Preliminary report released 6 August 2010

On 13 June 2010, a Robinson Helicopter Co R22 Beta, registered VH-RPN, was engaged in cattle mustering operations on a station property about 257 km east-north-east of Derby, Western Australia. During those operations the helicopter collided with the ground and caught fire. The pilot, the sole occupant of the helicopter sustained fatal injuries.

Preliminary report released 15 July 2010

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.

At about 0807 Eastern Standard Time on 15 June 2010, a Piper PA-31P-350 Mojave aircraft, registered VH-PGW, with a pilot and flight nurse on board, collided with terrain in a suburban area about 6 km north-west of Bankstown Airport, New South Wales. At the time, the pilot was attempting to return to Bankstown following a reported in-flight engine shutdown. Both occupants were fatally injured, and the aircraft was destroyed by the impact forces and an intense post-impact fire.

The Australian Transport Safety Bureau has conducted a series of examinations of the propellers, engines and some associated engine and airframe components that were not destroyed during the impact and subsequent fire. The examination of the propellers indicated that, at the time of impact, the right propeller was in the feathered position and the left propeller was in the full fine position, which was consistent with low engine power. The examination of the engines did not find any evidence of mechanical failure. Impact and fire damage to the cockpit area resulted in most of the instruments and systems being destroyed or extensively damaged. The position of several cockpit switches was determined but an examination of the cockpit instruments was unable to determine any instrument indications at the time of impact.

The investigation is continuing and will include:

• an ongoing examination of operational issues including pilot training and checking
• continued analysis of recorded radar data and voice transmissions
• an ongoing human factors review.

It is anticipated that the final investigation report will be released to the public in the first quarter of calendar year 2012.

Aircraft flight path chart

On 4 June 2010, at about 1345 Eastern Standard Time, a Diamond Aircraft Industries DA40-D (DA40), registered VH-YHM, was travelling in a westerly direction towards Esk, Queensland (Qld), maintaining 2,500 ft. When passing Dayboro, Qld, the DA40 came into close proximity with a Cessna Aircraft Company 172R (C172), registered VH-RQZ, which was descending through 2,500 ft, heading to the south.

The lateral separation between the aircraft was estimated at 10 m, with the DA40 in front of, and slightly below the C172. While the pilots of both aircraft had sighted each other, there was insufficient time to respond and take any action.

The pilots both reported maintaining a visual lookout, but having been temporarily distracted just prior to the incident.

Flights conducted outside controlled airspace (Class G) are not provided with a traffic separation service from air traffic control (ATC). Consequently, maintaining separation is the pilot's responsibility. It is crucial that pilots employ a number of defences to ensure that separation between aircraft is suitably achieved. Applying unalerted and alerted see-and-avoid principles by maintaining a vigilant lookout, and providing and interpreting radio communications will assist in enhancing situational awareness.

On 2 June 2010, a Cessna Aircraft Company 172R aircraft (C172), registered VH-IMV, was cleared to line up and hold on runway 17R at Moorabbin aerodrome, Victoria. On board the aircraft were an instructor and student, with the intention of conducting a training flight to Essendon aerodrome.

After processing a number of other aircraft, the controller cleared a Cessna Aircraft Company 152 aircraft (C152), registered VH-IVT, for a touch and go on runway 17R. The C172 continued to line up and hold at the end of the runway without making any further transmissions.

A Beech Aircraft Corporation 58 then reported ready for runway 17R at taxiway Alpha 1. The controller noticed the C172 lined up and instructed the C152 on final to go around. When the C152 was upwind, the C172 was cleared for takeoff.

Although Moorabbin was a General Aviation Aerodrome Procedures (GAAP) aerodrome at the time of the occurrence, runway separation standards were required to be applied. There was a loss of separation assurance.

Airservices advised that they would introduce the use of flight progress strips for Moorabbin control tower during the second half of 2010. They also advised that they planned to conduct an ergonomic study of the Moorabbin control tower layout.

On 1 June 2010, a Fairchild Industries Inc. SA226-TC (Metro II) aircraft, registered VH-NGX, was being prepared for a charter passenger service from Perth to the Southern Cross aeroplane landing area (ALA), Western Australia (WA).

Prior to departing, the crew obtained the weather forecasts for the flight. The area forecast (ARFOR), which covered a large area, forecast fog, while the aerodrome forecast (TAF), which covered a particular location, forecast conditions as clear. The crew contacted the Bureau of Meteorology (BoM) to confirm the conditions. The crew received an amended forecast for Southern Cross indicating fog, and visibility reducing to 300 m until 0800 Western Standard Time; after this time conditions were forecast to improve.

Due to the payload requirements of the flight, additional fuel for an alternate aerodrome could not be carried as required if the weather conditions at Southern Cross were unfavourable. Consequently, the crew elected to delay the departure from Perth until 0800.

While en route, the crew observed a band of cloud between Perth and Southern Cross. On arrival at Southern Cross, the conditions were not as expected by the crew, with overcast low cloud and fog present. The crew tracked to the north of the airstrip, where the fog had cleared, and commenced the approach. In order to remain clear of cloud and maintain visual sight with the runway, the aircraft was descended to 337 ft above ground level (AGL). From this point, the crew determined that a straight-in-approach could not be conducted and a low level circling approach to position the aircraft on final for runway 14 was performed. The aircraft landed at about 0915 without further incident.

The BoM conducted a review of this incident and made a number of recommendations, including making forecasters aware of the synoptic conditions behind this incident and its consequential effect on users; and as part of a national review, establishing the minimum observation requirements needed in order to issue and maintain a weather watch on a TAF.

