On 16 December 1988, at approximately 1015 hours a Mitsubishi MU-2B60 Marquise aircraft crashed on a Pastoral property 55 km WNW of Leonora Airfield, Western Australia. The pilot and nine passengers were killed, and the aircraft was destroyed by the impact and a subsequent fire.

The report concludes that the aircraft probably accrued icing on the frame which caused the airspeed to decrease to the point where the aircraft stalled and entered a spin; and that the pilot did not become aware of the decreasing airspeed in time to take action to prevent loss of control.

and

On 26 January 1990 at 0105 hours, a Mitsubishi MU-28-60 Marquise aircraft crashed approximately 10 km NNE of Meekatharra, WA. The pilot and passenger were both killed, and the aircraft was destroyed by impact and a subsequent fire.

The report concludes that the aircraft probably accrued icing on the airframe which caused the airspeed to decrease to the point where the aircraft stalled and entered a spin; that the pilot was not previously aware of the ice formation; and that he did not take action to prevent the aircraft's speed from decreasing.

On 10 July 2010, a Cessna Aircraft Company 210L aircraft, registered VH-FTM, was returning to Darwin aerodrome, Northern Territory (NT) after completing a scenic charter flight around the Katherine and Kakadu, NT areas.

During the approach, the pilot reported that the aircraft 'went quiet' and the engine revolutions per minute (RPM) decreased. The pilot initiated the
in-flight engine failure procedure, but the engine did not respond. After assessing the situation, the pilot determined that a landing at Darwin was not achievable and elected to land the aircraft on Casuarina Beach, NT. During the landing, the nose wheel separated from the aircraft. The pilot and five passengers exited the aircraft uninjured.

While a subsequent engineering examination and operational test of the aircraft's engine and fuel system was unable to determine the cause of the failure, the operator advised the ATSB that fuel vaporisation could have been a possible factor. As a precaution, the operator's pilots will be briefed on the in-flight restart procedure for fuel vaporisation.

This incident highlights the importance of knowing an aircraft's performance limitations and selecting an appropriate landing area within the gliding distance of the aircraft.

Abstract

At about 0830 on 8 July 2010, a crew member on board the multipurpose ship Cape Darnley was fatally injured following an explosion that occurred while he was attempting to cut the top off a 200 litre steel drum. When the oiler touched an angle grinder's spinning cutting disk onto the top of the drum, the heat generated ignited the vapours inside the drum. Once ignited, the rapid expansion of the vapour/air mixture resulted in the drum exploding.

The ATSB investigation found that an appropriate risk analysis was not undertaken and a hot work permit was not completed for the task.

The investigation also found that the oiler was not aware of the ship's work permit requirements or the risks associated with using an angle grinder to cut the top off a closed drum.

The ATSB acknowledges the safety actions taken by the ship's managers to address the two safety issues identified during the investigation.

Section 21 (2) of the Transport Safety Investigation Act 2003 (TSI Act) empowers the Australian Transport Safety Bureau (ATSB) to discontinue an investigation 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 12 July 2010, the ATSB commenced an investigation into an aircraft proximity event that occurred at about 1230 Eastern Standard Time on 8 July 2010 and involved a Reims Aviation S.A. F406 aircraft, registered VH-YZF (YZF) and a Bell Helicopter Co. 412 helicopter, registered VH-EMZ (EMZ). YZF was being operated on a search and rescue flight under the instrument flight rules and was on descent from 10,000 ft tracking 254° towards Badu Island, Queensland at the time of the occurrence. EMZ was operating under the visual flight rules on a northerly track between Thursday Island and Saibai Island. The crew of YZF reported that they saw the helicopter just after it passed beneath their level and to their right.

An initial examination of this occurrence showed that all parties to the event complied with the existing regulatory and procedural requirements for operations into Badu Island. However, in this instance, the pilot of EMZ did not hear the descent broadcast that the pilot of YZF reported making on Torres (Horn Island) Common Traffic Advisory Frequency (CTAF) 126.5 MHz.

The ATSB's primary focus is on enhancing safety with respect to fare-paying passengers and, in particular, those transport safety matters that may present a significant threat to public safety or are the subject of significant public concern. The ATSB therefore directs considerable attention to identifying systemic failures in aviation, marine, and rail mass public transport systems.

The Civil Aviation Safety Authority (CASA) released an aeronautical study into operations at Horn Island, including in relation to the airspace and radio frequency arrangements in the Torres Strait in October 2009.¹ The results of that study included that the airspace classifications around Horn Island were appropriate to the volume and complexity of the traffic in that area, and that the level of air traffic services and facilities was sufficient and provided an acceptable level of safety. In addition, the study included some recommendations for improvement. Since then, CASA has also implemented revised procedures for operations in the vicinity of non-towered aerodromes.

The ATSB therefore considered there was limited potential to enhance transport safety by continuing this investigation, and has elected to discontinue it. However, the data already collected may be used by the ATSB for future statistical analysis and safety research purposes.

¹ See horn_island_study.pdf | Civil Aviation Safety Authority (casa.gov.au)

On 1 July 2010, at 1003 Eastern Standard Time, a breakdown of separation occurred between an Airbus Industrie A320-232 aircraft and Boeing Company 767-338 aircraft, about 40 NM (74 km) to the north-west of Tamworth, New South Wales. The aircraft were operating on crossing tracks, with an angular displacement between the tracks of about 50°. Both aircraft were operating at standard cruising levels. The enroute air traffic controller first identified the confliction about 2 minutes before the separation breakdown occurred, when both aircraft were maintaining FL360 and there was 26.2 NM (48.5 km) between their lateral positions. An instruction to climb to FL370 was issued to the flight crew of the 767. When there was 14.6 NM (27.04 km) between the aircraft, the controller subsequently instructed the flight crew of the 767 to expedite their aircraft's climb. Shortly before a 1,000 ft separation standard between the 767 and A320 was established, the radar data indicated that longitudinal separation had reduced, below the required standard of 5NM (9.26 km), to 3.8 (7.04 km) NM.

