On 27 August 2012, at about 1330 Eastern Standard Time a Piper PA-28 aircraft, registered VH-BZE, departed Moorabbin Airport on a private flight to Colac, Victoria. The pilot was the only person on board. The pilot decided to return to Moorabbin due to the severity of the turbulence being experienced.  

While turning onto final for runway 35L at Moorabbin, VH-BZE drifted through the runway centreline. The pilot was having difficulty controlling the aircraft and requested a late change in runway to 35R. At the same time, a Cessna 172 aircraft, registered VH-EPB with an instructor and student on board, was established on finals for runway 35R. The two aircraft came within close proximity of each other.

This investigation is a reminder that personal minimums, when set, provide a safety buffer between the skills required for a flight and the skills available through training, experience, currency, and proficiency.

Aviation Short Investigation Bulletin – Issue 14

On 21 August 2012, at about 1430 Eastern Standard Time, an Aero Commander 500S registered VH-YJS (YJS) departed Charleville Airport, Queensland for Brisbane Airport via, Roma, Dalby and Toowoomba on a freight only charter flight under the IFR. The pilot was the only person on board.

During the landing roll the landing gear was inadvertently retracted and the lower fuselage contacted the runway.  The pilot exited the aircraft without injury however the lower fuselage of the aircraft was damaged. 

A manual safe pin was incorporated as a design feature to prevent inadvertent retraction of the landing gear. However operation of the gear lever and safe pin together had become an automatic response by the pilot and the effectiveness of the safe pin as a countermeasure reduced. Pilots are reminded to positively identify any control lever before actioning. 

Aviation Short Investigation Bulletin – Issue 14

On 22 August 2012, a Skippers Aviation Fairchild SA227-DC aircraft, registered VH-WBQ, was being operated on a charter passenger flight from Perth to Granny Smith aerodrome, Western Australia.

The aircraft arrived at the aerodrome and joined the circuit. When on downwind, the landing gear was extended, with the crew confirming that the three green down-locked lights were illuminated. The crew again confirmed, on a number of occasions, that the landing gear was extended.

During the landing flare, the left wing suddenly dropped. The first officer immediately applied right aileron in an attempt to counteract the wing drop and the aircraft touched down. After shutdown, the crew inspected the aircraft and determined that the left propeller had contacted the ground.

The aircraft operator examined the aircraft and believed that there was uncommanded retraction of the left landing gear on, or just after touchdown. The reason for the uncommanded retraction could not be determined.

Aviation Short Investigation Bulletin – Issue 14

On 23 August 2012 at 1733 Central Standard Time, a Cessna 210N, registered VH-WPD, departed Numbulwar for Urapunga, Northern Territory, on a charter passenger flight with the pilot and two passengers on-board. The pilot reported intermittent sun glare during descent to Urapunga, when at 3 NM for runway 28. On late final the sun glare on the windscreen greatly restricting visibility. During the flare, the pilot identified a runway edge marker in line with the nose of the aircraft. The pilot manoeuvered the aircraft back in line with the centre of the runway and the aircraft continued to float down above the runway.

The sun glare increasingly restricted visibility during the landing. The aircraft touched down and the pilot applied heavy braking in short bursts. The aircraft departed the end of the runway and travelled through two fences before coming to a stop. The pilot and two passengers evacuated the aircraft. The pilot received minor injuries and the two passengers were uninjured.

The operator has indicated that during pilot training greater emphasis will be placed on go-around procedures and identify situations when it would be used; particularly during training increase awareness to consider the planning of circuit entry and ensure a backup is considered if conditions are not what was expected; and go-around procedures are practiced during in command under supervision (ICUS) training.

The accident highlights the importance of the identification of approach and landing hazards, decision making when a hazard becomes evident, recognition of a destabilised approach and being go-around prepared and go-around minded.

Aviation Short Investigation Bulletin - Issue 16

Safety summary

What happened

On 21 August 2012, Genesee and Wyoming Australia (GWA) freight train 2AD1 was en route from Adelaide, South Australia, to Katherine, Northern Territory, when the train crew exceeded the limit of their train authority at Tarcoola, South Australia.

