At 0940 Eastern Daylight-saving Time on 2 December 2011 the crew of a Fairchild Industries SA227 aircraft (Metroliner) registered VH-UUN (UUN) was rolling through to the turning node after landing on runway 26 at Portland aerodrome, Victoria when a Cessna Aircraft Company 172 (C172) registered VH-VSH (VSH) was observed on short final for the reciprocal runway. VSH subsequently conducted a go-around.

The crew of UUN were completing a scheduled flight from Hamilton to Portland, Victoria. VSH was on a solo Visual Flight Rules navigation training flight from Ballarat. Despite both aircraft making all required Common Traffic Advisory Frequency (CTAF) broadcasts, the pilots of UUN and VSH were not aware of each other prior to the incident. Neither aircraft was fitted with a Traffic Collision Avoidance System, nor was fitment required.

The crew of UUN and VSH reported their radios were serviceable and that the correct frequency was used for all required CTAF broadcasts.

This incident highlights the need for pilots to apply all available methods to maintain separation with other aircraft when operating outside controlled airspace. These methods include:

• utilisation of both alerted and un-alerted see-and-avoid principles,
• conducting a radio serviceability check when operating at a non-towered aerodrome equipped with an Aerodrome Frequency Response Unit, and
• use of on-board collision avoidance systems where fitted.

Where ground-based personnel could provide regular operators with advice on the presence of other airspace users, operators should formalise the use of such resources to ensure maximum benefit without detracting flight crew from their prime duties.

On 30 November 2011, a Cessna 210L aircraft, registered VH-SKQ, departed Derby for Kalumburu, Western Australia, on a passenger charter flight. There was one pilot and six passengers (including an infant) onboard.

On landing, the aircraft touched down about 400 m from the landing threshold. The pilot attempted to slow the aircraft using brakes, however there was no brake pressure available.

The aircraft ran off the end of the runway at about 40 kts, colliding with some large rocks. The aircraft was seriously damaged, however there were no injuries to the passengers or the pilot.

The pilot stated that the normal approach procedure was to check the brake pressure prior to lowering the landing gear during the descent, however this step was missed during the pre-landing checks. If a brake fault had been detected prior to touchdown, the pilot would have had more time to consider the options available.

It is important for operators, training organisations and individuals to consider scenarios like this one as training scenarios, so pilots can formulate a plan prior to an actual event occurring. The pilot had not received any training for a brake failure.

Aviation Short Investigation Bulletin - Issue 11

On 27 November 2011, a Robinson Helicopter R22 Beta II, registered VH-RKN, departed Kununurra, Western Australia on a private flight.  The pilot was the sole occupant of the helicopter.

Whilst manoeuvring for a landing the low rotor RPM light and horn activated.  The pilot was unable to recover the rotor RPM nor arrest the rate of descent and the helicopter landed heavily and sustained serious damage, however the pilot was uninjured.

Robinson Helicopter Company has identified low rotor RPM as a significant factor in helicopter accidents.  The training requirements in regard to low rotor RPM avoidance and recovery procedures is under review by the Civil Aviation Safety Authority.

What happened

On 8 October 2011, the flight crew of an Airbus A380-800, registered VH-OQE, was preparing for departure from Los Angeles International Airport, United States of America.

Prior to take-off, the captain changed the departure runway that was entered in the aircraft's flight management system. The procedure for completing that task was not followed exactly, resulting in the take-off speeds not being displayed on the flight instruments.

During the take-off roll, the flight crew, becoming aware that the take-off speeds were not displayed, called out the speeds from their notes instead and proceeded with the take-off.

What the ATSB found

The ATSB found that the captain was distracted from initially updating the runway change in the aircraft's navigation systems prior to the aircraft taxiing for the runway. Twice prior to take-off the aircraft's systems displayed a message to check take-off data. The first officer cleared the first message on the understanding that the take-off data would be checked and in the second instance, believing that it had been checked. There were no other warnings in place to alert the crew that they were commencing the take-off without the take-off speeds in the aircraft's navigation systems.

What has been done as a result

Qantas has advised that the aircraft manufacturer has updated the aircraft's warning systems as part of a planned upgrade program. This upgrade will issue a warning if take-off is commenced without the take-off speeds having been entered into the aircraft's systems. They also advised that their standard operating procedures have been updated to avoid any misinterpretation regarding the required actions in the case of a runway change.

