On 12 August 2010, a Cessna Aircraft Company U206F aircraft, registered VH-TZV, was conducting parachuting operations near Gladstone, Queensland. Soon after take-off, as the aircraft was climbing through 1,000 ft, the aircraft's engine lost power.

The pilot was unable to restart the engine and conducted an emergency landing in a field. The aircraft was significantly damaged and some of the occupants sustained serious injuries.

The reason for the engine failure could not be determined.

Pilots should consider the effect an in-flight engine failure at low altitude would have on the time available to manage the failure and identify a suitable forced landing area. In this instance, the pilot was able complete some emergency checks and turn the aircraft away from a water course in an attempt to conduct a forced landing on a gravel road. It is likely that this action positively influenced the outcome for the occupants of the aircraft.

At about 1545 Eastern Standard Time on 7 August 2010, while returning to Moorabbin Airport, Victoria after conducting aerial photography work, the pilot of a Cessna 152 aircraft, registered VH-KKW, experienced a total loss of power that resulted in an emergency landing approximately 200 m short of the airport. The aircraft was significantly damaged. The pilot and single passenger sustained minor injuries.

The investigation found that the pilot, when preparing for the flight, had misread the aircraft's initial fuel state and had subsequently uplifted a lesser quantity of fuel than required for the flight. Although the fuel remaining was greater than the manufacturer's stated unusable quantity, the investigation determined that the accident was the result of fuel starvation. The aircraft was prone to asymmetric fuel delivery allowing one tank to deplete quicker than the other. That action may have led to the aircraft unporting fuel from the low quantity tank during manoeuvring, which allowed air to be drawn into the engine. The investigation identified inconsistencies in the application of the operator's procedures for recording aircraft fuel states.

As a result of the accident, the operator re-designed the flight time and serviceability log to provide clearer application and recording of aircraft pre- and post-refuel fuel state. It also advised that it had: introduced a requirement that a formal 'Fuel Required' calculation be made for all flights leaving the circuit or training area, with a copy to be attached to the passenger list/weight and balance data; inspected the seat-locking mechanisms on all club aircraft and reminded all staff/students/members of the importance of ensuring all seats are locked; and reviewed training requirements for engine failure

Pilots are reminded that there is the potential for asymmetric fuel delivery on Cessna 152 aircraft and as well as monitoring fuel use, they need to be alert to such situations, particularly in minimal fuel states.

The ATSB has completed its examination of the cockpit voice recorder from a Sikorsky UH-60 helicopter, registered A25-204, on behalf of the Australian Directorate of Defence Aviation and Air Force Safety (DDAAFS). The helicopter had been involved in an air safety occurrence during a training operation on 23 July 2010.

The Australian Directorate of Defence Aviation and Air Force Safety is responsible for investigating this occurrence. On 10 August 2010, DDAAFS requested assistance from the Australian Transport Safety Bureau (ATSB) in the recovery of information from a cockpit voice recorder (CVR) that was fitted to the helicopter.

To protect the information supplied by DDAAFS to the ATSB, and the investigative work undertaken to assist the Directorate, the ATSB initiated an investigation under the Transport Safety Investigation Act 2003.

The CVR was successfully downloaded on 13 August 2010 and a copy of the data file was provided to representatives from DDAAFS. The CVR was returned to the DDAAFS representatives following the download.

Information publicly released by DDAAFS is available on the Department of Defence website: www.defence.gov.au

Contact details for DDAAFS are:

Air Force Headquarters
Department of Defence
Russell Offices
Canberra ACT 2600

Switchboard: (02) 6265 9111

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

Abstract

At about 1121on 17 June 2010, a safeworking irregularity involving CityRail passenger service SN57 and train D231, a Pacific National light engine, occurred at Moss Vale in New South Wales. On the day of the occurrence, planned maintenance on the Argyle Street bridge, (southern end of Moss Vale) was being conducted in accordance with ARTC's SAFE Notice 2-1334/2010. By way of the SAFE Notice, the Australian Rail Track Corporation (ARTC) had promulgated that Down CityRail services would be routed from the Down Main via 140 points set reverse (an unsignalled movement) then terminate alongside the Moss Vale Up Platform before forming the return Up service to Campbelltown.