The train authority authorised the crew to travel to Northgate, which is located on the railway line branching to the north from Tarcoola. However, the crew did not take the line to Northgate and the train continued through Tarcoola, travelling west for about 2.6 km toward Perth before stopping.

What the ATSB found

The ATSB investigation found that the driver of train 2AD1 was a trainee who was unfamiliar with the route and had not completed the minimum competencies required by GWA to enable him to operate the train. The qualified supervising driver had allowed the trainee to take control of the train and had subsequently fallen asleep.

Following the occurrence, the supervising driver returned a positive test for amphetamine and methamphetamine, which he had consumed while off-duty. These drugs probably contributed to him falling asleep during the shift.

The ATSB found that the supervising driver’s performance was being managed in accordance with GWA’s drug and alcohol management program as a result of a previous positive drug test and that the company’s drug and alcohol policy/processes were effective in managing drugs and alcohol in the workplace.

The ATSB further found that the company’s safety management system procedures did not provide supervising and trainee drivers with sufficient guidance and direction in relation to their supervisory and permitted driving roles.

The report also notes that the actions of a crew member travelling in the crew van in alerting the locomotive crew and operating the emergency brake handle significantly reduced the distance that train 2AD1 travelled before it stopped.

What's been done as a result

GWA has introduced a ‘Category Card’ to enhance the classification system for trainee locomotive drivers. The card specifies any operational restrictions placed on trainees and instructs the supervisor/mentor driver of the level of oversight that must be exercised for each classification level. GWA has notified all drivers of changes to the classification system and has taken steps to clarify the responsibilities of drivers supervising a trainee.

While GWA had a robust alcohol and drug-testing program in place, the organisation has taken further action by introducing screening en route and at off-train resting locations and increasing the frequency of random screening at existing locations.

Safety message

This incident emphasises the need for rail transport operators to implement robust procedures that systematically manage the supervision, training and assessment of trainee drivers. It also highlights the risks associated with the use of amphetamines or methamphetamines and the impact that recreational drug use can have on safe rail operations.

The ATSB was advised of two aircraft proximity events at Ballarat Airport, Victoria on 4 August 2012, which occurred within a short period of time. Both incidents were witnessed by an observer on the ground.

The first incident involved VH-VSD and VH-VTA, who were observed passing in close proximity overhead the airport, on reciprocal headings.

About 20 minutes later, a second incident occurred overhead, when VH-PKH was observed to pass below VH-VTJ. Airservices Australia surveillance data indicated that the distance between the aircraft reduced to 0.1 NM laterally and 100 ft vertically.

These incidents highlight the importance of pilots effectively broadcasting and actively listen to the radio, and maintaining a vigilant lookout at all times, to enhance traffic and situation awareness. This is particularly important when operating in a high traffic density environment.

Aviation Short Investigation Bulletin – Issue 14

What happened

On 16 July 2012 at about 0830 New Zealand Standard Time, an Airbus A320-232 aircraft, registered VH-VQA and operated by Jetstar Airways, was conducting an Area Navigation (Required Navigation Performance) approach to runway 05 at Queenstown, New Zealand. During the approach the aircraft descended below two segment minimum safe altitudes. Upon recognising the descent profile error, the crew climbed the aircraft to intercept the correct profile and continued the approach to land.

What the ATSB found

The ATSB found that, contrary to their intentions, the crew continued descent with the auto-flight system in open descent mode, which did not provide protection against infringing the instrument approach procedure’s segment minimum safe altitudes. The ATSB also found that the crew were not strictly adhering to the operator’s sterile flight deck procedures, which probably allowed the crew to become distracted.

The ATSB found that the operator’s procedures did not specifically draw the crew’s attention to unchanged auto-flight system modes during descent or prompt crew reconsideration of the most suitable descent mode at any point during descent. Additionally, the operator’s procedures allowed the crew to select the altitude to which they were cleared by air traffic control on the Flight Control Unit altitude selector, irrespective of intervening altitude constraints. This combination of procedures provided limited protection against descent through segment minimum safe altitudes.

