On 7 November 2011, the pilot of a Robinson Helicopter R22 Beta, registered VH-CME, was conducting cattle mustering operations on a station property about 93km north of Julia Creek, Queensland. The pilot was the sole occupant of the helicopter.

The pilot's task was to locate and muster cattle through a gate into the adjacent paddock.  Whilst manoeuvring the helicopter to land at about 5 ft above ground level, the helicopter's main rotor blade struck the ground. The pilot was not injured, however the helicopter was seriously damaged.

Mustering at low level has an inherent risk profile that requires a high level of awareness by the pilot. Mustering without any assistance from ground personnel, increases that level of risk.

Following landing at Sydney Airport on the 8 Nov 2011, one of the main wheels of a Virgin Australia Boeing 737-8FE, registered VH-VUF, was found to have separated at the hub. The failure was traced to fatigue cracks emanating from an unpeened area of the inner hub's bearing bore. The operator had complied with the manufacturer's wheel inspection requirements. However, as a result of the occurrence, the operator increased the frequency of the ultrasonic inspection of the wheel hubs.

Aviation Short Investigation Bulletin - Issue 11

What happened

On 5 November 2011, a Construcciones Aeronáuticas S A C212-CC (C212) aircraft, registered VH-MQD, was conducting parachute operations, in controlled airspace, over the Western Grass Drop Zone at Royal Australian Air Force Base Richmond Aerodrome (Richmond), New South Wales (NSW). Air traffic control (ATC) had assigned the C212 flight crew clearance to conduct a parachute drop.

A Boeing Company 737-7BX (737) aircraft, registered VH-VBP, operating a scheduled passenger flight from Sydney, NSW to Cairns, Queensland, was cleared by ATC to track via Richmond, underneath the C212. A loss of separation occurred between the declared parachute operations area and the 737. At the time, the paratroopers had just exited the C212 and ATC issued the 737 flight crew, who were in the process of taking avoiding action, with a safety alert. The last paratrooper out of the aircraft reported that while in free fall and about 10 seconds after exiting the aircraft, they were at the same altitude as the 737, about 2,000 m away.

What the ATSB found

The ATSB identified that Airservices Australia (Airservices) had no standard, documented procedure to assure separation of aircraft departing Sydney via Richmond during parachute operations at Richmond, nor a documented means for controllers to display in the air traffic control computer system when a parachute drop clearance had been issued.

The ATSB also found that two of the controllers involved had not been provided with training in compromised separation recovery techniques. Furthermore, Airservices’ process for recognition of prior learning, and the subsequent training provided to one of the controllers, had not effectively addressed the variances between that controller’s skills and knowledge (after an absence working overseas) and the operational role requirements of a Sydney Terminal Control Unit air traffic controller.

What's been done as a result

Airservices advised that the Sydney Terminal Control Unit Local Instructions were amended to include a requirement for coordination between the Sydney Approach West controller and the adjacent Departures position when parachute operations were being conducted at Richmond.

Airservices also amended their procedures manual to include human-machine interface directives for the display of information for aircraft involved in parachute operations.

Safety message

This occurrence highlights three important safety lessons for air traffic controllers and flight crew:

• Documented procedures and phraseology are crucial when managing risks associated with unfamiliar operations
• Terminal area speed restrictions help maintain aircraft separation— air traffic controllers should always consider the potential safety implications before cancelling a speed restriction
• Flight crews need to be aware that the cancellation of a speed restriction may not always be available when requested, due to operational ATC requirements.

Preliminary report released 11 July 2011

At about 1140 Eastern Standard Time on 8 September 2011, a Eurocopter AS350BA helicopter, registered VH-RDU, with a pilot and two passengers on board, collided with terrain on approach to land at a helicopter landing site that was located on a peak of Double Mountain South, Queensland.

The pilot and front seat passenger were fatally injured, and the rear seat passenger received serious injuries. The helicopter was substantially damaged. There was no fire.

On 29 October 2011 a Bell Helicopter Company B206 BII Jetranger, registered VH-AYP, departed Maitland Aerodrome, New South Wales for a local training flight with an instructor and student on board.

On descent into the aerodrome, the instructor demonstrated a practice autorotation from 1,000 ft above ground level (AGL). The demonstration was not a planned exercise for the flight. It was intended that engine power would be restored and the autorotation would cease before ground contact, as a power termination.

The aircraft was levelled at approximately 5ft to 10ft AGL and the collective raised in anticipation of a power termination.  At the same time, the low RPM horn sounded, and light illuminated.  The throttle had not been opened completely as required and was wound to the full open position as the helicopter settled to the ground. 

The helicopter landed heavily and sustained serious damage.

The ATSB has been advised by the flying training organisation of the following proactive safety action in response to this occurrence:

• A briefing is to be conducted before any emergency training is performed.
• Implementation of the, IMSAFE personal checklist for both instructor and student, to assess their fitness to fly prior to every lesson.

Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, a limited-scope, fact-gathering investigation was conducted in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.

During a voyage from Tin Can Bay, Queensland to Brisbane, Queensland, the vessel's crew activated the tug's 406 MHz EPIRB, thus declaring an emergency, about 80 nm ENE of Cape Moreton after the tug's steering was damaged and couldn't be fixed. The crew of three were airlifted off to safety and a tug from Brisbane was sent to take it in tow.

Safety message

Regardless of the length of a voyage, or their experience, the crew should always adequately prepare their vessel before departing port. The proper stowage and securing of equipment to prevent movement in a seaway and the carriage of spare parts to repair critical equipment are essential parts of a thorough voyage preparation. The dangers of being ill-prepared for a voyage have been illustrated in previous ATSB investigations.

On 14 October 2011 at 0950 EST, a Boeing Company 747-400 aircraft, registered VH-OEH (OEH), operated by Qantas Airways, was taxiing for departure at Brisbane Airport. OEH was stopped at a taxiway holding point before applying power to initiate movement. At the same time, a Virgin Australia First Officer exited the rear door of a Boeing Company 737-800, registered VH-VUM (VUM).  The First Officer was standing on the rear push stairs as they were blown over by jet blast from OEH. The First Officer fell to the tarmac and sustained serious injuries.

Pilots are reminded of the very real danger posed by jet blast and the need to use only the minimum amount of power required to initiate aircraft movement.

Brisbane Airport Corporation (BAC) in collaboration with Airservices Australia responded to this incident by issuing a NOTAM requiring all aircraft vacating the international apron to do so without stopping and using minimum power.  Airservices Australia issued a local instruction to Brisbane tower and ground controllers to assist with the implementation of this requirement.

On 25 October 2011, a Cessna Company Aircraft 172, registered VH-PHV, departed Dairy Creek Aeroplane Landing Area (ALA), Western Australia for a private local area flight. The pilot was the sole occupant of the aircraft.

The flight was conducted to inspect a number of paddocks on Bidgemia Station, about 35 minutes flight time from Dairy Creek ALA. Prior to departure the pilot determined there was 80 litres total fuel on-board and then used an estimate of 30 litres/hour for fuel burn calculations.

Once reaching the paddocks, the pilot conducted land and cattle inspections for about 2 hours and 40 minutes before the engine failed due to fuel exhaustion. The pilot conducted a forced landing, and the aircraft was seriously damaged after impacting with trees, however the pilot was not injured.

The pilot stated that he did not conduct a formal fuel plan prior to the flight. During the latter stages of the flight, the pilot experienced a higher workload and forgot to return to a landing area to refuel.

This accident highlights the vital importance of pre-flight planning. Pilots should ensure that every flight is appropriately planned with accurate flight times and fuel calculations. CASA recommends private, visual flight rules flights should plan for 45 minutes of fixed fuel reserves.

On 13 October 2011, a Jetstar Airways Airbus Industrie A320-232 aircraft, registered VH-VGO (VGO), departed Christchurch, New Zealand on a scheduled passenger service to Brisbane, Queensland.

While VGO was on descent into Brisbane Airport, the air traffic controller was coordinating diversions and clearances for multiple aircraft due to significant weather in the vicinity. At 5,000 ft, the air traffic controller issued an instruction for VGO to turn left immediately due to conflicting traffic. The crew complied with the instruction and entered an active thunderstorm cell.

The aircraft encountered heavy rain, and the airspeed began to rapidly decrease. The autopilot disconnected and the pilot applied Take-off/Go Around thrust. The captain informed air traffic control (ATC) that they needed a different heading of 090 degrees to fly clear of the weather, which was subsequently granted. The aircraft landed at Brisbane Airport, there were no reported injuries to crew or passengers, and no damage to the aircraft.

High workload can cause narrowing of attention and task fixation. This makes it difficult to continually assess the big picture and develop appropriate strategies. Effective workload management includes, for line controller and supervisors alike; forward planning and seeking/providing assistance when needed.

In this incident, deteriorating weather combined with high traffic volume limited the options available to the controller to ensure separation. As a result, the controller used phraseology which led the flight crew to believe that there was an imminent risk of collision and to their subsequent turn into hazardous weather.

Preliminary report released 19 March 2012

This preliminary report details factual information established in the investigation’s early evidence collection phase and has been prepared to provide timely information to the industry and public. Preliminary reports contain no analysis or findings, which will be detailed in the investigation’s final report. The information contained in this preliminary report is released in accordance with section 25 of the Transport Safety Investigation Act 2003.

Abstract

At approximately 05:451 on 23 October 2011, train 7SP5 was passing through Wirrinya on the main line of the Stockinbingal to Parkes Railway. Soon after, the driver noted that the train was losing air and brought the train to a stop. An inspection found that the rear portion of the train had derailed. There was significant damage to the last six wagons of the train, approximately 1 km of track, and several shipping containers. Up to 17 km of track suffered minor damage.