The Beechcraft Queen Air and Rockwell Aero Commander were being used by a company to conduct private category passenger-carrying flights to transport its workers from Leonora to Laverton in Western Australia. The Aero Commander had departed and was established in the Leonora circuit area when the Queen Air took off. The pilot and one of the passengers of the Queen Air reported the take-off roll appeared normal until the aircraft crossed the runway intersection, when they felt a bump in the aircraft. The pilot reported hearing a loud bang and noticed that the inboard cowl of the right engine had opened. He also reported that he believed he had insufficient runway remaining to stop safely, so he continued the take-off. The cowl separated from the aircraft at the time, or just after the pilot rotated the aircraft to the take-off attitude. He reported that although the aircraft had left the ground after the rotation, it then would not climb. The aircraft remained at almost treetop level until the pilot and front-seat passenger noticed the side of a tailings dump immediately in front of the aircraft. The pilot said that he pulled the control column fully back. The aircraft hit the hillside parallel to the slope of the embankment, with little forward speed. The impact destroyed the aircraft. Although the occupants sustained serious injuries, they evacuated the aircraft without external assistance. There was no post-impact fire. The aircraft-mounted emergency locator transmitter (ELT) did not activate.

The Aero Commander pilot reported the accident to Perth Flight Service at 1746. Flight Service advised the local police of the accident at about 1750, however, the police were unable to locate the occupants until about 1848 because the details of the aircraft's whereabouts provided by the Aero-commander pilot were inaccurate.

Sequence of events

Three days before the accident flight, the Queen Air was privately hired from its owner and used to transport ten workers from Manjimup to Leonora. During the return flight to Manjimup, the pilot discovered that the left engine had developed a fuel leak and the right engine's oil pressure indication was low. The pilot returned the aircraft to Leonora and landed without further incident. He then returned to Manjimup using a commercial air service.

On the day of the accident, the original Queen Air pilot (pilot A) returned to Leonora in the Aero Commander. He was accompanied by a Licensed Aircraft Maintenance Engineer (LAME), another passenger and another pilot (pilot B). Pilot B was to fly the Queen Air to Manjimup.

By about 1330, the LAME had repaired the left engine. Pilot A then conducted a test flight and after landing, the aircraft was shutdown and checked. He then conducted a .6 hour refamiliarisation flight with pilot B. Both pilots reported that the flight included upper air work and three circuits. The aircraft landed at about 1600.

After the refamiliarisation flight, the aircraft was again shutdown and further maintenance was conducted on the left engine. The LAME reported that while he conducted maintenance on the left engine, both pilots were standing next to the right engine with the inboard cowl of the engine open. He reported that the pilots had found a set of pliers in the engine bay. Once he had ascertained that the pliers were not his, the LAME said that he went back to work on the left engine. He reported that he did not do any subsequent maintenance on the right engine and therefore did not check the security of the cowl of the right engine before the aircraft flew again. Pilot B said that he was assisting the LAME at the left engine and that pilot A had found the pliers in the right engine bay. A witness reported that pilot A had opened the right engine cowl and retrieved the pliers however, pilot A reported that pilot B had unfastened the cowls on the right engine to check for a small oil leak.

The pilots' original intentions were that once the Queen Air was repaired, the two aircraft would return the passengers to Manjimup. However, after the test and refamiliarisation flying had been completed, and during the planning for the flight to Manjimup, the pilots decided that the weather at Manjimup was unsuitable for VFR flight. They decided to conduct the flight the following day. Consequently, the pilots, LAME and passengers went to Leonora Township to find accommodation for the night and at about 1700 they met in a local hotel. Because there was insufficient accommodation available in Leonora, the group decided to fly to Kalgoorlie that afternoon. The pilots then became concerned about the wet weather approaching Kalgoorlie and Leonora, so they decided to fly both aircraft and all the passengers to Laverton for the night. Laverton was located about 15 to 20 minutes flying time north of Leonora.

Pilot A, who was flying the Aero Commander, reported that he had conducted the take-off in daylight conditions at about 1710. Pilot B, flying the Queen Air, reported that he had started the engines at the same time as pilot A had started the Aero Commander's engines but the time was about 1720. He reported that he had conducted the take-off in daylight conditions soon after. Documentary evidence indicated that the Aero Commander had been refuelled at about 1726. A witness reported that when he was leaving the airfield, he saw the passengers about a kilometre from the airfield and walking towards it at about 1710. Another witness reported seeing the passengers still walking towards the airfield at 1720 and that the aircraft were both on the tarmac without the engines running. One of the passengers of the Queen Air recalled seeing the Aero Commander depart at about 1730.

