What happened

On 2 April 2011, a Robinson Helicopter Co R44, registered VH-HXB (HXB), departed Orange, New South Wales on a private flight to a property in Macquarie Fields, 27 km south-west of Sydney Airport.

Approaching 30 NM (55 km) west of Sydney Airport, the pilot noticed the cloud cover increase. He climbed on top of the cloud and lost visual contact with the ground. He inadvertently flew into controlled airspace and was contacted by Air Traffic Control (ATC).

The Controller requested weather reports from other aircraft in the area and directed the helicopter to the north, east and then south of Sydney trying to find a hole in the cloud. About 30 minutes after the initial contact with ATC, the pilot saw a break in the cloud and was able to descend below the cloud base.

The helicopter landed at a private property in Macquarie Fields 10 minutes prior to last light. The pilot was not rated to fly at night.

During the event, two arriving aircraft and ten departing aircraft from Sydney Airport were affected.

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 1 April 2011, the ATSB commenced an investigation into an operational event that occurred at about 1910 Eastern Daylight-saving Time on 29 March 2011 involving a Bombardier DHC-8-402 aircraft, registered VH-QOP. The initial report indicated that, during the descent into Canberra, at an altitude of about 9,000 ft, a turn was commenced in preparation for the approach. During the turn, the aircraft bank angle was reported as approaching 45º, before returning to normal.

The ATSB conducted an analysis of the aircraft's flight data recorder, and along with crew interviews, identified that the maximum bank angle in the turn was 40º. The crew did not receive a 'bank angle' warning from the aircraft's enhanced ground proximity warning system (EGPWS). The crew interviews also indicated that the pilot flying was very experienced.

The ATSB's primary focus is on enhancing safety with respect to fare-paying passengers and, in particular, those transport safety matters that may present a significant threat to public safety or are the subject of significant public concern. The ATSB therefore directs considerable attention to identifying systemic failures in the aviation, marine, and rail modes of public transport.

The ATSB considered there was limited potential to enhance transport safety by continuing this investigation, and has elected to discontinue it. However, the data already collected may be used by the ATSB for future statistical analysis and safety research purposes.

What happened

On 2 April 2011, a Robinson Helicopter Company R44 Raven 1, registered VH-HUL, was conducting charter operations from a helicopter landing site at the Lorn Reserve on the east bank of the Hunter River, near Maitland, New South Wales. The helicopter had been positioned on flat ground, facing NE, 23 m south of three overhead 11kv power conductors that spanned the river next to the Belmore Bridge.

On the second flight of the day, the pilot commenced hover checks at the landing site having observed a gradual wind change from the SE to the SW before the flight. The pilot had used the trees on the eastern bank of the Hunter River as a visual cue and saw the wind gusting straight across the river from a SW direction.

After completion of the hover checks, the pilot flew the helicopter forward and commenced a left U turn to face the river. At about 50 ft above ground level, the helicopter was caught in a southerly wind gust and drifted towards the 11kv conductors. As the pilot turned the helicopter south, one of the main rotor blades severed a power conductor. After hearing a loud noise and feeling a slight shudder, the pilot landed back at the Reserve.

One of the severed conductors fell onto a safety railing on the Western side of the Hunter River. The ensuing electrical discharge resulted in a full thickness burn to the leg of a three-year-old child in contact with the railing, about 156 m south of the bridge.

As a result of this occurrence, the aircraft operator has introduced and documented new processes and completed a number of amendments, to their operations manual and safety manual relating to HLS/ALA procedures, pilot qualifications and HLS Records.

Abstract

At about 1308 on 28 March 2011 a collision involving freight train 7SP3 and a track mounted excavator occurred between Jaurdi and Darrine, Western Australia.

The train driver sustained a minor injury. There was significant damage to the lead locomotive and the excavator, and minor damage to the track as a result of the accident.

The investigation found that two track mounted excavators had been placed back on the track without permission of the Authorised Employee responsible for the coordination of track side safeworking activities between Jaurdi and Darrine. Other findings were that the communication equipment available to the track crews was inadequate, the sharing of safeworking protection information at pre-work briefings had not occurred and the application of a WestNet Rule had been simplified.

The investigation identified three safety issues, each of which has been addressed, as applicable, by the track access provider or track maintenance organisation.

Abstract

At about 2031 on Wednesday 30 March 2011 a southbound Port Kembla to Parkes empty bulk grain train experienced a train parting event at about the 285-track kilometre point near Gunning (Oolong), NSW, on the down main Sydney to Melbourne rail line. There were no injuries or damage as a result of the incident.

Safety summary

What happened

On 5 February 2011, the pilot of a Cessna Aircraft Company 310R aircraft, registered VH-XGX, was conducting a return flight to Darwin, Northern Territory, following a charter flight to Bathurst Island. The pilot departed from Bathurst Island Aerodrome at approximately 2140 Central Standard Time and the aircraft collided with terrain shortly thereafter - approximately 1 km from the upwind end of the departure runway. The pilot, the sole occupant of the aircraft, sustained fatal injuries and the aircraft was destroyed by the impact forces and a post-impact fire.

