On 29 June 2012, at about 1757 Eastern Standard Time, a Piper PA-31 Navajo aircraft, registered VH-LWW (LWW), took off from runway 05 at Mackay Airport on a charter flight to Emerald, Queensland.

At that time, an Airport Safety Officer (ASO) was conducting an airfield runway and lighting inspection in an airfield safety vehicle and moving in a north-westerly direction along runway 32. Despite an earlier air traffic control instruction to hold short of runway 05, the ASO was distracted by a telephone call and continued along runway 32, crossing runway 05. LWW passed over the airfield safety vehicle by an estimated vertical distance of 30 ft.

This incident highlights the importance of remaining vigilant during airside operations, and to be mindful of the potential distraction presented by portable communication devices.

Aviation Short Investigation Bulletin - Issue 13

On 21 June 2012, a breakdown of separation occurred between a Qantas Airways Boeing Company B737-438, registered VH-TJS (TJS) and a Sharp Aviation Fairchild SA227, registered VH-MYI (MYI) near Melbourne Airport, Victoria. After being radar vectored from the north-east and given an assigned heading of 230˚, TJS was cleared to conduct an instrument approach to runway 27 at Melbourne Airport. However, instead of intercepting the runway 27 localizer, TJS maintained the assigned heading and passed through the localizer by about 1 NM. As a result the separation between TJS and MYI reduced to less than the required standard of 3 NM.

Although the reason for the clearance deviation could not be positively identified, it was likely that a higher than usual workload resulted in the flight crew not arming the appropriate approach mode or observing the aircraft’s closure relative to the runway 27 localizer. The occurrence highlights the need for flight crews to closely monitor the aircraft flight path and be ready to take prompt action in the event of any deviation from the cleared route.

Aviation Short Investigation Bulletin - Issue 13

At 0557 Western Standard Time, an airport safety vehicle, Safety 2, entered runway 21 without a clearance during the operation of low visibility procedures. Prior to entering the runway, an air traffic controller used non-standard phraseology to instruct Safety 2 to conduct a runway visibility check.

In response to this incident, the Perth Airport Pty Ltd, the operator of Safety 2, has conducted a workshop for airport operations officers (AOOs) to reinforce the importance of seeking clarification of implied or unclear instructions from air traffic control (ATC). Training and procedures for AOOs are also being updated.

As a result of this incident, Airservices Australia will issue a Standardisation Directive to remind controllers of the importance of using standard phraseology for interaction with ground vehicles. In addition, they will review the industry communications document Airside Driver’s Guide to Runway Safety – Safe surface operations at controlled aerodromes to ensure that the document continues to be accurate and relevant for the promotion of runway safety performance.

This incident is a reminder that radio communications phraseology should be clear, concise and unambiguous. It is also a reminder to drivers of airport vehicle to seek clarification of ATC instructions, should there be any doubt as to the content or intent of the instruction.

Aviation Short Investigation Bulletin - Issue 13

On 21 June 2012, after a review of the initial Airservices Australia report of the occurrence, the Australian Transport Safety Bureau (ATSB) initiated an investigation into a breakdown of separation (BOS) between two aircraft near Melbourne Airport, Victoria on 20 June 2012.

A preliminary examination of the occurrence showed that the BOS involved an Airbus A320 aircraft (A320) that was inbound to Melbourne Airport from the north and a Bombardier Inc BD-700 aircraft (Bombardier) that had departed from runway 34 at Melbourne and was tracking to the north-west. The ATSB also reviewed information from the involved Melbourne Approach Departures controller, the relevant air traffic control automatic voice recordings, weather information from the Bureau of Meteorology and the respective aircrafts flight tracks on Webtrack recordings (see Airservices WebTrak). 

The preliminary investigation determined that the controller had planned for a lesser rate of closure between the two aircraft than eventuated, with the actual rate of closure being affected by the ambient conditions and a slower acceleration by the Bombardier than anticipated by the controller. No avoiding action was necessary by either crew. The controller became aware of the infringement of the 3NM (5.6km) separation standard when advised by the crew of the A320 that they had received a Traffic Alert and Collision Avoidance System traffic advisory on passing behind the Bombardier. Shortly after, the lateral and vertical distance between the two aircraft increased and a separation standard was re-established.

