On 20 September 2011, a Eurocopter AS.350B3 helicopter, registered VH-HTV (HTV), was returning to the Mount Coot-tha helicopter landing site (HLS), Queensland, at about 2,000 ft.

When 1 NM to the west of the HLS, descending through about 1,500 ft, the pilot received an alert from the helicopter's traffic and collision alert device (TCAD) indicating an aircraft was about 400 to 500 ft below.

The pilot was unable to sight the conflicting aircraft, so the descent was continued. Shortly after, a second alert was received from the TCAD indicating the aircraft was now 200 ft below. The pilot immediately stopped the descent and observed a Cessna Aircraft Company 180 aircraft, registered VH-UPF (UPF), below the helicopter tracking outbound from Archerfield, Queensland at 1,000 ft.

A review of Airservices Australia radar data indicated that the distance between HTV and UPF reduced to about 0.1 NM laterally and 200 ft vertically.

This serious incident highlights the benefits of onboard collision avoidance systems in assisting pilots with traffic awareness; and the need for pilots to regularly review documentation to remain up to date with procedures.

What happened

On 12 September 2011 at about 1000, the pilot of a Cessna 210N aircraft, registered VH-JHF, was conducting low-level aerial survey operations near Bourke Aerodrome, New South Wales. After encountering a brief turbulence event, the pilot had difficulty in making elevator control inputs and in maintaining height. The aircraft subsequently landed safely. There were no injuries.

What the ATSB found

The ATSB found that the reported elevator control input difficulties resulted directly from the fracture of the aircraft’s two horizontal stabiliser rear attachment brackets. The forward spar of the horizontal stabiliser was also extensively cracked. The fractures and cracking were all consistent with metal fatigue and, as such, were typical of the damage sustained by aircraft as they age and move beyond the manufacturer’s originally intended design life. Many manufacturers have addressed the growing potential for this type of damage by introducing supplemental inspections to the principal aircraft maintenance requirements.

The Australian Civil Aviation Regulations 1988 (CAR) were being misinterpreted by some class B aircraft registration holders, to the extent that they believed that their aircraft was exempt from the manufacturer’s supplemental inspections when their aircraft was maintained using the CASA maintenance schedule. While the CASA maintenance schedule did not make any specific reference to the incorporation of the manufacturer’s supplemental inspections, it was a CAR requirement that all aircraft be maintained in accordance with approved maintenance data that, by definition, included those inspections.

What's been done as a result

As a result of this occurrence, on 19 September 2011 the Civil Aviation Safety Authority (CASA) issued Airworthiness Bulletin AWB 55-001 issue 2; highlighting the failure of horizontal stabilisers on Cessna 200 series aircraft. The AWB made recommendations on the maintenance schedule and inspection of the stabiliser in order to ensure the structural integrity of the area.

CASA also published a series of Discussion Papers in December 2012, detailing a range of options for developing updated continuing airworthiness regulations for all aircraft not used in regular public transport operations. This included options for reform of maintenance program requirements for non-RPT aircraft – to bring the regulations up to date with modern technology and current international standards and practice.

The outcomes from the discussion papers were unresolved at the time of writing and therefore the Australian Transport Safety Bureau has recommended that CASA proceed with its program of regulatory reform to ensure that all aircraft involved in general aviation operations are maintained using the most appropriate maintenance schedule for the aircraft type, and to also ensure that the provisions of CAR Schedule 5 are clarified in relation to the incorporation of all relevant supplemental inspections specified for the aircraft type.

Safety message

This occurrence highlights the importance of comprehensive, periodic maintenance inspections and the role of supplemental inspections in maintaining ageing airframes. The ATSB strongly encourages registration holders of class B aircraft to review their aircraft’s maintenance schedule to determine if it is the most appropriate for their aircraft and to ensure that it adequately provides for the continuing airworthiness of the aircraft.

On 12 September 2011 a Vincent Airlines operated Raytheon Aircraft Company 1900D, registered VH-VAQ, departed Darwin Airport, Northern Territory on a local training flight. Onboard was a check captain, a check captain under training and a first officer (FO).

The purpose of the flight was to conduct a proficiency check in preparation for the FO to be checked to line operations. After take-off, at about 80 ft above ground level (AGL), the check captain announced, "simulating engine failure" and reduced the power on the left engine, setting above zero thrust. The FO recalled feeling pressure from the left rudder pedal under his foot and he instinctively pressed the left rudder pedal. He doesn't recall carrying out any actions to identify the failed engine.

The check captain observed that the aircraft had diverged left of centreline and was in about a 15-200 left level turn. The check captain took over the role of pilot flying and called "taking over". The FO replied, "handing over" and released the controls. The check captain applied right rudder, reduced the roll to the left and increased the power on the left engine while simultaneously reducing the power slightly on the right engine. The aircraft was established in a climb and reconfigured for a normal two-engine departure.

