On 30 April 2011, the owner-pilot of a Robinson Helicopter Co. R44 helicopter, registered VH-ETT, was conducting a local flight from a private property located near Kilmore Gap, Victoria. During low-level manoeuvring at low speed around a dam, the pilot lost directional control and landed heavily in the water. The helicopter was seriously damaged; the pilot and passenger sustained minor injuries.

The investigation found that the helicopter was probably serviceable, and that the loss of directional control was likely to be a result of a loss of tail rotor effectiveness.

The emergency locator transmitter (ELT) activated on impact and prompted an effective search and rescue (SAR) response through a broadcast on the 121.5 MHz frequency. However, the 406 MHz transmission that was monitored by the SAR agency did not trigger an alert or provide identification information. As a result, there was no assurance of an immediate and effective response from the SAR agency.

The investigation found that the ELT could be programmed with identification information either directly or (if fitted) by input from a component (dongle) in the ELT wiring connector. In this occurrence, the ELT had been inadvertently reprogrammed with incorrect information from the dongle.

A minor safety issue was identified in that there were only subtle cues to distinguish programmable dongles from the standard-type wiring connector. There was also variability in the conduct of post-installation ELT testing.

In response, on 6 June 2011, the Civil Aviation Safety Authority (CASA) published Airworthiness Bulletin 25-018 to alert maintenance organisations to the risk of programming dongles transferring potentially invalid details to the memory of ELTs. CASA advised that an article in Flight Safety Australia would also highlight the issue.

The helicopter manufacturer advised that they were introducing measures to increase awareness of programming dongles in their new helicopters.

On 28 July 2011, the crew of an Embraer EMB-120 ER Brasilia, registered VH-TWZ, were conducting an instrument approach at Perth, Western Australia in frontal weather conditions that included significant thunderstorm activity. At a time of high workload, the crew's situation awareness was compromised, resulting in the aircraft flight path being above the desired descent profile. An appropriate decision was made to discontinue the approach, but during the go-around the crew did not conform to the published missed approach procedure.

As a result of the incident, the operator advised the ATSB that it had taken the following safety actions:

• simulator retraining was conducted for the flight crew with specific focus on instrument flying skills and go around procedures
• a proficiency assessment was made after the retraining
• random monitoring of crews' ongoing performance from the jump seat during normal line operations was conducted
• incorporated aspects of the incident into recurrent simulator training for all EMB-120 ER crews
• a procedure to define removal from line, retraining and return to line has been developed for inclusion in the next edition of the Training and Checking Manual

This incident highlights the need for flight crews to be fully prepared for the go-around when it is required. As a go-around is not a regular occurrence, its preparation requires a complete knowledge of standard calls, sequence of actions, task sharing and cross-checking.

On 30 July 2011, a Virgin Australia Airlines, Embraer-Empresa Brasileira de Aeronáutica ERJ 190-100 IGW aircraft, registered VH-ZPA, was being operated on a scheduled passenger service from Sydney, New South Wales to Melbourne, Victoria.

The crew were assigned the LIZZI FIVE VICTOR standard arrival route for a visual approach to runway 34 at Melbourne by air traffic control, with a requirement to cross waypoint SHEED (overhead Essendon Airport) at or above 2,500 ft.

When about 3 NM before SHEED, the First Officer (FO) disconnected the autopilot as he believed he had visually identified SHEED (Essendon Airport) and passed overhead. Immediately after, the aircraft descended through 2,500 ft. The descent was continued with the aircraft actually crossing overhead SHEED at about 1,800 ft. Neither crew identified the error until receiving altitude alerts.

The operator conducted an investigation into the incident and identified that the crew's situation awareness had reduced, resulting in the aircraft being flown 700 ft below the required altitude restriction at SHEED.

This incident emphasises the impact reduced situation awareness can have, and the importance of monitoring not only the aircraft's state, but also the actions of other crew members.

What happened

On 29 July 2011, at 0756 Eastern Standard Time, a loss of separation occurred between a Boeing Company 737-838 aircraft, registered VH-VZC (VZC), and a Boeing Company 737-8FE aircraft, registered VH-VOT (VOT), in the holding pattern at BLAKA, an IFR reporting point south-west of Brisbane, Queensland. The aircraft were inbound to Brisbane on the same air route, with a requirement to hold at BLAKA for sequencing.

The air traffic controller, who had been recently endorsed on the control position, did not identify that the sequence in which the two aircraft entered the holding pattern had changed, and twice assigned VOT descent through the flight level of VZC. The flight crew of VZC identified the confliction and queried the controller, who then took action to recover the compromised separation situation. Separation reduced to 3.9 NM (7.2 km) and 400 ft. The required separation standard was either 5 NM (9.3 km) or 1,000 ft.