The preliminary investigation showed that the potential for any systemic issues to have contributed to the occurrence was low and that it was unlikely that any safety issues would be identified through further investigation. On that basis, the ATSB decided to discontinue its investigation, as provided for in Section 21 (2) of the Transport Safety Investigation Act 2003.

On 19 June 2012, at about 0815 Eastern Standard Time, a Cessna Aircraft Company 182P aircraft, registered VH-WTS, departed Mayvale Station, about 53 km east-north-east from Cunnamulla, Queensland. Shortly after becoming airborne, the pilot recalled the aircraft losing airspeed and then clipping a tree during the subsequent forced landing. The aircraft collided with the ground and came to rest inverted.

The pilot, the only occupant, was seriously injured and the aircraft was destroyed. The pilot was wearing a seat belt at the time, but had not used the shoulder harness. The pilot and aircraft were located about 3 hours after the accident following a search. The aircraft’s Emergency Locator Transmitter (ELT) had not activated and the pilot’s personal ELT was inaccessible.

The day before the accident flight, the pilot refuelled the aircraft from drum stock kept as an emergency fuel supply. The pilot did not test the drum fuel for water or contamination. Following the accident, a considerable amount of water was found in a number of fuel samples taken from the aircraft, and in a sample taken from the drum.

This accident highlights a number of safety messages, including that:

• pre-flight checks, including checking samples from all fuel drain points, are a vital barrier in reducing the likelihood of power loss after takeoff;
• aviation fuel stored in drums should be checked before use for water and other contaminants;
• aircraft occupants should fasten available restraints, both seat belt and shoulder harness, where provided, for takeoff and landing;
• pilots are encouraged to leave a flight note with a responsible person as discussed in the Aeronautical Information Publication (AIP); and
• survival equipment should be carried on the person so that it is readily available when most needed.

Aviation Short Investigation Bulletin - Issue 12

On 19 June 2012 at about 1645 Central Standard Time, a Eurocopter AS-350BA helicopter, registered VH-HEB (HEB), was en-route from Ceduna to Border Village, South Australia when abnormal fumes were detected in the cockpit. The pilot conducted an emergency landing. Once on the ground, the passenger exited the aircraft and noticed smoke and fire emanating from the aft cargo compartment. The pilot and passenger left the vicinity of the helicopter, which was subsequently destroyed as a result of the fire. This accident highlights the importance of having appropriate practices and procedures in place for the transport of dangerous goods and conducting remote area operations.

Aviation Short Investigation Bulletin – Issue 14

On 18 June 2012, an instructor and student were conducting practice autorotation training to the threshold of runway 25 at Redcliffe aerodrome.  The student initiated a practice autorotation at about 250 ft above ground level and 55 kts.  During the flare, the tail rotor of the helicopter struck the ground and control was lost.  The helicopter impacted terrain and sustained serious damage.  Both the instructor and student reported some minor injuries. 

As a result of this occurrence, the operator has advised that they are investigating a change to the company operations manual, to requiring at least 10 kts of wind in the runway direction for the performance of low-level practice autorotations.

Aviation Short Investigation Bulletin - Issue 12

Safety summary

What happened

At 2156 on 26 May 2012, the bulk carrier Furness Melbourne and the yacht Riga II collided about 15 miles north of Bowen, Queensland.

Riga II was dismasted and its hull was damaged but no-one was seriously injured and the yacht was towed into Bowen by a volunteer marine rescue vessel.

Furness Melbourne was not damaged and, after rendering assistance to the yacht, continued its voyage.

What the ATSB found

The investigation found that a proper lookout was not being kept on board either vessel in the time leading up to the collision.

Furness Melbourne’s lookout had sighted Riga II’s starboard sidelight prior to collision but the officer of the watch made a series of assumptions based on limited information and concluded that the light was from a distant navigation buoy rather than another vessel that presented a risk of collision.

Riga II’s watchkeeper did not visually identify Furness Melbourne’s navigation lights in time to make an effective appraisal of the situation, did not set the yacht’s automatic identification system (AIS) unit on a range scale that would provide adequate warning of approaching vessels and when alerted by the AIS of the approaching ship, misinterpreted that information.

