On 4 April 2010, the pilot of a Victa Airtourer 115 aircraft, registered VH-MTC was conducting a private visual rules return flight from Cambridge Aerodrome, Tasmania. The flight consisted of some aerobatics, followed by some sight-seeing over Hobart.

At about 1020, after the pilot commenced the return to Cambridge, the engine suddenly lost all power. The pilot conducted a forced landing onto a nearby road, seriously damaging the aircraft. The pilot, who was the sole occupant, was uninjured.

The investigation found that the power loss was due to exhaustion of the aircraft's fuel supply.

A number of safety issues were identified concerning the measurement of the quantity of fuel on board, and consumed before and during the flight. Those issues contributed to the pilot's belief that there was more fuel on board the aircraft than was actually the case.

As a result of this accident the aircraft's type certificate holder, aircraft owner's association and the aircraft's operator have undertaken a number of safety actions. Those actions include a number of pilot education initiatives and the amendment of the operator's maintenance processes to ensure compliance with all airworthiness directives.

In addition, the aircraft's type certificate holder is undertaking a number of enhancements in response to an unrelated Civil Aviation Safety Authority-initiated review of aspects of the aircraft's fuel system and concerns about the aircraft's original fuel system certification process.

On 24 March 2010, at about 1235 Eastern Standard Time, a Cessna Aircraft Company 208B (Caravan), registered VH-WZJ, was descending through cloud inbound to Horn Island aerodrome, Queensland (Qld), when the pilot received an aural traffic warning on the Caravan's traffic advisory system. The system indicated that an aircraft was 200 ft below and 3 NM (5.6 km) ahead of the Caravan. Communications were established with the pilot of a Pilatus Britten-Norman BN2A-26 (Islander), registered VH-WRR, who was transiting the area, and was confirmed as the conflicting aircraft.

In response, the pilot of the Caravan reported commencing a climb, and at this point observed the Islander pass to the right of the aircraft. The pilot of the Islander also reported sighting the Caravan pass above and to the right of his aircraft. It was estimated that the distance between the two aircraft was about 50 m. As a result of this incident, the following safety actions are being considered:

• The operator of the Islander is considering changing its procedures so that all flights conducted within the Torres Strait, in marginal weather conditions, are carried out under instrument flight rules (IFR).
• The Civil Aviation Safety Authority (CASA) is reviewing the two discrete frequencies currently assigned to the Horn Island and Northern Peninsula aerodrome Common Traffic Advisory Frequencies (Radio) ((CTAF(R)).

Preliminary report released 19 May 2010

On 22 March 2010, at 1009 Central Standard Time, an Embraer - Empresa Brasileira de Aeronautica EMB-120ER Brasilia with two crew, prepared to take off on a training flight from runway 29 at Darwin Aerodrome, Northern Territory. The crew were the only occupants. The training captain advised the aerodrome controller that the departure would incorporate asymmetric flight (simulated engine failure) and was approved by the controller to perform the manoeuvre.

After becoming airborne, witnesses reported seeing the aircraft roll and diverge left from its take-off path. They watched as the aircraft continued rolling left and entered a steep nose-down attitude. It disappeared into trees, south of the runway threshold from where a column of black smoke was seen shortly afterwards.

Aerodrome rescue and firefighting services were in attendance very shortly thereafter and extinguished the fire. Both pilots were fatally injured, and the aircraft was seriously damaged due to impact forces and an intense post-impact fire.

On 21 March 2010, a Gippsland Aeronautics GA8 Airvan aircraft, registered VH-AJZ, departed East Wallabi Island, in the Abrolhos Islands group, for a return flight to Geraldton, Western Australia (WA), under visual flight rules. On departure, the pilot reported observing a line of thunderstorms with frequent lightning, oriented in about a north-south direction, and approaching Geraldton from the west.

At about 27 km from Geraldton, flying through moderate rain, the pilot noted a vacuum pump failure. At about 11 km, the pilot encountered hail, and at 6 km a '...blanket of rain...' which had obscured the aerodrome, and turbulence which had increased '...quite dramatically...'.

The pilot turned the aircraft away from the line of storms to the south of Geraldton, and at 24 km and at about 1500, elected to conduct a precautionary landing. The pilot selected a suitable landing area in a paddock and landed the aircraft. The aircraft was undamaged and there were no injuries to the pilot or passengers.

Subsequent to this occurrence, the operator provided its pilots with a means for more reliable access to up-to-date weather information when on the ground at the Abrolhos Islands group.