Safety message

This incident highlights the problem of distraction during critical stages of flight preparation. It also highlights the importance of good flight crew communication to ensure a shared understanding of the aircraft's systems status.

On 17 September 2011, the first electrical engineer on board the passenger/ro-ro ship Spirit of Tasmania I fell through an opening in a catwalk between two of the ship's main engines. He fell about 2 m to the deck below, amputating the top of his left middle finger, fracturing his left ring finger and injuring his right shoulder and buttock. He was treated on board and later taken to hospital.

What happened

On 23 November 2011, a loss of separation occurred 6 km north of Cairns, Queensland, between a Cessna Aircraft Company 402C (C402), registered VH-TFK, and a Cessna Aircraft Company T210N (C210), registered VH-PDP.

The C402 was conducting an instrument landing system (ILS) approach for runway 15 and was 1.8 NM (3.3 km) from the airport when the pilot initiated a missed approach from a height of 1,000 ft in instrument meteorological conditions. At the time the C210 was on the same ILS approach and was 6.4 NM (11.9 km) behind the C402. About 1 minute after the pilot of the C402 turned left to establish the aircraft on the missed approach track, the distance between the two aircraft reduced below the required air traffic control separation (ATC) standard.

What the ATSB found

The Australian Transport Safety Bureau identified that a local ATC procedure, published in part to assist ATC in separation management during a missed approach event, was not clear and subject to varying interpretation. This resulted in the spacing between the two aircraft being closer than intended at the point when the pilot of the C402 commenced the missed approach.

The local ATC procedure did not fully consider all operational aspects that may lead a pilot to initiate a missed approach in instrument meteorological conditions above the procedure-defined minimum cloud base height.

What has been done as a result

In response to this occurrence, Airservices has initiated a number of safety actions including amending the local procedure to assist with the clarity and intent, changing the Cairns local instructions to enforce minimum flow (distance) spacing and updating controller missed approach procedures refresher training. This updated training will increase controller awareness of separation assurance issues relating to consecutive approaches and ensure that due consideration is given by controllers to the broad mix of aircraft types using straight-in approaches.

Safety message

This occurrence reinforces the need for all local procedures, in particular those that assist controllers in separation management, to be unambiguous and to encompass all possible operational circumstances. The importance of effective radar navigation guidance when positioning an aircraft for an approach is also highlighted.

On 25 November 2011, a Saab Aircraft Company S340B was being operated on a scheduled passenger service from Lismore to Sydney, New South Wales (NSW). During the taxi to the gate after arrival at Sydney, a cabin crew member noticed smoke coming from near a passenger seat and instructed the passenger to throw the source of the smoke into the aisle. The cabin crew member then discharged a fire extinguisher onto what was later identified as a mobile telephone. After several minutes, the smoke cleared.

An Australian Transport Safety Bureau (ATSB) investigator travelled to Sydney airport to commence an investigation into the event. The mobile telephone was transported to the ATSB technical facilities in Canberra for initial examination and then forwarded to the United States for detailed examination at a specialist facility.

The technical examinations found that a small metal screw had been misplaced in the battery bay of the mobile telephone; the screw puncturing the battery casing and causing an internal short circuit leading to heating and thermal runaway. It was probable that the screw had been misplaced during an earlier repair carried out on the telephone. That repair had not been conducted by an authorised service provider.

This investigation highlights the risks associated with the use of non-authorised agents for the repair of lithium battery-powered devices and reinforces the Civil Aviation Safety Authority (CASA) recommendations that these devices should be carried in the cabin and not in checked-in baggage.

Safety summary

What happened

On 17 November 2011, a wave knocked a seaman off MSC Siena’s accommodation ladder while he was rigging a combination pilot ladder in preparation to embark a harbour pilot. The ship was near Rottnest Island off the port of Fremantle. An immediate search for the seaman was initiated by Australian search and rescue agencies but the search was unsuccessful.

What the ATSB found

The ATSB’s investigation found that a risk assessment for the task of rigging the pilot ladder was not undertaken and a number of precautions, including taking into account the poor weather conditions, were not taken. With regard to this task, the ship’s safety management system was not effectively implemented and documented procedures, including issuing a work permit, were not followed.

