On 13 April 2012, at about 1440 Eastern Standard Time, a Guimbal Helicopters Cabri G2 helicopter, registered VH-ZZT (ZZT), collided with terrain at Camden Airport, New South Wales. On board the helicopter was an instructor and a student.

The Guimbal Cabri G2 is a two-seat helicopter manufactured in France. It features a 7-bladed fenestron in place of a conventional tail rotor and a 3-bladed main rotor, which rotates clockwise when viewed from above. It received the European Aviation Safety Agency’s Type Certificate in December 2007.  ZZT was the first of the type to be registered in Australia.

The student was undergoing type endorsement training. The instructor simulated a jammed right yaw control pedal forward emergency in the hover.

The instructor then demonstrated a recovery procedure from the simulated emergency.  During the demonstration a rate of decent developed, which was assessed to be too fast.

The instructor attempted to abort the manoeuvre by increasing collective, applying full throttle to increase the rotor revolutions per minute and full right pedal to counteract the left yaw. The helicopter rotated to the left through several full rotations at an increasing rate.  The instructor was unable to recover the rotor RPM nor arrest the left yaw or left roll that developed.

The helicopter collided with terrain in a left skid-low, nose-high attitude.  The student suffered minor injuries and the helicopter was seriously damaged.

This accident highlights that different helicopter types have their own specific handling characteristics; and that pilots should be familiar with the emergency procedures prescribed in the flight manual and the immediate actions to be performed to ensure a successful outcome.

Aviation Short Investigation Bulletin - Issue 12

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 17 April 2012, the ATSB commenced an investigation into an airspace event, between an Airbus A330 aircraft registered VH-EBE and a Bombardier DHC-8 aircraft registered VH-TQL, near Cairns Airport on 21 March 2012.
 
Examination of the information collected during the investigation indicated a loss of separation assurance had occurred. However, the controller was aware of the potential conflict between the two aircraft and was actively managing the situation, which resulted in the separation standard between the aircraft being maintained.
 
The investigation did not find any systemic issues had contributed to the occurrence. The ATSB assessed that no safety issues would be identified through further investigation. On that basis, the ATSB has decided to discontinue its investigation.

On 15 April 2012, a Virgin Australia, Boeing 737-8FE aircraft, registered VH-VOL departed Gold Coast, Queensland on a scheduled flight to Melbourne, Victoria.

During climb, the crew observed that both engines were being supplied only from the right fuel tank. This resulted in a fuel quantity difference between the left and right fuel tanks. The crew conducted the fuel leak engine checklist which confirmed that no engine fuel leak existed. With centre tank fuel available, the crew selected the centre tank pumps on, which resulted in the fuel imbalance stabilising.

Given that the crew were unable to confirm fuel from the left tank could be used once the centre tank pumps were selected off, or that no fuel leak existed, they elected to divert to Brisbane, Queensland and declare a PAN. The aircraft landed without further incident.

An overhaul organisation inspected the engine fuel feed crossfeed valve and identified wear to the sealing materials and Teflon within the valve body as consistent with the existence of a leak within the valve. However, the overhaul organisation was unable to confirm whether the sealing material degradation would explain a high volume fuel leakage rate. 

Virgin Australia Airlines had previously established an inspection program for the crossfeed valves in accordance with Boeing recommendations. The operator also has a program in place to replace existing crossfeed valves with a modified version at scheduled maintenance servicing.  This program is currently under review for acceleration.

Aviation Short Investigation Bulletin - Issue 13

On 12 April 2012, a Cessna Aircraft Company 310R, registered VH-JOF, departed Jabiru aerodrome on a charter flight.  On board the aircraft were one pilot and two passengers.

While on final approach to Marlgawo Aircraft Landing Area the aircraft encountered suspected sudden and severe windshear at approximately 50 ft above ground level.  The aircraft landed heavily and was seriously damaged.  One passenger sustained minor injuries, the other occupants were uninjured.

The Flight Safety Foundation's Approach and Landing Accident Reduction tool kit provides guidance on avoiding, recognising and recovering from windshear. The tool kit reinforces the importance of following the windshear recovery technique recommended in the aircraft operating manual and flying a stabilised approach.