One of the passengers in the Aero Commander reported that it was getting dark with the sun just above the horizon when he embarked in the aircraft while pilot A conducted post- refuel checks. He also reported that the Aero Commander taxied about 10 minutes after refuelling and that the Queen Air had not started at the time they taxied. One of the witnesses also reported hearing the aircraft start at about 1735 and seeing one of the aircraft take-off soon after and circle the airfield. He also reported hearing the police sirens at about 1755. The police running sheet shows the police responded to the accident at 1755.

Pilot B reported that he had conducted the run-up checks on the apron before taxying to the runway and backtracking to the threshold of Runway 30. He reported that during the take-off roll he felt a "substantial impact" when the aircraft crossed the runway intersection. The passenger occupying the front passenger seat reported feeling a "fair bump" as the aircraft crossed the intersection. Pilot B said that it was after the bump that he heard a, "loud metallic bang". He reported that the noise caused him to look across the cockpit and out the right side window. He noticed the inboard cowl of the right engine opening in the propeller slipstream. The front seat passenger recalled seeing the cowl open when the aircraft experienced the bump. He said that the cowl fully opened as the aircraft left the ground and soon after, fell away. Another passenger recalled seeing the cowl open and come off before the aircraft took off.

Pilot B recalled having set a power of 45 inches of manifold air pressure (maximum continuous power) on the engines. He also recalled rotating the aircraft to lift off at 85 kts when he saw the engine cowl fall away. He said that he maintained the power setting because he, "was being very careful to avoid an overboost (engine) condition" and that the aircraft would not climb, remaining just above treetop level. He then saw the tailings dump embankment. He said that at about that time, the front seat passenger was telling him to pull up. He pulled back on the control column and the aircraft pancaked onto the embankment.

A passenger located in the Aero Commander, reported seeing the Queen Air "wallowing at low speed" just after it took off. He said that he saw the aircraft's landing lights illuminate the tailing dump before the aircraft pitched-up and bank to the right before hitting the hill. Pilot A reported the accident to Perth Flight Service but the details initially passed indicated that the aircraft had hit the ground on the airfield. The tailings dump was about 1 km beyond the airfield boundary.

Weather information

Last light for Leonora on the day of the accident was at 1732. There was mid- to high-level cloud with the lowest base being about 16,000 ft over the Leonora area. The wind was a light north-westerly.

Airfield information

Runway 12/30 was the only useable runway at Leonora airfield at the time of the accident because extensive works were being conducted on the main runway. Runway 12/30 was not lit and was therefore, unsuitable for use at night.

Pilot Information

Pilot B had extensive experience flying single engine aircraft but had last flown a twin-engine aircraft at night 3 years prior to the refamiliarisation flight. He had not flown a Queen Air for 7 years. He had advised the owner of the Queen Air that he had 300 hours flying experience in the Queen Air aircraft type. However, his pilot's logbook revealed that he had accumulated a total of just 30 hours flying experience in the type of which about 6 hours were as pilot in command. He subsequently reported that he had gained many more, "unofficial", hours in the Queen Air.

His licence was not endorsed with a night visual flight rules (NVFR) rating and his single engine instrument rating had expired 10 months prior to the day of the accident. His multi-engine command instrument rating had expired 6 years previously. The pilot's interpretation of the regulations and orders was such that he claimed that he did not require a NVFR rating because he previously held an instrument rating. The Civil Aviation Safety Authority reported that the pilot's interpretation of the requirements was incorrect.

The pilot who conducted the refamiliarisation flying reported that the accident pilot handled the aircraft well during the short refamiliarisation flight.

Wreckage Examination

The aircraft hit halfway up the embankment of a tailing dump about 1.7 kms from the runway and slightly left of the extended centreline. The embankment was about 30 ft high, with a 38-degree slope. The trees between the runway and the embankment were about 3 to 5 m tall. The fuselage had failed at the rear window line and twisted to the left. The cabin door was torn off and the right cabin windows were broken. The rear left seat had separated from the seat rails and the forward cabin ceiling lining had collapsed onto the seats. A small aluminium ladder was on the rear right seat. Several small hand tools and three protective helmets were in the rear of the cabin. All the cargo was unrestrained although a cargo tie-down net lay loosely in the rear of the cabin. The remote ELT control switch was in the armed position but the ELT had not activated. The ELT was undamaged and mounted correctly behind the rear cabin bulkhead. A subsequent inspection of the ELT found no fault with the unit.

The inboard cowling of the right engine was missing from the wreckage. It was found resting to the right side of the runway, about 850 m from the threshold of runway 30. An engineering inspection of the engine bay and cowl found that all its latches and locking mechanisms were serviceable. The two top hinges had failed in overload. The cowl was otherwise in good condition.

