What happened

On 30 December 2011, a Bombardier DHC-8-102 aircraft, registered VH-QQA, was being operated on a scheduled passenger service to Cairns, Queensland. During the landing, the crew perceived that the aircraft decelerated much quicker than they expected given that reverse thrust and landing gear brakes had not been selected. A subsequent inspection of the aircraft found nothing to explain the perceived problem, and a review of the flight recorder data indicated that there was no abnormal operation of the engines or propellers, and that reverse thrust had not been used.

What the ATSB found

Although unrelated to the reported occurrence, subsequent inspection of the aircraft identified a design problem within the aircraft’s power lever control quadrant. The problem related to the friction device within the power levers and its interaction with the flight idle gate, which was designed to prevent the power levers from going into the ground range in flight. When the friction knob was wound to the full out (friction off) position, the flight idle gate was lifted by contact between the friction device and the flight idle gate. That action rendered the flight idle gate inoperative.

The design problem only applied to the first 39 DHC-8-100 aircraft that were manufactured; subsequent aircraft were manufactured with a modified design. The aircraft manufacturer introduced a service bulletin requirement in 1986 to retrospectively modify these 39 aircraft, but the service bulletin omitted a requirement to modify or replace a specific part, which resulted in the bulletin being ineffective.

What has been done to fix it

Once informed of the design problem, the aircraft manufacturer took prompt action to address the issue. It issued a service bulletin to modify the relevant part, and this action was subsequently mandated by Transport Canada and the Civil Aviation Safety Authority of Australia.

Safety message

This investigation highlights the importance of crews reporting occurrences and other perceived problems. Although in this case the actual event reported by the crew was not serious, and no problems relating to the aircraft or crew performance leading to the perceived event were identified, the subsequent investigation did identify a safety issue in the design of the aircraft.

At about 1000 Eastern Standard Time on 4 January 2012, a Cessna 172 N aircraft, registered VH-ZWR, operating under the Visual Flight Rules in G Airspace, was taking off to conduct a charter flight with the pilot and three passengers on board.

When the aircraft had reached about 25 to 30 ft above ground level, after take-off from The Oaks beach at Fraser Island, Queensland, the aircraft descended. The right wingtip struck the beach near the water line and the aircraft came to rest on the left wingtip and nose. The occupants exited the aircraft with minor injuries before the aircraft was turned on its back several minutes later by wave action.

The circumstances of the accident were consistent with an aircraft stalling as it climbed out of ground effect while flying at an airspeed and configuration where the airspeed was unstable.

As a result of this accident the operator has reviewed their soft field take-off procedures.

This accident highlights that pilots should be aware of the effect that flap extension has on the stall attitude of their aircraft, and the need for pilots to be aware of performance variations when conducting a soft field take-off.

On 23 December 2011, a Robinson Helicopter Company R22 Beta, registered VH-LNC departed Caloundra aerodrome on a Trial Instructional Flight (TIF).  On board the helicopter were an instructor and student.

Whilst attempting to hover the helicopter the student made a significant and unexpected control input.  Before the instructor could take control, the left skid contacted the ground, and the helicopter rolled over and sustained serious damage.  The instructor and student were uninjured.

Robinson Helicopter Company has identified inexperienced individuals manipulating the controls and dynamic rollover as a significant factor in helicopter accidents.  In response to this accident the helicopter operator has introduced a new policy in regard to TIFs and students manipulating the flight controls below 500 ft above ground level.

On 1 January 2012, at about 0900 Eastern Daylight- savings Time, a Cessna Aircraft Company A188B/A1 aircraft registered VH-ZAP (ZAP) was conducting aerial work about 40 km south of Forbes, New South Wales. During the application of chemicals, the aircraft developed a high sink rate as a result of a downdraught and the left wing impacted trees. The subsequent post-impact fire seriously damaged the aircraft, and the pilot received minor injuries. The pilot reported that he had difficulties activating the emergency dump control system to lighten the aircraft.

This accident highlights the risks associated with executing a turn when in close proximity to the ground. Such manoeuvres require heightened pilot vigilance regarding controlling the aircraft. In addition, pilots must be prepared to immediately identify the situation and act to control the aircraft, in order to compensate for a change in wind direction or downdraughts.

Discontinued

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 3 January 2012, the ATSB commenced an investigation into a loading issue involving a Boeing Company 747-438 aircraft registered VH-OJM, at Melbourne Airport, Vic, on 22 December 2011. Examination of the information collected during the investigation identified that the circumstances of the occurrence were limited to incorrect load data being entered onto the provisional loadsheet. The discrepancy was identified by the flight crew and amended prior to the final loadsheet being produced.
 
The operator advised the ATSB that they had identified the nature of the error and had put in place measures to prevent its reoccurrence.
 
Accordingly, the ATSB decided that 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.

Preliminary report released 29 February 2012

Abstract

At approximately 0542 CST on 27 December 2011, freight train 7AD1 derailed at the rail bridge over the Edith River near Katherine in the Northern Territory (NT).

As a result of the derailment, the co-driver suffered minor injuries. The train driver was unhurt. There was significant damage to the bridge and rolling-stock and a number of wagons, including the crew van which was unoccupied at the time, derailed into the river.

