What happened

On 7 July 2011, a Skywest Airlines operated Fokker B.V. F28 MK 0100 aircraft, registered VH-FNU, departed West Angelas mine site on a charter passenger flight to Perth, Western Australia.

While in the cruise, the copilot reported feeling pain in his lower abdomen. The pain continued to increase during the flight until he was unable to continue his flight duties. Soon after, the copilot became unconscious. After regaining consciousness, he reported feeling ill and nauseous, with continued pain. The senior cabin crew member assisted administering oxygen to the copilot, locking his shoulder harness in place, and moving his seat rearwards. The copilot's pain and nausea persisted for the remainder of the flight. Despite remaining conscious, he did not resume his flight duties.

After landing, the copilot was transported to hospital, being released about 2.5 hours later. The copilot was further examined by a Designated Aviation Medical Examiner, who determined that he had most likely suffered an aggravated acute gastric event.

Flight crew incapacitation may be subtle, or sudden, partial or complete; it may be due to the effects of a pre-existing medical condition, the development of an acute medical condition, or some physiological event. It is important that pilots not only know what incapacitation is and how to avoid it, but how to respond when faced with such an event.

Safety summary

What happened 

At 2102 Eastern Standard Time on 7 June 2011, an Airbus A320 aircraft, registered VH-VNG and operated by Tiger Airways, was on an approach to runway 27 at Melbourne Airport, Victoria. Air traffic control (ATC) had cleared the aircraft to descend to 2,500 ft. Shortly after, ATC identified that the aircraft had descended to 2,000 ft, which was below the limiting altitude for that segment of the approach. ATC notified the flight crew of the deviation. The crew re-established the aircraft at 2,500 ft, then continued the approach and landed. 

What the ATSB found 

The ATSB found that the flight crew had based the descent profile on information displayed on the aircraft’s Multipurpose Control and Display Unit (MCDU). The MCDU drew on information stored in the aircraft’s flight management guidance system (FMGS). The FMGS information included data provided through a third party that had a missing altitude limitation; that limitation was, however, included in the paper charts also used by the crew. The data error was not identified by the crew during their preparation for the approach. 

The ATSB also found there was an increased risk of inadvertent non-compliance with published instrument approach procedures because of the inconsistent application of the operator’s safety management system to the identification and management of database anomalies. In addition, different assumptions by the data suppliers and the operator compromised the quality assurance of the navigational data. 

The action by ATC to alert the flight crew triggered their recovery from the descent below the required flight profile. 

What has been done as a result 

In response to this occurrence, the operator implemented an auditable process for identifying and managing any navigational database anomalies in its aircraft fleet. 

Safety message 

This occurrence reinforces the safety benefits of a resilient safety management system and operator procedures in the management of safety-critical database and other information. The accurate application of those procedures by all key personnel is also important as a safety defence.

Safety summary

What happened

On 9 May 2011, the pilot of a Robinson Helicopter Company R22 Beta II helicopter, registered VH-DSD, was conducting mustering operations 83km north-west of Julia Creek, Queensland. The helicopter was operating in close proximity to the ground when drive to the rotor system was lost resulting in a high rate of descent at the point of impact. The pilot was fatally injured.

What the ATSB found

The ATSB found that the two v-belts that transfer torque from the engine to the rotor system had failed. The damage to the forward v-belt indicated that it had partially dislodged from the drive sheave, resulting in significant damage to the belt. At some point the v-belt fragmented, compromising the redundancy of the belt-drive system. Once the rear v-belt failed, all drive to the rotors was lost.
As a result of the drive failure and operating conditions at the time, the pilot was faced with the need to conduct an autorotative landing from a low altitude and at minimal speed. As a consequence, there was limited time for the pilot to recognise the condition, respond accordingly, and for the autorotation to develop. This situation resulted in a high rate of descent at the point of impact.

What has been done as a result

Although no organisational or systemic issues that might adversely affect the future of aviation operations were identified, the importance of the correct installation and maintenance of the drive system and v-belts in R22 helicopters, and their operation within the stipulated power limits was reaffirmed. ATSB safety advisory notice AO-2011-060-SAN-001, which was issued as part of the preliminary factual report into this occurrence, reinforced the need for continued vigilance by operators and maintenance organisations regarding the routine inspection of the R22 drive system.

Safety message

Pilots and operators should pay particular attention to the installation, maintenance, and inspection of R22 drive belts and other components of the helicopter’s drive system. In the event of an aircraft malfunction, pilot proficiency in emergency situations and particularly autorotations is especially important.