On 17 March 2010, a Cessna Aircraft Company 152 (C152), registered VH-PVV, and a Robinson Helicopter Co. R44 (R44), registered VH-HUL, were operating from the Cessnock Common Traffic Advisory Frequency (CTAF) aerodrome, New South Wales (NSW). A flight instructor and student pilot were on board the C152 and were preparing to take off from runway 35 to commence a session of dual circuit training. At about the same time, the R44 was taxied for a departure from runway 17 grass-left on a private flight with only the pilot on board the helicopter. Both aircraft were operating under the Visual Flight Rules (VFR) in Visual Meteorological Conditions (VMC). Both aircraft's radio communication systems were serviceable and used by the pilots during the occurrence sequence.

The pilot in command (PIC) of the C152 reported taking evasive action, shortly after becoming airborne on runway 35, to avoid the R44 allegedly taking off in the opposite direction. The PIC of the R44 reported that he had positioned the helicopter outside of the runway 17 flight strip and had sighted the C152 taking off. The R44 pilot also reported that he had just transitioned into forward flight from the hover when the C152 was abeam his position and that at no time did a collision risk exist. However, the C152 pilot was adamant that the R44 commenced the take-off along runway 17 and presented an imminent collision risk.

The differing accounts from both pilots could not be reconciled. No additional reports from potential eyewitnesses were received by the ATSB. The incident serves as a useful reminder for both fixed-wing and rotary-wing pilots to review the various requirements governing their respective operations at CTAF aerodromes and, in particular, to be mindful that helicopters may not be operating to the same pattern as fixed-wing aircraft. Pilots are advised to consult relevant Civil Aviation Advisory Publications (CAAPs), effective 3 June 2010, regarding changes to operations at non-towered (non-controlled) aerodromes.

On 26 February 2010, a Cessna Aircraft Company U206G aircraft, registered VH-WYN, departed Forest River, Western Australia (WA) on a charter passenger flight to Kununurra, WA under visual flight rules (VFR) conditions.

Shortly after departing Forest River, the pilot observed dark clouds in the direction of Kununurra. The pilot listened to the aerodrome weather information service (AWIS) at Kununurra and determined that the conditions were appropriate to continue the flight. While en route, the weather conditions deteriorated further. The pilot diverted to the east in an attempt to avoid the weather, however, a rain band was also moving in a north-easterly direction.

The pilot reported that the weather conditions deteriorated around the aircraft and after considering the available options, the instrument flight rated pilot elected to enter instrument meteorological conditions (IMC). The aircraft was flown through moderate to heavy rainfall and light turbulence for a period of between 1 and 2 minutes, but remained clear of cloud. The remainder of the flight was conducted in visual meteorological conditions (VMC) and the aircraft landed at Kununurra without further incident.

Weather-related general aviation accidents remain one of the most significant causes for concern in aviation safety; the often fatal outcomes of which are usually all the more tragic because they were avoidable.

The ATSB has published several weather-related research reports. The Civil Aviation Safety Authority (CASA) also provides pilots with weather-related educational resources.

On 4 March 2010, a Boeing 717-200 aircraft, registered VH-NXM, was being prepared to depart Ayers Rock, Northern Territory (NT) on a scheduled passenger flight to Cairns, Queensland (Qld).

At about 1500 Central Standard Time, the passengers had boarded the aircraft and the pilot in command instructed the cabin crew to close the aircraft doors. The cabin crew member allocated to the forward left door had difficulty unlatching the door, so the cabin crew member allocated to the forward right door came to assist. The assisting cabin crew member placed one foot outside the aircraft onto the portable stairs to assist with closing the door. At this point, ground personnel commenced moving the portable stairs and the assisting cabin crew member fell through the open door onto the apron. The cabin crew member sustained a fractured left arm, a sprained right wrist and some other minor injuries.

The aircraft operator and ground handling agent advised the ATSB that as a result of this occurrence, the ground handling agent has issued an interim procedure, which includes increased safety checks to ensure that the aircraft's doors are closed prior to the removal of the portable stairs.

On 15 March 2010, an Airbus A320-232, registered VH-VQO, departed Adelaide, South Australia on a scheduled passenger flight to Darwin, Northern Territory. On board were six crew and 175 passengers. When climbing through 12,000 ft, the flight crew observed a loss of thrust from the number 2 (right) engine, accompanied by a loud bang and several warning indications. Passengers also reported seeing flames and smoke emanating from the right engine tailpipe.

The crew shut down and discharged both fire bottles into the right engine. They then returned and landed at Adelaide.

A post-landing inspection by maintenance personnel found metal debris and evidence of a fire in the tailpipe of the right engine. Removal and examination of the engine revealed evidence of a titanium fire that originated in the vicinity of the 6th stage high pressure compressor.

The engine was identified in an engine manufacturer service bulletin. This included new production engines that received a limited number of High Pressure Compressor Stage 6 Stator Vanes from the suspect batch. The engine manufacturer recommended certain serial number engines (which included the incident engine) in this category remain in service until the next scheduled overhaul shop visit. It was considered likely that the partial power loss was initiated by a failure of one or more of these vanes.