The derailment was the result of a severe weather event, a tropical low, which formed on December 26 after tropical Cyclone 'Grant' crossed the coast. The tropical low resulted in torrential rains falling in the vicinity of Katherine causing severe flooding of the Edith River. The flooding was sufficient to cause catastrophic damage to the southern bridge embankment which initiated the derailment of train 7AD1 as it traversed the bridge.

The investigation is continuing.

The information contained in this preliminary report is derived from the initial investigation of the occurrence. Readers are cautioned that it is possible that new evidence may become available that alters the circumstances as depicted in the report.

What happened

On 24 December 2011 an Agusta Westland AW139 helicopter departed Bankstown Airport in response to an emergency personal locator beacon in the Budderoo National Park, about 16 km west-south-west of Wollongong Airport, New South Wales. On board the helicopter were a pilot, an air crewman, two paramedics and a doctor.

On locating the emergency beacon, the crew identified a seriously injured person on a rock ledge near the bottom of a waterfall. They assessed that it would not be possible to winch emergency personnel directly to the patient. In response, the crew landed at a nearby clear area and devised a plan to access and retrieve the patient. During the retrieval, the patient and one of the paramedics hit rocks at the base of the waterfall. The paramedic died from the impact. The patient was subsequently transported to hospital for treatment.

What the ATSB found

The Australian Transport Safety Bureau (ATSB) identified that, due to reduced light, the paramedic and patient were accidentally pulled from the rock ledge as the helicopter was manoeuvred in preparation to lift them out using its winch.

The ATSB also identified several safety issues relating to training and use of the helicopter’s lighting and radios. A number of organisational issues that could adversely influence the way crews act in similar circumstances were also identified.

What has been done as a result

In response to this accident, the Ambulance Service of New South Wales and the helicopter operator took safety action in respect of the operating scope applied to retrieval operations and procedures used by helicopter emergency crews. In addition, paramedics, in their role as ambulance rescue crewmen, are now required to conduct annual night winching currency training. Finally, proactive safety action was taken by these parties in the areas of general crew training and operational risk assessment.

Safety message

This accident highlights the dangers associated with modifying established procedures in order to complete a difficult, and potentially not previously experienced, rescue task. Specifically, the use of procedures that are neither documented nor trained for by crews makes it difficult to identify hazards and manage the related risks.

At about 1500 Eastern Daylight-saving Time, on 17 December 2011, a Cessna 172R aircraft, registered VH-LWX (LWX), landed on runway 13L at Moorabbin Airport. On board were a student pilot and instructor. The student was the handling pilot, and the instructor was the pilot in command.

On vacating the runway, LWX was issued a clearance by air traffic services to taxi back to base via taxiway C, but to hold short of runway 13R. The pilot read back the requirement to hold short of runway 13R. The holding point on taxiway C was appropriately marked; however, LWX did not stop at the holding point, but continued across the runway, resulting in a runway incursion.

At the time of the incursion, a Cessna 172S, registered VH-EOR (EOR), with two persons on board, had just touched down to land on runway 13R. On seeing LWX cross the runway, the pilot of EOR applied full power, commenced a go-around, and passed overhead LWX. EOR subsequently completed a circuit and landed safely. There were no injuries or damage to either aircraft.

The pilot in command of LWX reported that he had been distracted by discussions with his student. The quick action by the pilot of EOR demonstrated the need for landing aircraft to keep a good lookout. The incident also highlights the need to avoid distractions when operating on or near an aerodrome.

About 1045, Eastern Standard Time, 25 December 2011, a Cirrus Aircraft Company SR22 aircraft, registered VH-MMG, with the pilot and two passengers onboard, was on final approach from the south to land on runway 02 at Warnervale aerodrome, New South Wales. Just prior to the runway threshold, at about 30 ft above ground level, the stall warning sounded. The pilot immediately applied full engine power, but the aircraft continued to descend rapidly landing on soft ground short of the bitumen runway.

The aircraft sustained minor damage. All of the occupants exited the aircraft safely with no injuries reported.

As a result of this incident, the pilot advised that in future he would be adopting a steeper approach to runway 02. He would also increase the approach airspeed when landing into headwinds greater than 10 kts.

This serious incident demonstrates the importance of establishing wind direction and strength using all available references, including those on the ground while on approach. Ground references could better position the pilot to adjust the aircraft approach profile and airspeed to suit the weather conditions.

The incident also highlights the unexpected nature of wind gusts and the need to identify an appropriate touchdown point on the runway that provides an adequate safety margin.

On 20 December 2011, at about 1500 Eastern Standard Time, a Cessna Aircraft Company 188B Ag wagon, registered VH-SHM, collided with terrain after experiencing difficulty becoming airborne from a station property near St George, Queensland. The purpose of the flight was the aerial application of herbicide to control weeds on the property. The pilot was the sole occupant of the aircraft and sustained serious injuries.

The pilot was relatively new to the aerial application industry and inexperienced on the aircraft type. The aircraft had recently had a new propeller and hub fitted pursuant to an engineering order.

Approved Agricultural pilots are reminded of the importance of supervision of newly rated agricultural pilots. The accident also highlights the importance of pilots being aware of the maintenance that has been performed on an aircraft and the value of a test flight being performed by a pilot experienced with the aircraft type following maintenance.