Safety summary

What happened

At 2302 Eastern Standard Time on 30 June 2011, an Airbus A320 aircraft, registered VH-VNC and operated by Tiger Airways Australia Pty Ltd (Tiger Airways) on a regular public transport flight, conducted a go-around procedure after an unsuccessful approach to land on runway 18 at Avalon Airport, Victoria. The flight crew contacted air traffic control (ATC) and were directed to climb to 3,000 ft and, after further discussion, to visually position as required for return and landing on Avalon runway 36. During that re-positioning, the flight crew descended below the assigned altitude without clearance. After a brief discussion with ATC, the flight crew were cleared for a conditional visual approach. In continuing the approach, the aircraft descended to 1,600 ft at a point where the minimum permitted altitude was 2,000 ft. The aircraft subsequently landed on runway 36.

What the ATSB found

The ATSB found that the flight crew, despite recognising the potential that a go-around may be required, did not plan for a return to runway 36 before commencing their first approach. The workload associated with the execution of the go-around prevented them from planning the return to land until levelling at 3,000 ft. The flight crew’s comprehension of the aircraft’s position during the second approach was probably influenced by the workload associated with the approach. Similarly, this high workload may have resulted in their not recognising the ramifications of descending to 1,600 ft.

The ATSB also found that the controller did not provide the flight crew with the required minimum vector altitude as part of the visual approach clearance, which resulted in a missed opportunity for the flight crew to identify the lowest altitude to which the aircraft could be descended. In addition, despite the controller identifying that the aircraft had descended below the minimum permitted altitude and querying the flight crew, a safety alert was not issued. This meant that the aircraft remained at heightened risk for an extended period of time.

Finally, a number of discrepancies in the operational and air traffic services documentation relating to night visual approaches and Avalon airspace were identified.

What's been done as a result

Tiger Airways advised that they have implemented a process to identify and manage the risks associated with any organisational change. This process will apply to any future changes to operational documentation.

Airservices Australia has completed a review of the Manual of Air Traffic Services and incorporated a number of amendments to improve its readability.

Safety message

This incident highlights the importance of preparation by flight crew in order to avoid the adverse effects of high workload. The potential safety benefit of intervention by air traffic controllers is also highlighted.

On 14 January 2010, a Royal New Zealand Air Force (RNZAF) Red Checkers aerobatics team CT-4 Airtrainer aircraft collided with terrain while practicing for an upcoming aerobatics display. The pilot was fatally injured in the accident and the aircraft was destroyed by a post-impact fire.

An Appareo Systems GAU1000 data recorder was fitted to the aircraft to gather performance data as part of a fatigue monitoring programme. Although the recorder was severely fire damaged, it was recovered from the aircraft wreckage by RNZAF investigators, who subsequently requested assistance from the Australian Transport Safety Bureau (ATSB) in the recovery of any stored data on the recorder that may have survived the accident and fire.

Following preparatory research into the nature of the recorder's design and operation and the subsequent non-destructive examination to evaluate the physical condition of the damaged unit, a number of attempts were made to recover data from the removable secure digital/multimedia memory card (SD/MMC) - all of which were unsuccessful. Further examination of the recorder, however, located an on-board NAND flash memory device, which subsequently yielded a large quantity of valid recorded data after its removal from the primary circuitry and interrogation in a universal reader/programmer unit. The data was provided to the RNZAF on 12 August 2010.

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

What happened

During preflight performance calculations, the crew of an Airbus A321 inadvertently referenced the performance chart for a longer runway length. That produced inappropriately high take-off reference speeds that would have adversely affected the operation of the aircraft in the case of an engine failure.

Jetstar Airways advised that they had reminded pilots to independently calculate take-off data and prohibited the use of bookmarking the performance manual. They also commenced an internal investigation.

The application of correct operating data is a foundational and critical element of flight safety, but errors in the calculation, entry and checking of data are not uncommon. The ATSB has published a research report that addresses this issue.

Safety summary

What happened

At about 1246 on 11 June 2011, the harbour tug Adonis, with four persons on board, capsized during an operation with a second tug, Wolli, to relocate a barge in the port of Gladstone, Queensland. Three of the persons on board escaped the capsizing tug but the fourth did not and drowned in the tug’s wheelhouse.