On 1 June 2010, an Airbus A320-232 aircraft, registered VH-VQL, was being operated on a scheduled passenger service from the Gold Coast, Queensland (Qld) to Sydney, New South Wales (NSW). On arrival at Sydney the passengers commenced disembarking through the aircraft's forward and rear doors. During this time, a ground handler drove a cargo loader towards the rear cargo door of the aircraft in preparation for unloading baggage and cargo.

When the loader was about 3 m away from the aircraft, the ground handler stopped the loader, completed the relevant safety checks and then commenced moving towards the aircraft. After moving forward about 0.3 m the loader unexpectedly accelerated towards the aircraft. The ground handler reported he was unable to stop the loader or turn it away from the aircraft prior to it impacting the aircraft just forward of the rear cargo door. The aircraft, cargo loader and rear passenger stairs sustained serious damage. No one was injured in the incident.

A subsequent inspection by the operator identified that when the throttle pedal was depressed to the full open position, the pedal would intermittently become caught on the throttle stop due to a missing striker plate on the back of the pedal assembly.

As a result of this incident, the operator inspected all their cargo loaders of the same model to ensure they were not missing the striker plate. One loader was found to be missing a striker plate and this has since been repaired.

On 30 May 2010, an Airbus Industrie A320-232 aircraft, registered VH-VQZ, departed Sydney, New South Wales (NSW) on a scheduled passenger service to the Gold Coast, Queensland (Qld). The copilot, who was under training, was designated as the pilot flying for the flight.

The aircraft arrived at the Gold Coast and an instrument approach was commenced. During the landing, the flare was initiated early and the aircraft floated along the runway. The pilot in command (PIC) instructed the copilot to lower the nose of the aircraft; however, the aircraft appeared to maintain a level pitch attitude. The PIC determined that the landing could not be achieved and assumed control of the aircraft. The PIC initiated a go around, during which time the aircraft's main landing gear momentarily contacted the runway. The missed approach procedure was commenced, and a second approach was made without further incident.

The failure to identify or execute a go around/missed approach procedure has been cited by the Flight Safety Foundation as one of the major causes of approach-and-landing accidents. This incident highlights the importance of recognising when a go around should be initiated and supports the safety benefits of being 'go-around-prepared' and 'go-around-minded'.

On 16 May 2010, an Embraer ERJ 190 aircraft, registered VH-ZPF, was being operated on a positioning flight from Adelaide, South Australia (SA) to Brisbane, Queensland (Qld). After arriving in Brisbane, the pilot in command (PIC) reported that the load and trim sheet for the aircraft was inaccurate due to certain items being counted twice in the aircraft's load and trim calculations.

It was found that an error occurred when the Adelaide airport movements coordinator (AMCO), during a period of high workload, inadvertently selected the incorrect aircraft configuration in the company's computerised load and trim system.

The aircraft was not operated outside its weight and balance limitations; however, there were implications for how the pitch trim was set prior to takeoff.

The operator has raised an amendment to its flight operations manual to clarify the correct configuration to use when compiling a load and trim sheet for a positioning flight. The operator has also implemented changes to its load control system software to prevent the inadvertent selection of the incorrect configuration while preparing a load and trim sheet.

At about 1253 Eastern Standard Time on 20 May 2010, a Bell Helicopter 206L LongRanger III helicopter, registered VH-OSU, commenced forestry spraying operations about 37 km south-south-west of Latrobe Valley Airport, Victoria. At about 1354 the pilot commenced a final spray run that resulted in the helicopter's flightpath crossing a powerline that was known to the pilot. The helicopter contacted the wire, seriously damaging the helicopter's flight control system and main rotor mast, which likely rendered it uncontrollable. The helicopter subsequently impacted the ground. The pilot was fatally injured.

The investigation found that it was likely that the pilot failed to recall the existence of the wire. The inherent difficulty of visually detecting the wire, combined with the operating groundspeed, meant that the pilot would not have had sufficient time to avoid the wire after seeing it. An examination of the wreckage of the helicopter did not find any mechanical abnormalities that might have contributed to the accident.

No permanent or temporary high visibility devices were attached to the powerlines, nor were they required to be. The helicopter was not fitted with wirestrike protection system (WSPS) equipment, nor was it required to be by aviation regulation. The investigation was unable to determine if a WSPS might have altered the outcome of the wirestrike.

As a result of this accident, Energy Safe Victoria issued a wire safety alert to aerial work operators and infrastructure providers. The Australian Transport Safety Bureau (ATSB) issued a Safety Advisory Notice to Energy Networks Australia and operators and pilots that are involved in low-level operations. The notice suggested that, where wires exist in areas where low-level activity occurs, operators and pilots consider the need for any powerlines to be marked in accordance with AS 3891.2, 2008, Part 2: Marking of overhead cables for planned low level flying operations. In addition, the ATSB has published an educational report aimed at increasing awareness among low-level operators and those agencies organising such activities. The ATSB has also commenced a research investigation that seeks to more fully understand the wirestrike risk in Australia.

At 1845 Singapore Time on 27 May 2010, an Airbus A321-231, registered VH-VWW and operating as Jetstar flight JQ57, was undertaking a landing at Singapore Changi International Airport. The aircraft was not in the correct landing configuration by 500 ft height above the aerodrome and, as required by the operator's procedures in the case of an unstable approach, the crew carried out a missed approach.

The investigation identified several events on the flight deck during the approach that distracted the crew to the point where their situation awareness was lost, decision making was affected and inter‑crew communication degraded. In addition, it was established that the first officer's performance was probably adversely affected by fatigue.

The investigation did not identify any organisational or systemic issues that might adversely impact the future safety of aviation operations. However, following this occurrence, the aircraft operator proactively reviewed its procedures and made a number of amendments to its training regime and other enhancements to its operation.