What's been done as a result

In the past 25 years, 60 collisions involving ships and small vessels have been reported to the ATSB and its predecessor, the Marine Incident Investigation Unit. Of these, 39 have been investigated.

The findings from these investigations have invariably included the failure of the watchkeepers on board one or both vessels to keep a proper lookout and the absence of early and appropriate action to avoid a collision.

The safety lessons from these investigations have been included in the published investigation reports. A number of safety bulletins that aim to highlight the risks and educate seafarers with regard to the similar contributing factors have also been published.

These documents and further safety related information can be downloaded at: www.atsb.gov.au/marine.aspx

Safety message

This incident again emphasises the need for those charged with the navigation of vessels of all types and sizes to keep a proper lookout and to take early and appropriate action to avoid a collision in accordance with the international collision regulations.

A Kawasaki BK117 helicopter, registered VH-CSG (CSG), departed Townsville on a flight to Cairns, Queensland, under the visual flight rules (VFR). The pilot requested a clearance from Townsville (military) air traffic control (ATC) to track outbound via the Rollingstone VFR route at 1,000 ft.  

At about the same time, a West Wing Aviation Cessna 404 aircraft, registered VH‑XDA (XDA), was inbound to Townsville from Palm Island, under the instrument flight rules (IFR). The aircraft was cleared by ATC to enter the Townsville military-controlled airspace via the Rollingstone VFR route, at 1,500 ft, visual. This provided the required 500 ft vertical separation with CSG.

At 1502, the Townsville Approach controller (trainee) advised the pilot of CSG that he was now outside Class C airspace; provided traffic information on a military helicopter operating in the vicinity, about 10 NM ahead, on descent to 2,500 ft (operating in Class C); and that the Brisbane Centre frequency was available when 36 NM from Townsville. The pilot acknowledged the call.

As the pilot of CSG was aware of another aircraft operating in the area at 2,500 ft, the pilot elected to commence a slow climb to 1,500 ft, to maintain separation with the known traffic. 

At 1506:20, Department of Defence (Defence) radar surveillance data showed that CSG was at 1,400 ft and XDA was at 1,500 ft, with 0.1 NM lateral separation. At that time, the pilot of CSG observed an aircraft ahead (XDA) and immediately descended. The pilot of CSG reported that he was at 1,260-1,280 ft when he passed an estimated 20‑30 ft below XDA. 

The pilot of XDA was in the process of broadcasting an inbound call on the company frequency when he observed a ‘flash’ (CSG) an estimated 6 ft below. The pilot immediately initiated a climb. 

A Defence investigation determined that the Townsville Approach trainee, Training Commander, and Approach Supervisor were prioritising the provision of air traffic services to aircraft operating in Class C over the provision of a flight information service (FIS) to aircraft operating in Class G. While this led to compromised safety between XDA and CSG, this was not evident to the controllers as the prioritisation of tasks in Class C reduced their situational awareness of the developing situation in Class G. 

As a result of this occurrence, Defence has advised the ATSB that controllers have been briefed on the importance of providing accurate traffic information to IFR aircraft operating in Class G, and a training package has been incorporated into the Approach controller training guide to further develop controller understanding of the provision and importance of a FIS.

Aviation Short investigation Bulletin Issue 21

On 10 June 2012, a Robinson Helicopter Company R44 Raven 1, registered VH-HOU, was seriously damaged following a reported loss of power and collision with terrain near Maryvale Northern Territory. On board the helicopter were a pilot and three passengers. One passenger was seriously injured as a result of the accident.

The helicopter was to provide support and aerial filming of a competitor participating in the annual Finke Desert race. A definitive reason for the reported loss of engine power could not be determined. However, a review of the carburettor icing chart reveals that the temperature / dew point spread, put the accident flight in the “Serious Icing – Descent Power” operating realm.

The helicopter manufacturer has previously issued a Safety Notice in regard to the use of the carburettor heat assistance system, warning that if used it will reduce carburettor heat on lift off and may require adjustment in flight.

Aviation Short Investigation Bulletin - Issue 12