What's been done as a result

Following this occurrence, the operator included additional guidance material in its Flight Crew Training Manual regarding mode awareness. It also included a warning on its Queenstown approach charts to state that managed descent was required beyond the initial approach fix.

Safety message

The ATSB reminds operators and flight crew of the importance of continuous attention to active and armed auto-flight system modes. Equally, the ATSB stresses the importance of continually monitoring descent profiles and an aircraft’s proximity to segment minimum safe altitudes, irrespective of any expectation that descent is being appropriately managed by the auto-flight system. For flight crew, this occurrence illustrates once again the fallibility of prospective memory and the potentially serious effects of pilot distraction. For operators, it highlights the importance to safe operations of robust management procedures for auto-flight systems.

On 19 August 2012 at about 1520 Eastern Standard Time, a Kawasaki Heavy Industries 369HS helicopter, registered VH-JWJ, was approaching a landing site at Konwack, Victoria. As the helicopter approached the intended landing site the ‘engine out’ caution light illuminated, accompanied by the low rotor revolutions per minute (RPM) horn and a loss of power.

The pilot immediately lowered the collective to enter autorotation, but then increased the position of the collective lever to clear a line of trees directly in his path. Clearing the trees, the pilot was able to maintain speed by keeping the nose of the helicopter down while descending. The right skid contacted the ground and was torn off, taking the tail boom with it. The aircraft skidded for about 80 m before coming to rest. The pilot was uninjured while the passenger sustained a minor head wound.

The cause of the reported power loss could not be determined. The accident highlights the value of restraints and helicopter safety helmets for both pilots and passengers.

Aviation Short Investigation Bulletin – Issue 14

On 5 August 2012, the pilot and flight nurse of a Raytheon B200 aircraft, registered VH-MSH, were tasked with transporting a patient from Port Macquarie to Sydney, New South Wales.

After departing Sydney, the pilot reported that he began to feel unwell, experiencing abdominal pain and nausea. When about 10 NM to the south-west of Williamtown Airport, his conditioned worsened. After donning his crew oxygen mask, the pilot’s health improved and a return to Sydney was commenced. During the descent, the pilot removed his oxygen mask and, soon after, he began to feel unwell again

The aircraft landed at Sydney and after shutdown the pilot became physically ill. The pilot recovered from the illness about 1 week later. It was determined that he most likely suffered viral gastroenteritis.

While pilots conduct a pre-flight inspection of their aircraft to determine airworthiness, this incident highlights the importance of pilots also assessing their own wellbeing. Tools such as the ‘I’m safe checklist’ allows pilots to determine if they are physically and mentally prepared for a flight.

Aviation Short Investigation Bulletin - Issue 13

On 9 August 2012 at 1235 Eastern Standard Time, a breakdown of separation occurred between a Raytheon Beech 200, registered VH-FDD (FDD) operating under the callsign FLYDOC 423, and a Raytheon Beech 350, operating under the callsign DINGO 008, near Cooktown, Queensland. An air traffic controller had issued clearance for FDD, tracking north, to climb to flight level (FL) 300. During the climb, the air traffic control system’s Short Term Conflict Alert (STCA) activated, when the aircraft were 10.1 NM horizontally and 200 ft vertically apart. The STCA alerted the controller to a pending breakdown of separation with the southbound aircraft, DINGO 008, maintaining FL270. The controller issued both flight crews with safety alerts and instructions that limited the severity of the separation breakdown. The aircraft passed 4.8 NM horizontally and 100 ft vertically of each other.

The controller had not identified the conflict before the STCA activation, but their knowledge and application of effective compromised separation recovery techniques was integral to resolving the issue, following their recognition of the situation.

This incident highlights the importance for controllers to effectively balance their professional desire to promptly facilitate pilot requests with the overriding requirement to provide a safe and efficient air traffic control service.

The prompt and effective controller reaction to re-establish the appropriate separation standard highlights the benefit of and importance of regular compromised separation recovery training as an integral defence.

Aviation Short Investigation Bulletin - Issue 13