The left propeller and reduction gearbox, both main gears and the lower nose gear had all separated during the accident. Damage to the blades of both propellers was consistent with both engines delivering power at impact. A considerable quantity of Avgas was drained from both wing tanks during the recovery operation. Evidence indicated that both engines were capable of normal operation at the time of the accident.

The aircraft was not fitted, nor was it required to be, with a flight data or voice recorder.

The aircraft's maintenance release had not been completed during the 8 days prior to the accident including the maintenance conducted on the day.

Circumstances:

The aircraft was operating on a pleasure flight in a mountainous area. The aircraft had been flown to the area at 6000 ft and was planned to operate below 5000 ft for 20 min before returning to Canberra. The aircraft was observed flying at low level following the floor of a valley. After completing a pass in a northerly direction, the aircraft continued tracking north-west to climb over a range. While over rising terrain, the aircraft struck a tree, the impact tearing the right wing from the airframe. The right wing remained lodged in the tree approximately 27 m above the ground while the aircraft descended through the trees and impacted the ground, on its right side, approximately 35 m beyond the first tree impact. The aircraft was destroyed by fire and the occupants received fatal injuries. Examination of the wreckage at the accident site and a subsequent strip examination of the engine did not reveal any technical defects that would have caused the accident. Examination of the propeller indicated that it was rotating as the aircraft descended through the trees but was stationary at the time of impact with the forest floor. Onsite examination of the engine revealed the throttle in the closed position and the mixture selected to 'Idle Cutoff'.

However, damage to the right wing was consistent with a high-speed impact, indicating that the aircraft possessed the necessary kinetic energy to maintain terrain clearance. The flap lever was found in the fully retracted position, a further indication that the initial impact with the tree was unexpected and did not result from the pilot attempting a forced landing in the treetops. The pilot was medically fit and endorsed on the aircraft type. The aircraft was serviceable at the time of the occurrence, but its gross weight was estimated to have been approximately 37 kg above the permissible maximum. The weather was clear and mild, but the combination of high terrain and temperature produced density altitudes between 3900 and 5500 ft which would have adversely affected aircraft performance. Reduction of available engine power, coupled with high aircraft gross weight, would have degraded climb performance and aircraft manoeuvrability, both critical factors for low level operations in mountainous terrain. The pilot had not been formally trained in low level operations, his training having been limited to low level.

Significant Factors:

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

1. The aircraft was flown at low level in mountainous terrain.

2. The pilot lacked the necessary experience for safe low-level operations.

3. The aircraft gross weight was above the permissible maximum.

4. Density altitude degraded aircraft engine performance.

5. The combination of density altitude and high aircraft gross weight degraded aircraft manoeuvrability.

6. The pilot either misjudged clearance from treetops or under-estimated the effect of aircraft inertia on aircraft manoeuvrability.

On 20 January 2011, a Piper Aircraft Corporation PA‑28-140 aircraft, registered VH-TXW (TXW), was approaching the Moorabbin, Victoria inbound visual flight rules (VFR) approach point of Brighton. At the same time, a Cessna Aircraft Company 172 aircraft, registered VH-TSP (TSP), had departed Moorabbin, tracking   for Williamstown via Brighton. TSP was at an altitude of about 1,500 ft at Brighton.

When about 1.5 NM (3 km) north-west of the Brighton visual flight rules (VFR) approach point, descending through 1,600 ft, the pilot of TXW observed TSP on a reciprocal track, about 200 ft below and a horizontal distance of 2 km. In response, the pilot of TXW took evasive action and observed TSP pass about 100 ft below the left wing of his aircraft. The pilot of TSP did not see TXW.

When flying in the vicinity of busy airports, pilots should be aware of the potential traffic conflicts, particularly around VFR approach points. The Civil Aviation Safety Authority's VFR Flight Guide recommends that aircraft departing Moorabbin should avoid the inbound approach points. For aircraft flying inbound via these approach points, it is important for pilots to maintain a vigilant lookout for conflicting traffic and be aware that aircraft may be in unexpected locations.

On 26 January 2011, at about 1315 Eastern Standard Time, a Robinson Company R44 Clipper II helicopter, registered VH-HFG, departed the Knuckle Reef Helipad, Queensland, for a 20-minute charter flight. On board the helicopter, were the pilot and three passengers. While returning to the Helipad 15 minutes later, at about 950 ft above mean sea level, the helicopter experienced mechanical problems, including a sudden loss of cylinder head temperature indication and variations in the engine manifold pressure.