What's been done as a result

Senior representatives from Allseas Marine, Greece, MSC Siena’s manager, attended the ship in Fremantle and conducted an internal company investigation. Since then, Allseas Marine has taken a number of steps to address the safety issues identified by its own and the ATSB’s investigation.

The company’s shipboard safety management system procedure for its work permit system has undergone major revision with regard to work over the side and a new, improved work permit form has been introduced. Importantly, the revised procedure specifically addresses the task of working on combination pilot ladders and task specific guidance and precautions have been provided.
Crew induction and familiarisation procedures, particularly for ships new to the company fleet, have been enhanced to support implementation of the revised work permit system procedure. On board training has been improved through safety videos and computer based training focusing on permit to work systems. A fleet wide safety campaign was carried out to promote the company’s work permit system. A requirement to report all work for which a permit is necessary to the company and submit the permit forms has been introduced.

Allseas Marine also obtained independent advice with regard to rigging pilot ladders. Based on that advice, the company considers that if pilotage services have not been suspended due to the weather conditions, rigging a pilot ladder may be permissible subject to the master’s overriding authority and judgment on safety matters.

The ATSB has assessed the action taken by Allseas Marine and is satisfied that it will adequately address the safety issues identified.

Safety message

Rigging a pilot ladder while working over the side of a ship can be a hazardous task and it is imperative that all the precautions necessary to prevent a person falling overboard are taken.

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 13 December 2010, the ATSB commenced a safety issue Investigation into Procedures and Practices used to Provide Access to Track, NSW.  Examination of the information collected during the Access to Track investigation identified significant similarities to aspects of other occurrences being investigated by the ATSB as part of the safety issue investigation of rail operations on the interstate rail line between Sydney and Melbourne, which commenced on 16 August 2011.

Accordingly the ATSB decided to examine the issues related to Access to Track as part of the broader RI-2011-015 safety issue investigation and the separate RI-2010-014 investigation was discontinued.

What happened

On 8 November 2011, a loss of separation occurred between a Boeing Company 737-8FE, registered VH-VUV, and a Boeing Company 737-838, registered VH-VXM, near Ceduna, South Australia. The aircraft were conducting scheduled passenger flights and were under the air traffic control of Airservices Australia (Airservices). The aircraft were operating on converging tracks at 39,000 ft. The procedural longitudinal separation standard of 20 NM (37 km) was infringed. It is likely that there was between 6 NM (11.1 km) and 12 NM (22.2 km) longitudinal separation between the aircraft.

What the ATSB found

The ATSB found that the two controllers involved were experiencing a high workload due to a range of factors, including the number of tasks and their limited experience. Airservices’ processes for monitoring and managing controller workloads did not ensure that newly-endorsed controllers had sufficient skills and techniques to manage the high workload situations to which they were exposed. In addition, Airservices’s fatigue risk management system (FRMS) did not effectively manage the fatigue risk associated with allocating additional duty periods. The ATSB is also concerned that there had been increasing traffic levels and complexity in some sectors in recent years, combined with a decrease in the experience levels of controllers and without a concomitant increase in controller resources. In addition, although Airservices has been in the process of developing and trialling a flight plan conflict function for procedurally-controlled aircraft for several years, the fact that it is still not operational is a safety issue.

What's been done as a result

Airservices reported that the airspace sectors involved in the occurrence had been re-sectorised into three sectors in November 2012 to manage workload and that a working group had been established to determine a suitable workload model to monitor and forecast controller workload on a sector by sector basis. The first stage of a flight plan conflict function had also been deployed in Brisbane Upper Airspace, with further roll out planned in Melbourne Centre in 2014.
In addition, Airservices reported that an updated FRMS had been implemented in July 2012 and that it had addressed the systems limitations outlined in the report.

Safety message

High workload can have significant effects on a controller’s performance. It needs to be monitored and managed using a systemic approach, particularly for less experienced controllers but also those who have recently received a new endorsement. Other recent loss of separation occurrences involving high workloads and newly-endorsed controllers indicate that this problem is not restricted to the sectors involved in this occurrence. Ideally the best way of managing workload is to reduce the level of work demands and distractions. If the work demands cannot be reduced, then another option is to ensure the controllers have the experience, skills techniques and support to effectively manage their task demands.