers requested assistance from the Australian Transport Safety Bureau (ATSB) in the recovery of data from the aircraft's electronic flight instrumentation systems (EFIS). To protect the information supplied by the NSW Police Service to the ATSB and investigative work undertaken to assist the police service, the ATSB initiated an investigation under the Transport Safety Investigation Act 2003.

The EFIS was sent to the ATSB's technical facilities in Canberra for examination. The examination established the existence of relevant data on the EFIS and a download procedure was developed and tested successfully.

On 24 November 2011, a technical specialist from the ATSB attended the Cooma Police Station and provided assistance and guidance to the police in their download of the EFIS equipment. The data was successfully recovered and was retained by the police service.

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

The ATSB has completed its examination and analysis of the damaged tailrotor blade from the helicopter that went missing near Manus Island, Papua New Guinea on 13 February 2011.

On 13 February 2011, a Eurocopter AS350 helicopter, registered P2-PHL, was reported missing during operations over the Bismarck Sea, near Manus Island, Papua New Guinea. The pilot, who was the sole occupant of the helicopter, is also missing. A small amount of wreckage from the helicopter, including the damaged tailrotor blade, was recovered from the sea during search operations.

The Accident Investigation Commission (AIC) of Papua New Guinea is responsible for investigating this occurrence. As part of its investigation, the AIC requested assistance from the Australian Transport Safety Bureau (ATSB) in the examination and analysis of the damaged tailrotor blade. 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 AIC and initiated an investigation under the Australian Transport Safety Investigation Act 2003. The ATSB provided a technical report to the AIC on the results of its examination of the tailrotor blade.

The AIC of Papua New Guinea is responsible for releasing the final investigation report on this occurrence.

Contact details for the PNG AIC are:

Mr David Inau
Chief Executive Officer
Papua New Guinea Accident Investigation Commission
Telephone: +675 311 2406 

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

Abstract

At about 1545, on Wednesday 13 July 2011, freight train 3SP7 collided with a road-rail vehicle in the Kaleentha to Menindee section of track, located in western New South Wales (NSW). The road-rail vehicle, a Toyota Landcruiser station wagon, was extensively damaged. The lead locomotive of train 3SP7, NR4 incurred only minor damage and after effecting repairs at the incident site the train continued through to Port Augusta en route to Perth. There were no injuries and no damage to fixed infrastructure.

What happened

On 12 July 2011, a Robinson Helicopter R22 BETA II, registered VH-HSW, departed the rural property "Tinnenburra", about 90km SW of Cunnamulla, Queensland, for a local cattle mustering flight.

The take-off was delayed due to another operational matter and the pilot reported feeling distracted and under time pressure to commence the flight.

Shortly after commencing mustering, the pilot initiated a descent to move the cattle away from a fence line. Following the descent, and while focusing on the cattle, the pilot noticed a powerline near the helicopter skid but was unable to avoid the wire. After colliding with the powerline, the pilot could not maintain control of the helicopter and it impacted the terrain.

The pilot sustained serious injuries, and the helicopter was seriously damaged.

The aircraft operator has previously looked into a wire alerting system using the onboard GPS. They are continuing to examine ways in which this technology could be incorporated into their operation.

At 0706hrs a protection officer obtained a track occupancy authority from the network controller at Junee to carry out work on the track between the 271.000 km - 271.900 km near Fish River, NSW within the Yass to Joppa Junction track section. The protection officer had also identified that train 8938 had passed his worksite. At 0710hrs the network controller realised that another train (8138) was within the track section and contacted the driver of train 8138 to stop. The train stopped about 11km from the worksite. There were no injuries. The ATSB has commenced an investigation into the incident.

Section 21 (2) of the Transport Safety Investigation Act 2003 (TSI Act) empowers the Australian Transport Safety Bureau (ATSB) to discontinue an investigation into a transport safety matter at any time. Section 21 (3) of the TSI Act requires the ATSB to publish a statement setting out the reasons for discontinuing an investigation.

On 10 July 2011, the ATSB commenced an investigation into a safeworking irregularity incident that occurred at about 0706 Eastern Standard Time on 10 July 2011 near Fish River, New South Wales.  Examination of the information collected during the investigation identified that the occurrence had significant similarities to aspects of other occurrences being investigated by the ATSB as part of the safety issue investigation of rail operations on the interstate rail line between Sydney and Melbourne (RI-2011-015).  

Accordingly the ATSB decided to examine the Fish River occurrence as part of the broader safety issue investigation and the separate RO-2011-010 investigation was discontinued.