Following the event, the FO believed that the upward pressure he felt from the left rudder pedal was due to the normal operation of the rudder boost system deflecting the right rudder during the simulated engine failure.

The operator has actively pursued the establishment of a Beech 1900 simulator in the Australasian region. The operator is hopeful that an appropriate simulator will become available shortly and will endeavour to use the simulator for non-normal training.

On 12 September 2011, a Robinson Helicopter Co. R44 Astro helicopter, registered VH-HBA, departed Heartbreak Hotel, Northern Territory, for a local scenic flight with one pilot and three passengers onboard.

The pilot conducted a thorough safety brief prior to departure. Shortly after take-off, and at about 1,500 ft above ground level, the engine fire warning light illuminated. The pilot commenced a descent to carry out a precautionary landing. Shortly before touchdown the engine oil pressure light illuminated, and the pilot observed a rapid loss of oil pressure. 

After landing, the pilot observed flames originating from under the engine cowling at the rear of the helicopter. All three passengers evacuated the helicopter. The helicopter was subsequently destroyed due to fire.

An engineering inspection could not determine the cause of the fire.

This incident highlights the importance of thorough pre-flight safety briefs. The brief assisted the passengers in being able to exit the helicopter quickly. The pilot also commented that emergency equipment stored under the seat was difficult to access in a fire. Future consideration would be given to placing this equipment in a more accessible location.

On 2 September 2011, a Howard Hughes Engineering Lightwing SP-2000 aircraft, registered 24-5040, was being operated on a private flight with the pilot and one passenger on-board. While operating to the north of Sydney Harbour, witnesses observed the aircraft descend and impact the water adjacent to the North Curl Curl shoreline. The aircraft was destroyed by the forces of the collision and one of the two occupants was fatally injured.

Recreational Aviation Australia (RA-Aus) is assisting the New South Wales Police Service with their investigation of this occurrence. Following recovery of the aircraft wreckage, RA-Aus officers requested assistance from the Australian Transport Safety Bureau (ATSB) in the recovery of data from some of the aircraft's electronic instrumentation systems and portable navigation devices. To facilitate this work, the ATSB initiated an investigation under the Transport Safety Investigation Act 2003.

In summary, four devices in total were examined by the ATSB. Raw data was successfully recovered from a portable GPS navigation unit and a fuel monitoring instrument, however ATSB analysis showed that neither data set contained usable information that was relevant to the accident flight. The data from both units was provided to RA-Aus on 26 October 2011 and the instrumentation returned on 2 April 2012.

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

What happened

On 3 September 2011, the pilot and one crewman of a Robinson Helicopter Company R44 helicopter, registered VH-HCA (HCA), departed an airstrip located near Kumarina roadhouse, approximately 150 km south of Newman, Western Australia. The crew were conducting low-level geophysical survey operations when the pilot was observed to have slumped forward in the seat. The crewman, who was seated behind the pilot, made unsuccessful attempts to rouse the pilot. The helicopter subsequently impacted terrain causing significant injuries to the crewman and pilot. After the impact the pilot regained consciousness but later succumbed to his injuries prior to the arrival of medical assistance.

What the ATSB found

The investigation found that, following the pilot’s probable incapacitation during flight, the helicopter’s descent could not be arrested before impacting terrain. It was likely that the incapacitation was of a similar nature to other previous unconsciousness events reported experienced by the pilot while not flying.

The pilot held a Class 1 Aviation Medical Certificate with no restrictions, despite inconsistencies in recorded information in the pilot’s aviation medical questionnaires, and one previous unconsciousness episode being recorded. If information about the pilot’s medical history had been accurately documented and included on the medical questionnaires, further medical tests may have been required and the results used to better assess the pilot’s current medical status.

What has been done as a result

The ATSB advised the Civil Aviation Safety Authority (CASA) of the reporting inconsistencies identified in the pilot’s aviation medical questionnaires. CASA confirmed that the medical section of the CASA website is currently being reviewed and guidance material pertaining to medical issue reporting requirements will be available on that site when that work is complete.

Safety message

In addition to the regular aviation medical assessments, should a pilot become aware of any condition that may affect their ability to safely carry out the privileges of a licence, the advice of a Designated Aviation Medical Examiner (DAME) should be sought. Additionally, all information documented on the pilot’s aviation medical assessment should be checked by the pilot for accuracy and completeness to allow for accurate assessment of medical status and potential risk to the safety of flight.

What happened

On 26 August 2011, the pilot of an MD Helicopter Inc. 369D helicopter, registered YJ‑HEL, was conducting sling load operations near a small village 183 km north‑north‑west of Port Vila, Vanuatu. As the helicopter approached the village, with two passengers onboard, witnesses heard a single, loud bang and watched the helicopter fall 10 to 15 m to the ground before coming to rest on its right side. One of the passengers received minor injuries and was able to exit the helicopter unaided. The other passenger received serious injuries, and the pilot was fatally injured.