What the ATSB found

The ATSB found that while the masters of the two tugs involved with the tow were aware of the risks of tugs capsizing, neither of them realised that Adonis had entered a classic capsize scenario when it moved abaft of the barge’s port bow before the barge had begun to slow down. The barge’s speed was not reduced in time to allow Adonis’s master to regain control of the tug and manoeuvre it back into a safe position ahead of the barge. The tug’s crew were not able to release the towline using the towing hook’s quick release arrangement before the tug capsized.

Investigation of the accident found that the retrospective fitting of a set of ‘H’ bitts to the tug, aft of the towing hook, had a detrimental effect on the tug’s manoeuvrability. The fitting of the ‘H’ bitts, and a towing winch, also resulted in Adonis being unstable when undertaking towing operations over the stern. This fact was not identified by the tug’s owners because the tug’s stability had not been recalculated following the fitment of the additional equipment.

What has been done as a result

Sea Swift, the owners of Adonis, have produced new procedures covering the quick release arrangements on its tugs and enhanced the training and familiarisation of its crews with these arrangements. The company has also carried out a review of all its tugs’ towing and quick release arrangements and introduced regular testing of this equipment.

In addition, a program for the review of all stability data for its tugs which were purchased overseas has been instigated, and an experienced training manager has been employed to review and monitor the company's health and safety policies and practices. A review of Sea Swift’s training assessment for new masters or potential masters for the towing fleet has extended the period of training to include mentoring runs and supernumerary runs with other masters to facilitate the development of a greater understanding of towage requirements.

Safety message

The masters of tugs, regardless of size, need be actively aware of the signs that a tug might be in danger of capsizing and what to do to lessen this danger. For multiple tug operations, the masters of the tugs should plan the passage and consider the speed of passage and when it is time to release the towline. It is also important that the masters regularly communicate during the passage and that any concern regarding speed is immediately brought to the other master’s attention.

What happened

At 0720 Western Standard Time on 15 June 2011, a Piper Aircraft PA-46-310P Malibu, registered VH-FAL, departed from Doolgunna Station, on a private flight to Meekatharra WA, with the pilot and one passenger on board.

While on finals to land at Meekatharra, the pilot initiated a go-around due to another aircraft occupying the runway.

On the downwind leg of the second approach, the engine lost power and the aircraft impacted terrain about 500 m short of the runway threshold. Both occupants sustained injuries.

The pilot stated that his usual actions were to set the aircraft fuel selector to the fullest fuel tank for take-off, then manage the fuel balance by appropriate tank selection during the flight. He stated that as this process was routine for him, he could not actually recall having made a change to the tank selection during the flight

To ensure the safe conduct of a flight, it is crucial that pilots establish a disciplined cockpit routine that covers all critical aspects of in-flight management.

On 14 April 2011, a Christen Eagle aircraft collided with terrain about 60 km north-east of Bangkok, Thailand. Both persons on board, one of whom was Australian and held a Recreational Aviation Australia pilot certificate, were fatally injured.

As the accident took place in Thailand, the Aircraft Accident Investigation Committee (AAIC) of Thailand is responsible for its investigation. As part of its investigation, the AAIC requested assistance from the Australian Transport Safety Bureau (ATSB) to gather details of the Australian pilot's qualifications and experience. In accordance with clause 5.23 of Annex 13 to the Convention on International Civil Aviation (Annex 13), the ATSB appointed an accredited representative to assist the AAIC and initiated an investigation under the Australian Transport Safety Investigation Act 2003. The ATSB provided details of the pilot's qualifications and experience to the AAIC.

In accordance with Annex 13, the AAIC of Thailand is responsible for releasing the final investigation report on this occurrence.

Contact details for the AAIC are:

Acting Chief, Aircraft Accident Investigation Group
(Member & Secretary, the Aircraft Accident Investigation Committee of Thailand)
Flight Standards Bureau
Department of Civil Aviation
71, Soi Ngarmduplee, Rama IV Road
Sathorn, Bangkok, 10120, Thailand
Tel: +66 2286 2933, Fax: +66 2286 2925

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

Qantas Airways Boeing 747-300 (B747) VH-EBT aircraft was towed across the path of Cathay Pacific Airways Boeing 747-300 (B747) VR-HIJ which had commenced take-off on runway 34 on a scheduled flight to Hong Kong.

The incident occurred at Sydney (Kingsford Smith) Airport on Tuesday 11 September 1990 at 1350 hours Eastern Standard Time.