The helicopter was unable to maintain altitude and began to descend at 200 ft a minute. The pilot elected to conduct a precautionary water landing, about 3.5 NM (6.5 km) south of Knuckle Reef and 0.5 NM (0.9 km) east of Line Reef. The pilot inflated the emergency floats, commenced an auto rotation at 500 ft and landed on the sea in a 1.5 m swell. The pilot secured the helicopter and radioed his GPS coordinates to another helicopter, who relayed these to Hamilton Island air traffic control. The other helicopter then liaised with the passenger transfer boat from Knuckle Reef, which picked up the pilot and passengers from HFG.

The helicopter was unable to be recovered before rapidly drifting into the path of an oncoming cyclone. A subsequent search failed to locate the helicopter which is presumed to have sunk.

The pilot's training underpinned the successful precautionary autorotation water landing onto a 1.5 m swell, thereby preventing significant injuries to the occupants.

On 20 January 2011, a Pacific Aerospace Corporation Cresco 08-600 aircraft, registered VH-KPY, was conducting a low level survey flight in the vicinity of Bingara, New South Wales.

The survey flight was conducted at 130 ft above ground level. During the fourth survey line the aircraft struck a powerline. The powerline was strung between two hilltops about 1,000 m apart at a height of 130 ft.

Following the collision with the powerline, the pilot noticed the wing skin was torn and he experienced some difficulties in controlling the aircraft.

The pilot elected to conduct a forced landing. During the landing the right wing collided with a hay bale. The pilot was not injured.

As a result of this accident, the aircraft operator intends to contact the power authority in each state to request the location of powerlines which they will overlay onto their Google Earth and topographic plans. It is proposed that this will occur on all surveying flights that present a risk.

The operator is also considering increasing the minimum height at which a survey can be conducted. If lower survey heights are required, and assessed to be suitable, they will be conducted by more experienced flight crew.

Safety summary

What happened

On 16 January 2011, while the products tanker Qian Chi was at anchor in Moreton Bay, Queensland, the ship’s number two oil-fired thermal oil heater exploded. The explosion seriously injured three crew members and severely damaged the thermal oil heater and surrounding equipment and fittings. The injured crew members received only rudimentary first aid on board. Shore-based emergency paramedics attended the ship and the injured crew members were evacuated by helicopter for treatment and recuperation.

What the ATSB found

The ATSB found that, during maintenance, the thermal oil heater burner nozzle had been assembled incorrectly. This was because the crew lacked experience with the equipment and the manufacturer supplied instructions were not clear and detailed. As a result, the nozzle leaked fuel into the furnace throughout the pre-ignition start sequence. The furnace exploded when the burner igniter started.

The ATSB also found that the ship’s crew were not aware of the importance of providing immediate and accepted first aid treatment for burn injuries. It was also found that deficiencies in the Brisbane port vessel traffic service procedures and preparedness contributed to delays in providing emergency assistance.

What has been done as a result

The ship’s operators have renewed the burner equipment installed in the ship for both oil-fired thermal oil heaters and altered the control system to better suit the fuel being used and the load demands placed on the heaters.

The heater’s supplier, Garioni Naval, advised they were updating documentation supplied with their machinery. They had also been in contact with the burner equipment manufacturer and others regarding this incident and equipment design.

Maritime Safety Queensland has undertaken a review of its procedures and practices to take into account the risks associated with ships within port limits but not at a berth and the emergency response required in such situations.

Safety message

Ship’s crew should remain vigilant to safety even when conducting repeated or seemingly simple tasks. Personnel need to consult equipment documentation and pay increased care and attention when undertaking unfamiliar tasks. To support that process, equipment documentation needs to be comprehensive and accurate.

Ship’s crew should also understand the importance of providing immediate and appropriate first aid to injured persons, especially burn victims. Burn injuries should always be immediately cooled, under clean, cold running water, for at least 10 minutes.

Preliminary report released 9 March 2010

Abstract

At about 1603 on Tuesday 28 December 2010, freight train 1MP5 derailed on the Trans Australian Railway Line approximately 240 km east of Kalgoorlie in Western Australia. There were no injuries as a result of the derailment but there was significant damage to rolling stock and track. The investigation to date indicates that the most probable initiator of the derailment was a track misalignment due to a heat related track buckle. The investigation is examining a number of other factors that contributed to the magnitude of the derailment.

The information contained in this preliminary report is derived from the initial investigation of the occurrence. Readers are cautioned that it is possible that new evidence may become available that alters the circumstances as depicted in the report.