What the ATSB found

The ATSB found that as the helicopter approached the village to land, the wire rope attached to the helicopter’s cargo hook contacted a tree. That contact resulted in the rope fouling on the main rotor blades, which in turn led to the detachment of segments of the rotor blades and the tail boom. This rendered the helicopter uncontrollable. It was also found that the occupants of the helicopter were not wearing the installed shoulder harness restraints or using flight helmets during the flight.

What has been done as a result

This investigation was conducted by the ATSB at the request of the Civil Aviation Authority of Vanuatu and no organisational or systemic issues that might adversely affect the future of aviation operations in Vanuatu were identified.

Safety message

The circumstances of this accident serve as a reminder that the severity of contact injuries in survivable helicopter accidents can be significantly reduced by the use of shoulder harnesses and protective flight helmets. As such, pilots and operators should consider the use of such equipment in the interest of enhancing survivability should an accident occur.

On 26 August 2011, at about 1545 Western Standard Time, an Air Tractor Inc. AT-802, registered VH-NIW, struck power lines and impacted terrain, during agricultural spraying operations.

Earlier that day, the pilot had commenced the first of six agricultural spraying flights. At mid-morning, he was approached by a farmer to carry out an unscheduled spraying operation of wheat paddocks next to a main road. The farmer supplied the pilot with a map of the fields to spray, which included the location of two powerlines.

On reaching the property, the pilot commenced his field inspection and identified the two powerlines and paddocks marked on the farmer's map. At the same time, he noticed vehicle traffic on the main road located next to the spraying area and a third set of powerlines.

The pilot noted a break in the traffic and commenced the spraying operation. When about 300 m into the paddock, the aircraft struck an unseen fourth set of powerlines. The aircraft's engine lost power and impacted terrain in a neighbouring paddock. The aircraft sustained serious damage, and the pilot was not injured.

This accident highlights the vital role hazard identification plays, particularly when operating at low-level, and how distractions can impact operations. It is a reminder that distractions are not unique to any one type of operation and that no pilot is immune.

On 26 August 2011, a Hawker Beechcraft Corporation B200 aircraft, registered VH-MWH (MWH), departed Ivanhoe for Broken Hill, New South Wales. While maintaining flight level 140, the pilot of MWH received a traffic alert and collision avoidance system (TCAS) traffic advisory (TA) on a Regional Express S.A.A.B. Aircraft Corporation 340B aircraft, registered VH-ZRC (ZRC), which had departed Broken Hill for Sydney and was on climb to flight level 170.

At about the same time, while climbing through flight level 130, the crew of ZRC received a TCAS TA, shortly followed by a resolution advisory (RA). As the First Officer (FO) believed they were above MWH, he immediately commenced a climb. Shortly after, the Captain noted that the FO's response was contrary to the RA command to descend and advised the FO, who immediately commenced a descent.

A review of the Airservices Australia radar data indicated that, with both aircraft at flight level 142, lateral separation reduced to 2.2 NM.

This incident highlighted the benefit of TCAS in assisting pilots with traffic awareness and the importance of responding appropriately to a TCAS RA.

What happened

At 1157 on 19 July 2011, a PZL-Mielec M18A Turbine Dromader aircraft, registered VH-FOZ, impacted terrain on a cotton station about 23 km west-south-west of Dirranbandi, Queensland while conducting a spraying flight. The pilot was fatally injured, and the aircraft was destroyed by impact forces.

What the ATSB found

The ATSB found that, for reasons that could not be determined with certainty, the aircraft departed from controlled flight during a turn at low altitude and the pilot was unable to recover before impacting the ground.

The ATSB also identified a significant safety issue affecting the safety of future spraying operations in turbine Dromader aircraft: the potential for the aircraft's centre of gravity to vary significantly depending on the weight in the aircraft's chemical/spray tank and exceed the forward and aft limits during a flight. This safety issue was unlikely to have contributed to the accident as the aircraft was probably within the approved weight and balance limits at the time of the accident.

Moreover, although also not found to have contributed to the accident, there was an increased risk to the flight from the aircraft's operation, at times, in excess of its published airspeed and angle of bank limitations.

What has been done as a result

During the investigation, the Australian Transport Safety Bureau worked with the Civil Aviation Safety Authority (CASA) and the Aerial Agricultural Association of Australia to address the risk to turbine Dromader aircraft of the potential for excessive movement of the aircraft's centre of gravity as the contents of the aircraft's chemical/spray tank are dumped or dispensed.

CASA and the owner/developer of the approval for operations at weights of up to 6,600 kg, which had effect during the flight, took action to improve operator and pilot understanding of the issue. In addition, the owner/developer indicated that the design would be reviewed to address any excessive centre of gravity variations.

Safety message

Although it was not contributory in this instance, the ATSB highlights the importance of pilots maintaining their aircraft's weight and balance within limits throughout a flight, and of understanding the implications of changing weight and balance. Similarly, the ATSB reaffirms the importance of being familiar with and adhering to aircraft operational limitations.