What the ATSB found

The Australian Transport Safety Bureau (ATSB) identified that the controller received a reduced amount of on-the-job training, was allocated multiple training officers, and was required to intermittently staff another control position during and immediately following their training on the Gold Coast en route sector. As a result, the controller probably had not consolidated effective control techniques for the sector, particularly for high workload situations.

The ATSB also found that, even though the quality of the controller’s training had been affected by several factors, the controller’s planned on-the-job training period had been reduced from 6 weeks to 4 weeks. More importantly, there was no requirement for a systematic risk assessment to be conducted and documented when the planned amount of training for a controller was reduced.

What has been done to fix it

Airservices Australia advised that it would develop a training variation form to systematically assess risk associated with amendments to the planned length of controller training programs, and completion of the form required the involvement of the controller’s line manager and the Operational Training Manager. Airservices also indicated several other proposed enhancements to its controller training.  

Safety message

In order for the training of operational personnel to be managed safely and effectively, organisations should have a structured risk assessment process in place to evaluate proposed changes to a training program.

On 28 July 2011, a Jetstar Airways, Airbus A320-232 aircraft, registered VH-VQA, departed Newcastle, New South Wales on a scheduled passenger service to Melbourne, Victoria. The First Officer (FO) was designated as the pilot flying.

While on approach to runway 34 at Melbourne, at about 245 ft (radio altitude), the Captain realised that the landing checklist had not been completed. At the same time, the crew received a 'TOO LOW FLAP' aural and visual warning from the aircraft's enhanced ground proximity warning system (EGPWS). The Captain identified that the aircraft was not in the landing configuration, immediately called for a go-around which the FO initiated. Prior to establishing a positive rate of climb, the crew received a second 'TOO LOW FLAP' warning.

The operator conducted an investigation and determined that the following factors had contributed to the incident: incomplete approach brief, loss of situation awareness, improper coaching techniques and cognitive overload. As a result, the operator intends to:

• provide the Captain and FO with a remedial training and coaching program
• conduct a review of their command upgrade training to ensure it focuses on the development of a positive cockpit authority gradient, and the command of flight capabilities
• incorporate this incident into the command upgrade training course as a case study
• conduct a review of their recurrent human factors training.

What happened

On 28 July 2011, at around 1615 Central Standard Time, a Robinson R44 Raven II helicopter, registered VH-ZWC, departed Darwin Airport on a charter flight to Bamurru Plains, Northern Territory. Approximately 30 minutes into the flight, the aircraft lost main rotor drive and the pilot conducted an autorotative descent and landing. There were no reported injuries.

What the ATSB found

The ATSB’s investigation found that the loss of main rotor drive was associated with corrosion and subsequent fatigue failure of the main rotor gearbox gear carrier, as a result of water present in the main rotor gearbox.

What has been done as a result

The helicopter manufacturer has modified the design of the gear carrier to incorporate a metallic cadmium surface plating to improve the corrosion resistance of the assembly.

In May 2012, the Civil Aviation Safety Authority (CASA) released Airworthiness Bulletin 63-008, to raise awareness among operators and maintenance providers of Robinson R44 helicopters of the hazards associated with gearbox internal corrosion due to water ingress. The bulletin made several recommendations aimed at reducing the associated risks.

Safety message

Operators and maintainers of Robinson R44 helicopters are alerted to the potential for the ingress of water into the main rotor gearbox, and for the subsequent corrosion and possible fatigue cracking of componentry, which could lead to a loss of main rotor drive while in flight. Responsible persons are referred to the recommendations contained within CASA AWB 63-008, which are aimed at limiting the likelihood of water ingress and provide guidance on remedial action should water ingress be suspected.

On the evening of 27 July 2011, the owner-pilot of a Robinson Helicopter Co. R22 helicopter, registered VH-YOL, was conducting a local flight from Big Rock Dam to Brooking Springs homestead near Fitzroy Crossing, Western Australia. The pilot was reported missing, and the wreckage of the helicopter was located the following day, 14 km north-west of Fitzroy Crossing township. The helicopter was seriously damaged, and the pilot sustained fatal injuries.

The pilot was attempting to fly visually at low level on a dark night in an area that did not contain any local ground lighting. About halfway into the flight, the pilot inadvertently allowed the helicopter to develop a high rate of descent, resulting in a collision with terrain.

The investigation found that the pilot was operating at night without the appropriate training or qualification in a helicopter that was not suitably equipped. An examination of the helicopter found no evidence of any pre-existent defects or anomalies.

No organisational or systemic issues were identified that might adversely affect the future safety of aviation operations. However, the accident highlighted the significant risk to non‑night-qualified pilots of spatial disorientation and subsequent collision with terrain when attempting visual operations at night.