On 27 December 2010, a SOCATA TB-10 Tobago aircraft, registered VH-YTF, was being operated on a solo flying training exercise. The planned exercise was from Parafield, South Australia to Mildura, Victoria, then overflying Remark, Swan Reach, and returning to Parafield. On climb out of Renmark, the pilot reported feeling hot and began to sweat. He checked that the cabin heat was selected off and the cabin air vents were open and climbed to 6,500 ft to allow cooler air into the aircraft.

The pilot reported that he lost consciousness in the climb with the aircraft auto-pilot engaged in heading mode and the elevator pitch setting trimmed for the climb attitude.

It is estimated that the pilot remained unconscious for approximately 55 minutes. The aircraft remained on a heading of 234⁰ magnetic and climbed to 8,000 ft before descending again to 6,500 ft.

The pilot regained consciousness approximately 12 NM (22 km) south-west of Adelaide Airport and responded to a radio call from Adelaide Radar. He was issued a clearance to return to Parafield Airport.

Subsequent medical examinations could not find the cause of the loss of consciousness. The pilot's medical certificate was subsequently suspended.

Both the ATSB and Civil Aerospace Medical Institute of the U.S. Federal Aviation Administration have conducted recent research into pilot incapacitation. The reports conclude that medical incapacitation is a rare event. The most common causes of loss of consciousness were gastrointestinal, neurological, cardiac and urological events.

On 31 December 2010 a Cessna Aircraft Company C404 Titan aircraft, registered VH-LAD, departed Alpha Airport, Queensland, to conduct two survey flights. Onboard the aircraft were the pilot and two navigators. The intention was to climb to a flight level of 16,000 ft, conduct two survey runs and then land at Emerald, Queensland. Nearing the completion of the first survey run, the pilot noticed a fluctuation in the left fuel flow and decided to land at Emerald. The pilot calculated that he still had 300 L of fuel onboard, but did not check the fuel gauges.

Shortly after, both engines failed, and the pilot lowered the landing gear. After securing both engines, the pilot reduced airspeed to 115 kts which gave a 1000 ft/min descent rate and at 14,000 ft the aircraft was 17 NM from Emerald. The pilot then transmitted a PAN call informing air traffic control of their position. With both propellers feathered the pilot made a forced landing at Emerald Airport. After landing, the pilot checked the aircraft fuel gauges which showed the tanks as empty.

In response to this occurrence, the aircraft operator implemented the following proactive safety actions:

• This incident was raised as the topic of safety during the January 2011 internal safety meeting.
• An emergency response plan has been developed, implemented and tested ensuring company management and staff can react quickly in the unlikely event of an incident or emergency
• All aircrew are participating in an aviation approved crew resource training management course. Training records will be published in relevant pilot record files.
• Fuel totalisers are scheduled for fitment in both 400 series Cessna aircraft operated by the company to provide a more accurate means of establishing fuel used and quantity remaining.
• The operator's managing director has raised this serious safety incident, with the board of directors of the parent company and has taken steps to reinforce the existing proactive movement towards safety, implemented within both companies.

On 3 January 2011, at about 1530 Eastern Standard Time a Robinson Company R44 Raven 1 Clipper helicopter, registered VH-HOT, departed Cairns Airport, Queensland for a 30-minute charter flight. On board the helicopter was the pilot and three non-English speaking passengers. About 25 minutes into the flight, at about 400 ft above sea level, the engine failed and the rotor low rpm horn sounded. The pilot broadcast a Mayday and entered autorotation. During the descent he deployed the inflatable floats, however the right float did not fully inflate.

The pilot stated that at 50 ft above the sea, the helicopter entered an uncommanded 360⁰ yaw to the left. The pilot was unable to control the yaw, and the helicopter impacted the water heavily and turned onto its right side. The pilot assisted the passengers to egress the helicopter and inflated their life preservers. They were rescued from the water by fishermen in a small boat.

As a result of this accident, the aircraft operator has advised the ATSB that they are taking the following safety actions:

• A GPS-based flight monitoring system is to be installed on the operator's passenger-carrying aircraft.
• Cutters for harnesses to be carried on aircraft.
• A 406MHz impact activated emergency locator beacon to be installed on all company aircraft.
• Passengers are to be briefed in small groups of 4-6.
• A review is to be carried out of the emergency response procedure for the operators Cairns base.
• The operator's latest safety minutes emphasises the requirements and value of using the maintenance release for defect reporting.

In July 2003, the Robinson Helicopter Company released a safety notice, SN-39. This notice addressed unusual vibration that can indicate a main rotor blade crack. It directs pilots to make an immediate safe landing if main rotor vibration rapidly increases or becomes severe during flight. They are not to attempt to continue flight to a convenient destination.