What happened

At about 0400 (CDT) on Wednesday 11 April an ARTC ballast train 8M24N travelling on the interstate mainline between Broken Hill to Kinalung derailed at the 1118.500 km mark. The derailment was initiated by the 26th wagon as a result of a loading irregularity. The crew of the train was physically unhurt. There was minor damage to the wagon and considerable track damage over a 4 km length.

Safety message 

Uneven loading of ballast wagons increases the potential of derailment. In 2010, the Independent Transport Safety Regulator (ITSR) released a Rail Industry Safety Notification (RISN) No. 32 on the "operation of less than safely loaded wagons". Although the notice refers to coal trains, some of the issues raised in the RISN are also applicable to ballast trains such as ensuring the appropriate wagon loading configurations are in place.

To ensure wagons are evenly loaded, the rail operator's procedures for checking the load distribution need to be followed and carried out to the required standard.

On 6 April 2012 a Boeing Company 737-838 aircraft (B737), registered VH-VXI, on a scheduled passenger flight from Sydney, New South Wales to Darwin, Northern Territory was involved in a breakdown of separation with an Airbus Industries A330-243 aircraft (A330), registered B-6073, on a scheduled passenger flight from Melbourne, Victoria to Shanghai, China.

Both aircraft were operating under Instrument Flight Rules and were in airspace controlled by Brisbane Centre utilising radar.

The B737 and A330 were on converging tracks at Flight Level (FL) 360. As the aircraft approached Tindal, Northern Territory at 1342 Central Standard Time, a breakdown of separation occurred when the distance between them reduced to about 3.5 NM, before vertical separation was established. The incident occurred about 16 minutes after a handover between two Air Traffic Controllers.

As a result of a number of incidents involving handovers, Airservices Australia advised the ATSB that they had amended the handover procedure to require supervision and for the relinquishing controller to remain at the console to provide assistance until the accepting controller indicated that assistance was not required.

The incident highlighted the importance of separation assurance and thorough handovers.

What happened

On 30 March 2012, Airservices Australia was unable to resolve two short-notice controller absences for night shift coverage of the Kimberley and Cable airspace sectors, located over north-western Australia. A contingency plan was activated, and a Temporary Restricted Area (TRA) initiated for that airspace from 0015 to 0515 Eastern Standard Time on 31 March.

Two aircraft separately entered the TRA without the knowledge of Airservices personnel. An Airbus A330 registered PK-GPA, on a flight from Denpasar, Indonesia to Melbourne, Victoria, was detected at 0500 when the flight crew contacted a Melbourne Centre controller because their aircraft was at the Brisbane/Melbourne Flight Information Region (FIR) boundary after transiting the TRA. The second aircraft, an A330 registered PK-GPO, on a flight from Denpasar to Sydney, New South Wales, was detected at 0641, when the crew contacted Melbourne Centre at the FIR boundary. The aircraft had been operating in controlled airspace for 86 minutes, without the knowledge of any controllers. The minimum standards for separation from other aircraft were met, but both situations constituted losses of assurance that separation would be maintained.

What the ATSB found

Overall, Airservices had many risk controls in place to manage the situation where it was unable to provide the published air traffic services (ATS) and had to activate a TRA. In this case, a TRA had to be activated at short notice in airspace adjacent to an international ATS provider, and a range of actions by operational personnel did not conform to expectations. Airservices’ risk controls were not robust enough to effectively manage this situation and ensure they would be made aware of all aircraft that were operating within the TRA.

The ATSB concluded that a number of procedures and processes were not fulfilled on the night of the occurrence and identified four safety issues: Airservices’ process for ensuring that all aircraft operating in the TRA were known to ATS; selection and preparation of personnel for the Contingency Response Manager role; the contingency plan testing and review process; and the absence of a defined process for recording the actual hours worked by Air Traffic Control Line Managers.

What's been done as a result

Airservices has revised its contingency plan documentation and procedures. In addition, its updated Fatigue Risk Management Requirements have addressed the recording and monitoring of the actual hours worked by Air Traffic Control Line Managers.

The ATSB is not satisfied that Airservices has adequately addressed the identified safety issues regarding processes for managing a Temporary Restricted Area to ensure that all aircraft were known to air traffic services and contingency plan testing and review effectiveness. As a result, the ATSB has made formal recommendations to Airservices.