What happened

At 2019 Eastern Standard Time on 24 July 2011, a Thai Airways International Boeing Company 777-3D7 aircraft, registered HS-TKD, was conducting a runway 34 VOR approach to Melbourne Airport, Victoria. During the approach, the tower controller observed that the aircraft was lower than required and asked the flight crew to check their altitude. The tower controller subsequently instructed the crew to conduct a go-around. However, while the crew did arrest the aircraft’s descent, there was a delay of about 50 seconds before they initiated the go-around and commenced a climb to the required altitude.

What the ATSB found

The ATSB established that the pilot in command may not have fully understood some aspects of the aircraft’s automated flight control systems and probably experienced ‘automation surprise’ when the aircraft pitched up to capture the VOR approach path. As a result, the remainder of the approach was conducted using the autopilot’s flight level change mode. In that mode the aircraft’s rate of descent is unrestricted and therefore may be significantly higher than that required for an instrument approach. In addition, the flight crew inadvertently selected a lower than stipulated descent altitude, resulting in descent below the specified segment minimum safe altitude for that stage of the approach and the approach not being managed in accordance with the prescribed procedure.

What has been done as a result

In response to this occurrence, Thai Airways International issued a notice to flight crews that emphasized the importance of constant angle non-precision approaches and adherence to the segment minimum safe altitudes. Other actions included a review of the training in support of non-precision approaches and the provision of additional information relating to the use of the aircraft’s autopilot flight director system.

Safety message

This occurrence highlights the risks inherent in the conduct of non-precision approaches and reinforces the need for flight crews to closely monitor the aircraft’s flight path to ensure it complies with the prescribed procedure.

Modern air transport aircraft are equipped with ever increasing levels of automation that, when used appropriately, can greatly reduce flight crew workload. While flight crews retain the option of flying the aircraft manually, the use of automation is generally preferred and often provides increased levels of safety and efficiency. To effectively manage the aircraft and flight path, however, flight crews need to maintain a thorough understanding of the relevant automatic flight systems. Worldwide, errors associated with the use and management of automatic flight systems have been identified as causal factors in more than 20% of approach and landing accidents.

On 19 July 2011, a Virgin Australia operated Boeing Company 737-81D aircraft, registered VH-YFE, departed Brisbane on a scheduled passenger service to Mackay, Queensland. The First Officer (FO) was designated as the pilot flying for the flight.

While conducting a high-speed descent into Mackay, the aircraft became low on profile and descended below the 8,500 ft lower limit of the control area (CTA) step. The aircraft departed Class C and entered Class G airspace for 2.9 NM and 32 seconds, before re-entering Class C. A clearance to depart, or re-enter Class C airspace was not obtained from ATC.

The Captain realised that they were low on profile and advised the FO, who reduced the aircraft's rate of descent. The flight continued without further incident. No other aircraft were affected during the event.

The operator conducted an investigation and determined that the crew's situation awareness of the aircraft's descent profile and proximity to the CTA steps had reduced.

This incident highlights the effect reduced situation awareness can have on aircraft operations and the importance of using all available resources, including instruments and charts, to assist with monitoring the descent profile.

What happened

At 0900 Eastern Standard Time on 22 July 2011, a Bell 206L helicopter, registered VH-CIV, with a pilot and one passenger, departed from Rosehill, New South Wales on a private flight to the Sydney Adventist Hospital near South Turramurra. As the aircraft neared the destination, the pilot encountered low cloud and rain in the area. Shortly thereafter, witnesses observed the helicopter descending rapidly, with the tail section separated. The helicopter subsequently collided with terrain, fatally injuring both occupants.

What the ATSB found

The ATSB found it was likely that during manoeuvring in the area of low cloud and rain, the pilot inadvertently flew into reduced visibility conditions, leading to the onset of disorientation and a loss of control of the helicopter.

What has been done as a result

There were no systemic safety issues identified as a result of the ATSB investigation and no specific safety actions taken. An ATSB research report released in July 2011 addressing avoidable accidents is relevant to the circumstances found during the investigation of this accident.

Safety message

The hazards associated with visual flight into conditions of limited visibility are significant. The ATSB has investigated a number of accidents associated with visual flight rules (VFR) flight into instrument meteorological conditions (IMC), and has published several research reports into the factors that can contribute to this type of accident. The Civil Aviation Safety Authority (CASA) also maintains a library of advisory materials aimed at assisting pilots in decision-making before and during visual flights in conditions where continued visibility cannot be assured.

Pilots and operators are encouraged to familiarise themselves with guidance material on safe visual flight operations, and use this to develop appropriate strategies for planning and in-flight decision making if reduced visibility conditions are encountered.

Although no definitive conclusion could be made with respect to the extent to which any external pressures may have affected the pilot’s decision making, the accident does serve as a reminder to pilots of the need to manage pressures and external factors in the planning and conduct of any flight.