The investigation determined that the network controller, in error, gave the driver of CityRail passenger train SN57 verbal authority to pass signals MV15 and MV39 in the Stop position, over 140 points set reverse, to access the Up Platform at Moss Vale. A little earlier, the controller had authorised train D231 to travel into the Moss Vale Up Refuge Siding, also over 140 points, thereby placing the two trains into direct conflict.

Fortunately the network controller recognised the error and stopped train D231 about 200 m before 140 points, the potential point of conflict. There were no injuries or damage to rolling stock or infrastructure as a result of the incident.

The investigation established that an error by the network controller was the main factor contributing to the incident. However, the ATSB considers that the use of a checklist or similar systemic defence measure by network controllers for this type of working may enhance the integrity of ARTC's current safeworking arrangements.

Abstract

At about 0840 on Wednesday 4 August 2010 a safeworking incident occurred within the Junee station yard limits when a locomotive was moved from one road to another without authority while a Track Occupancy Authority (TOA) was in force. No injuries or damage resulted.

The investigation identified the following:

• non-conformances to the rules in regard to communication by the train drivers and protection of the fixed worksite
• deficiencies in the rules relating to lines of communication and protection of infrastructure booked out of service.

The investigation concluded that it was unlikely the safeworking incident would have resulted in a breach of the worksite at Junee station yard.

On 5 August 2010, the crew of a Fairchild Industries Inc. SA227-AC aircraft, registered VH-TAG, were cleared for a visual approach to runway 30 at Williamtown aerodrome, New South Wales (NSW) by air traffic control (ATC). The flight was a scheduled passenger service from Canberra, Australian Capital Territory (ACT), with two crew and 18 passengers onboard.

After landing, the crew was instructed by ATC to taxi to holding point Alpha, runway 30. During the taxi, the crew received an amended clearance to taxi to holding point Bravo, runway 30.

On approaching holding point Bravo, the crew checked the runway for other aircraft and taxied beyond the holding point. The crew was instructed by ATC to hold short of runway 30. The crew immediately stopped the aircraft and advised ATC that the aircraft had crossed the holding point, but was about 5 m away from the edge of the runway.

Shortly after, the crew observed a Boeing F/A-18 Hornet aircraft takeoff. About 10 seconds later a second Boeing F/A-18 Hornet took off on runway 30.

The crew discussed the incident and determined that they had not received a clearance to cross runway 30.

This incident highlights the importance of pilots utilising all of their available resources to confirm if the appropriate clearance has been received from ATC. Furthermore, if there is some doubt as to the location of other aircraft operating in the area, contact ATC or the pilot of the other aircraft to establish their position.

On 30 July 2010, an Aerospatiale Industries AS.350BA (Squirrel) helicopter, registered VH-HVT, was being flown up a valley between Healesville and Narbethong, Victoria (Vic.). There was low cloud in the area, which was sitting on a ridgeline the helicopter needed to cross. The pilot reported that he hovered the helicopter near the ridgeline, about 10 ft (3 m) above the tree canopy and on the edge of the cloud base for about 2 to 3 minutes, hoping for a break in the cloud sufficient to allow passage.

The pilot reported that he decided it was not possible to cross the ridgeline and commenced a right turn to return via the same route. About two thirds of the way through the turn, when the helicopter was travelling at between 10 and 15 kts, it struck a branch that was protruding above the tree canopy. The branch broke the helicopter's right side chin bubble and brushed against the side of the helicopter. The pilot assessed the damage and decided to continue the flight back to Essendon, Vic. The helicopter landed at Essendon without further incident.

An inspection of the helicopter found that the branch had scraped against the flat side of one of the tail rotor blades. A closer examination of the blade found a small void in the composite core of the blade. The blade was subsequently repaired and returned to service.