What the ATSB found

The ATSB did not identify any technical deficiencies within the aircraft that may have contributed to the impact with terrain. The location of the wreckage, together with the dark night conditions and the relatively light load of the aircraft suggested that it was likely that the pilot was influenced by the effects of somatogravic illusion following take-off. The somatogravic illusion is a powerful human physiological illusion that produces an upward-pitching sensation under conditions of acceleration accompanied by limited visual or other references.

What has been done as a result

Following the accident, the subcontracted operator (the pilot's employer) advised of increased night operational checks of new pilots and low/medium time pilots operating from Darwin. These increased checks were implemented in November 2011.

Safety message

The somatogravic illusion can affect any pilot, and the ATSB highlights the importance of pilots being aware of the conditions under which the illusion may occur and the importance of understanding the ways in which they can manage the associated hazard. This includes strict vigilance in the use of the attitude indicator (artificial horizon) as the primary source of aircraft pitch angle information, and correct instrument scanning techniques to verify the attitude and performance of the aircraft.

Websites of the ATSB, the Civil Aviation Safety Authority and the US Federal Aviation Administration provide a number of sources of information on spatial disorientation and illusions.

What happened

On 25 March 2011, a Cessna 172 aircraft, registered VH-SMY, departed Geraldton on a charter passenger flight to East Wallabi Island (in the Abrolhos Islands group), Western Australia.

While on final approach to the Island, the nose of the aircraft was positioned at a 45° angle to the runway to remain aligned with the centreline due to gusty winds. The wind conditions appeared to be from an east to south-easterly direction. When at about 500 ft the pilot elected to overfly the runway.

A second approach was commenced, but the wind was again too strong for a landing with a go-around conducted. Despite full power being applied the engine did not perform as expected during the climb for another circuit.

During downwind, the pilot noted that the windsock was moving considerably. On final, the aircraft was again at a 45° angle and experiencing wind buffet.

During the landing flare, the aircraft floated, before touching down about halfway along the runway. Determining the aircraft could not be stopped by the runway end, the pilot elected to go-around. He moved the throttle full forward, but the engine did not deliver full power. The aircraft momentarily became airborne before contacting a sand dune and coming to rest upright in the water.

The pilot reported that, due to the recent commencement of his employment with the operator, he wanted to complete the flight.

This accident highlights the need for pilots to be aware that self-imposed undue pressure, can come about for a variety of reasons (time or task-oriented). It is important to understand one's personal limitations, especially when flying in or around adverse weather conditions.

What happened

On 22 March 2011, an Airbus Industrie A330-203 aircraft, registered VH-EBL, was being operated by Qantas Airways, on a scheduled flight from Manila to Sydney, New South Wales. At about 365 NM (676 km) northwest of Cairns, at 39,000 ft, a smell became noticeable on the flight deck and the passenger cabin. The flight crew actioned the aircraft quick reference handbook checklist for Smoke/Fumes/Avionics which removed the odour.

Following electrical arcing of the left windshield heater, a small flame appeared from the bottom left corner of the captain's windshield. The crew donned oxygen masks and extinguished the flame using the cockpit BCF fire extinguisher. There were about four more occasions when arcing and flames appeared and were extinguished. The crew advised air traffic control (ATC) that due to a technical issue they would be diverting to Cairns. The crew also advised ATC that they had extinguished repeated fires as a result of electrical arcing in the captain's windshield heater. ATC declared an INCERFA. The captain advised that emergency services were not required but would advise if the situation changed. The aircraft completed an uneventful landing at Cairns a short time later and the INCERFA was cancelled.

Due to similar reported events, the aircraft operator had in place a windshield replacement program, with a projected completion date for the replacement of identified windshields, by the end of September 2011. This was well within the Airbus Industrie compliance date of May 2012.

What happened

On 8 March 2011, an Eastern Australia Airlines operated (the operator) Bombardier Inc. DHC-8-315 aircraft, registered VH-SBI, departed Melbourne, Victoria on a scheduled passenger service to Devonport, Tasmania.

On arrival at Devonport, a runway 24 area navigation global navigation satellite system (RNAV (GNSS)) approach was commenced. The crew did not become visual with the runway at the minima due to the prevailing weather conditions and a missed approach was conducted. The aircraft was climbed to 3,100 ft and a holding pattern conducted.

A second approach was commenced, during which time, the aircraft's speed decayed. The pilot in command (PIC) made two airspeed advisory calls and the copilot responded immediately by increasing power on each occasion. The two power applications failed to accelerate the aircraft, and the crew observed the airspeed reduce to 107 kts. The PIC called assertively for more power to be applied, and the copilot immediately responded by applying power. During the recovery, the aircraft's engines were over-torqued to 120% for about 2 seconds. The operator and engine manufacturer transient over-torque limits were not exceeded.

A second missed approach was conducted, and the flight was diverted to Launceston, Tasmania where the aircraft landed without further incident.

In response to this incident, and a stickshaker warning event involving a Eastern Australian Airlines Bombardier Inc. DHC-8-315 aircraft on 1 March 2011 (ATSB investigation AO-2011-036), the operator issued a safety alert stating that the primary consideration for pilots is to maintain an awareness of the aircraft's speed, altitude and position; and controlling its flight path.