The operator advised the Australian Transport Safety Bureau (ATSB) that it had been operating four engines (one on each of four aircraft) that were identified within the service bulletin.

At the time of writing this report, the operator was working with the engine manufacturer to remove all four engines from service by September 2010.

The plan for the flight was for the tug aircraft to air-launch the glider and then to fly to Tipton to retrieve another glider. The glider pilot indicated to the tug pilot that he wanted to be towed to a thermal to the north west of the strip. Flying conditions in the area were reported to have been moderately turbulent.

Radio communications for the initial tow-rope hook-up were normal, with the tug pilot responding normally to the glider pilot's instructions. After becoming airborne, the tug pilot made a right turn through about 40°, onto a heading of 340°, and continued the climb. When the aircraft were about 1,200 ft AGL they encountered a strong thermal. After both aircraft had stabilised in the thermal, the glider pilot noted that the variometer was indicating lift in excess of 10 kt. He then disconnected the tow and transmitted 'rope gone' over the radio while commencing a right turn. He observed the tug aircraft begin a gentle turn to the left.

The glider pilot completed a turn through 360° and decided to fly another orbit, but at a greater angle of bank to better utilise the thermal. When heading approximately south-west at about 1600 ft, the glider suddenly yawed violently to the right and the control column was torn from the pilot's hand. At the same time, the glider adopted a steep nose down altitude. The pilot was able to regain control of the glider at a height of about 11 00 ft above ground level and saw the tug aircraft below spiralling anticlockwise towards the ground.

The pilot was able to control the glider by the use of left rudder and almost full right aileron. A right circuit was flown and the glider landed on the departure strip.

A ground witness observed the release of the tow but did not observe the mid-air collision. He and another ground witness observed the tug aircraft spiral and dive vertically into the ground. The tug aircraft impacted the ground at an indicated airspeed of 116 kts and was destroyed.

Damage to the glider was restricted to its left wing. The inboard half of the left aileron had been broken off in a downward motion. The trailing edge of the left wing was split for most of its length, and a small dent was present on the trailing edge about 500 mm from the wing root.

Examination of the impact marks on both aircraft indicated that the left wing of the tug had collided with the trailing edge of the left wing of the glider when it was banked right at about 40°. The strut attachment area on the front spar of the tug's wing had impacted the glider about 300 mm inboard of the aileron while the tug was moving outboard relative to the glider. The leading edge of the tug wing had then broken off part of the glider aileron and become snagged on the wing at the aileron cutout. This tore the wing fabric, destroying the aerofoil shape of the outboard section of the left wing. The top of the tug's left wing was then dragged inboard and rearwards across the lower surface of the glider's left wing. The top left corner of the cockpit roof of the tug probably made light contact with the trailing edge of the left wing of the glider at a point about 500 mm from the wing root. This indicated that the angle of bank of the tug was about 23° greater than that of the glider at the time of collision.

Analysis of the possible flight paths from glider release to the impact point indicated that the tug pilot might not have heard the glider pilot call 'rope gone' and could have been still trying to maintain the glider in the thermal, pending tow release by the glider pilot. It could not be determined why the tug remained in the thermal. It is possible that the tug pilot was aware that the glider pilot had released and was using the strong thermal updrafts in the manner of a glider. Other tug pilots report that it is difficult to determine if the glider is still under tow in turbulent conditions. Thus, it is possible that the tug pilot was unaware that the glider pilot had released.

The glider pilot reported that there was a significant amount of radio traffic on the local airstrip frequency at the time he released the tow. This was caused by the number of gliders in the air in both the local and Kingaroy areas. Gliding organisations use one radio frequency for operations at the airstrip and another for area operations. However, it was reported that the airstrip frequency was used almost exclusively while the area frequency received little use. In this instance, the frequency for airstrip operations was also the Kingaroy common traffic advisory frequency (CTAF).

Significant factors

The following factors were considered relevant to the development of the accident:

 The tug remained in the thermal for reasons that could not be determined.

1. The tug pilot did not see the glider in time to avoid a collision.
2. The tug pilot was unable to regain control of his aircraft due to the damaged wing.

Safety Action

Recommendation

The use of radios and control of glider operations have been the subject of investigation in three recent, fatal, mid-air collisions between gliders and fixed wing aircraft:

• Tocumwal NSW 2 November 1990 VH-CAG/GXO
• Tocumwal NSW 8 February 1992 VH-UTKlGOR, and
• This accident, Jondaryan Old 1 November 1992 VH-SCT/WGR.

The Bureau of Air Safety Investigation therefore recommends that:

1. The Civil Aviation Authority, in conjunction with the Gliding Federation of Australia, develop and implement national standard operating procedures for radio use in glider operations.