On 16 July 2010, the pilot of a Cessna Aircraft Company 210M on a passenger charter flight was preparing to land at Mount Borradaile Station, Northern Territory (NT). The pilot reported that it was quite windy during the approach, with the aircraft being blown off course. At about 300 ft above the airstrip, a small bird struck the windshield and briefly distracted the pilot. The pilot continued the approach. Just prior to touch-down the aircraft was picked up by a gust of wind. After the pilot corrected this, the aircraft touched down, but bounced three times.

The pilot assessed that there was not enough landing strip left to recover and initiated a go-around. The pilot pushed the throttle forward and raised the flaps to 15 degrees. As the aircraft took-off from the strip, the pilot retracted the undercarriage. The aircraft failed to climb and settled back onto the strip, skidding for about 30 m on its belly, before coming to rest prior to the end of the strip. The pilot and passengers were uninjured; however, the aircraft sustained minor damage.

On exiting the aircraft, the pilot realised that the pitch and mixture controls had not been placed in the full forward position resulting in insufficient power for the go-around.

This occurrence highlighted the potential impacts of distractions on the safety of operations. The following report (available at www.atsb.gov.au) provides further information:

• Dangerous distraction: An examination of accidents and incidents involving pilot distraction in Australia between 1997 and 2004 (2006)

The ATSB has completed its technical examination of a cockpit-mounted Global Positioning System (GPS) unit from Hughes Engineering Lightwing SP-2000 aircraft, registered 24-7057. The aircraft was involved in a fatal accident on 4 April 2010 at Tartrus Station, Queensland.

Recreational Aviation Australia Inc (RA-Aus) is assisting the Queensland Police in their investigation of this accident. RA-Aus requested assistance from the Australian Transport Safety Bureau (ATSB) in the recovery and analysis of information from the GPS unit, which had been recovered from the aircraft wreckage by RA-Aus investigators. To protect the information recovered from the GPS unit and the investigative work undertaken to assist RA-Aus, the ATSB initiated an investigation under the Transport Safety Investigation Act 2003.

In summary, while the GPS unit was found to be functional, the ATSB's examination of the device found that the unit's track and data recording functionality had not been enabled, and as a result, there was no data relating to the accident able to be recovered.

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

On 13 July 2010, a Cessna Aircraft 210M aircraft, registered VH-TIJ, with two people on board was engaged in geophysical survey operations about 100 km south of Kalgoorlie, Western Australia (WA). Shortly after commencing a grid survey at low level, the aircraft collided with terrain in a shallow descent at around 140 to 150 kts in a wings level attitude. The pilot and survey equipment operator received serious injuries and the aircraft sustained serious damage.

The equipment operator raised the alarm and maintained contact with the rescue coordinators throughout the operation. He may have reduced the extent of his injuries had he been wearing his upper body seatbelt restraint. The emergency locator beacon fitted to the aircraft failed to activate.

As a result of this accident and a previous industry accident in December 2009 involving a different operator and owner, the geophysical survey company have been investigating the fitment of a 4-point harness into the operator's seat, and movement of the equipment such that the operator could still complete his/her work.

They further advised that they have already placed 4-point harnesses in the pilot's seat in their other aircraft and expect engineering work to be completed to allow modification of the operator position soon.

The aircraft operator advised that they were undertaking work on the radio altimeters fitted to survey aircraft to add an aural warning function to the existing warning light to enhance pilot awareness of when the selected aircraft operating height has been acquired.

The aircraft was fitted with a ME406 emergency locator beacon that was designed to be activated by impact forces. No activation was recorded probably because a necessary jumper link had not been installed. The Civil Aviation Safety Authority (CASA) has undertaken to raise industry awareness of the circumstances of this beacon non-activation through publication of an article in the next Flight Safety Australia Magazine. This article will highlight correct emergency locator transmitter (ELT) installations and possible pitfalls of not following approved methods and designs.