This incident highlighted the importance of the provision of timely and appropriate traffic information to flight crew by air traffic control, in that it can significantly enhance pilots' situational awareness.  It also supported the opportunity for flight crew to enhance the situational awareness of air traffic control, such as in providing direct information regarding individual aircraft performance.

Airservices Australia (Airservices) has advised that they are conducting a systemic review into the number of breakdown of separation occurrences. Outcomes from that review will be considered in terms of further safety improvement. In addition, Airservices has implemented a Compromised Separation Recovery training module for enroute air traffic control groups.

On 30 June 2010, a Grob - Burkhaart Flugzeugbau G-115C2 (Grob) aircraft, registered VH-BDP, and an Avions Pierre Robin R-2160 (Robin) aircraft, registered VH‑JXY, were conducting flying training north-west of Mandurah, Western Australia (WA). On board both aircraft were a flight instructor and student.

At about 1400 Western Standard Time, the Robin was travelling to the south-west, maintaining about 3,500 ft. The instructor in the Robin reported that he had just cleared the area in preparation for conducting a manoeuvre when he saw the Grob on a reciprocal heading, at about the same altitude. The aircraft was sighted too late to take any action. The instructor in the Grob also sighted the Robin, slightly to the left, and immediately initiated a steep turn to the right. It was estimated that the distance between the aircraft was about 50 m horizontally and 150 ft vertically, with the Grob positioned above the Robin.

As a result of this incident, the operator of the Grob has modified their operating procedures so that flying training will only be conducted in the designated training area. The operator of the Robin has implemented a procedure requiring pilots to request traffic information or flight following from air traffic control prior to commencing aerial work.

On 1 July 2010, an Aeronautica Macchi S.P.A. AL60 aircraft, registered VH-ELI (ELI), departed Devonport, Tasmania (Tas.) for Portee Station, South Australia (SA) with planned refuelling stops at King Island, Tas. and Hamilton, Victoria (Vic.).

While enroute from King Island to Hamilton, the crew observed low cloud along the track and   diverted to Mount Gambier, SA to refuel. After departing Mount Gambier, the crew observed that the left fuel tank gauge was indicating half full. The crew discussed the situation and elected to continue the flight. Also, the directional gyro had to be aligned twice by the crew due to gyroscopic precession. As a result, the aircraft diverted to the left of the planned track by about 2-4 km. The crew commenced correcting the track when an inbound Pilatus Aircraft Ltd. PC-12/45 aircraft, registered VH‑FDK (FDK), passed to the left in close proximity.

It was estimated that the distance between the two aircraft was between 5 and 15 m horizontally and about 20 ft vertically.

While the operator of FDK determined that their pilot had complied with the required procedures, they advised the Australian Transport Safety Bureau (ATSB) that they will be conducting an internal education to remind pilots that maintaining a lookout and the use of radio telephony procedures are the primary tools used for traffic separation, supported by the traffic alert and collision avoidance system (TCAS).

On 22 June 2010, a Saab 340B aircraft, registered VH-KDQ, was conducting a passenger charter flight from Adelaide to Ceduna, South Australia (SA). After departure, the copilot notified the pilot in command (PIC) that he was feeling unwell. The copilot's condition deteriorated to the point where he was unable to continue the flight to Ceduna. Shortly after reaching the top of climb, the pilot in command (PIC) decided to return the aircraft to Adelaide due to the copilot's deteriorating condition.

During the event, air traffic control (ATC) was not made aware of the reasons for the aircraft returning to Adelaide. Had the wellbeing of the copilot deteriorated further during the return to Adelaide, there may have been unnecessary delays in medical help being available.

On 30 June 2010, a Cessna Aircraft Company 172H (C172), registered VH-RZV, with one pilot on board, was engaged in cattle spotting, about 21 km NNW of Cunnamulla, Queensland (Qld.).

While orbiting a water trough at about 500 ft, the pilot lost control of the aircraft. Damage to the aircraft was consistent with the right-wing colliding with a tree branch, followed by the aircraft impacting the ground inverted, with a steep nose-down attitude

The pilot sustained serious injuries, and the aircraft was severely damaged. The pilot reported that the most likely reason for the accident was an inadvertent stall. This probably occurred while the pilot was performing a steep turn, with his attention divided between flying the aircraft and looking for cattle.

Most stall/spin accidents occur when a pilot is momentarily distracted from the primary task of flying the aircraft. This accident highlights that even an experienced pilot performing a familiar task can be momentarily distracted, resulting in the loss of control of the aircraft.

On the morning of 21 June 2010, the owner/pilot of a Cessna Aircraft 172N, registered VH‑UFN, departed from a private airstrip near Woolcunda Lake, New South Wales for a flight over the pilot's property. The aircraft did not return and was reported missing that afternoon. A search was initiated and, 2 days later, the aircraft was located in Woolcunda Lake.

The investigation identified that the aircraft impacted the lake in a left banking turn. Irrespective of the reason for being at low level, it is probable that the pilot misjudged the height of the aircraft above the lake's surface or was distracted at a height from which the pilot was unable to recover before impacting the water.

Australian Transport Safety Bureau report AR‑2009-041 Avoidable Accidents No. 1: Low‑level flying addressed the dangers associated with low-level flight and in particular, the reduced time available to recover from any loss of control. This investigation provides a timely reminder of the effect on that risk of flight over expanses of flat, featureless terrain or water.