The operator of the A330 aircraft, Garuda International, specified that, as the use of procedures associated with TRA activation was an infrequent requirement and not practiced in daily operations, it would ensure the procedures were reviewed as part of check and training programs.

Safety message

The occurrence provides a timely reminder to all organisations operating in high reliability systems of the importance of having multiple risk controls in place to effectively manage rare combinations of events during abnormal situations, and to regularly review the effectiveness of these controls.

On 7 January 2012, while operating in the vicinity of Carterton, New Zealand, a Cameron Balloons A-210 hot-air balloon, registered ZK-XXF, contacted power lines and caught fire before colliding with terrain.  The 11 occupants were fatally injured.

The Transport Accident Investigation Commission (TAIC) of New Zealand is responsible for the investigation of this occurrence.  On 14 March 2012, the TAIC formally requested the assistance of the Australian Transport Safety Bureau (ATSB) in the recovery of data from a damaged GPS receiver found at the accident site.

The ATSB successfully recovered the accident data from the GPS receiver. This data and a technical report have been sent to the TAIC of New Zealand to assist its ongoing investigation. The TAIC is responsible for releasing a final investigation report regarding this occurrence.

• TAIC website: www.taic.org.nz

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

What happened

At about 0910, on 11 April 2012, an Ayres Corporation S2R-G10 Thrush aircraft, registered VH-WDD, collided with terrain in a fallow wheat field about 36 km north-west of Moree, New South Wales while on a ferry flight from St George, Queensland to Moree. The owner-pilot was fatally injured, and the aircraft was destroyed by impact forces and an intense fuel-fed fire.

What the ATSB found

The ATSB found that the aircraft departed controlled flight, and the pilot was unable to recover before impact with the ground. On the basis of the evidence available to the ATSB, it was not possible to determine with any certainty the reasons for the loss of control.

There was no evidence of any mechanical fault with the aircraft that could have contributed to the accident. A number of other possible factors could not, however, be completely discounted: pilot incapacitation; aircraft handling, such as to avoid a bird or flock of birds or other deliberate manoeuvring by the pilot; or a mechanical problem which could not be identified during the post-accident site and aircraft examinations.

Although it did not contribute to the accident, an issue was identified with the potential to affect the safety of agricultural operations in S2R-G10 Thrush aircraft in Australia. The aircraft’s permitted load-carrying capability, based on its published maximum take-off weight, was very low in comparison with other agricultural aircraft types. The aircraft type’s operational history indicated that it could be operated at higher loads, but the absence of a more practical published weight limit increased the risk of pilots flying at weights where the aircraft had not been fully tested for safety.

What has been done as a result

In June 2012, Statewide Aviation, the Australian distributor for Ayres aircraft, in consultation with the Civil Aviation Safety Authority, commenced developing a Supplemental Type Certificate (STC) for some Ayres Thrush variants. This STC would permit an increase in the aircraft's maximum take-off weight, and is expected to be available to Thrush owners in October 2013.

Safety message

Although the investigation did not determine why the aircraft departed controlled flight, the potential for the operation of the emergency cut-off lever in Garrett-engined Thrush aircraft to prevent significant control difficulties in the event of a serious engine or propeller problem was highlighted.

On 29 August 2011, the Papua New Guinea Accident Investigation Commission (AIC) requested technical assistance from the Australian Transport Safety Bureau (ATSB), in the recovery of information from the global positioning system (GPS) and several engine and flight instruments from a MBB BO-105 aircraft that impacted terrain 5 km south of Timini, Morobe Provence, Papua New Guinea, on 8 August 2011. The pilot and two passengers on-board the aircraft were fatally injured in the accident.
 
The AIC is responsible for investigating this occurrence. 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.
 
Examination of the GPS was commenced with the intent of downloading the GPS data, however the data was unrecoverable due to the absence of the memory device (chip) containing the GPS data for the accident flight. The flight and engine instruments were examined for evidence of indicating pointer contact marks on the instrument face. Support and information was provided to the AIC during the course of the investigation and the ATSB's Technical Analysis Reports were provided to the AIC.
 
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.