On 20 June 2007, at approximately 0615 Western Standard Time, a Cessna Aircraft Company C208 Caravan float plane, registered VH‑NRT, departed Broome Airport, WA on a Visual Flight Rules (VFR) charter flight to Talbot Bay. On board the aircraft were the pilot and 10 passengers.

About 35 to 40 minutes into the flight, the weather conditions deteriorated, and the pilot elected to discontinue the flight and return to Broome. During the return flight, the aircraft entered an area of reduced in-flight visibility that resulted in the loss of the visual horizon.

Whilst manoeuvring the aircraft to regain visual meteorological conditions (VMC), the pilot became disoriented. The pilot made a general radio broadcast requesting assistance, which was intercepted by the crew of another aircraft who then provided advice and reassurance to the pilot. The pilot was able to regain control of the aircraft and, shortly after, resume the remainder of the flight.

The approach to Broome required the non-instrument-rated pilot to descend through cloud before becoming visual and landing.

This incident highlighted the risks of inadvertent flight into Instrument Meteorological Conditions (IMC) and of the recovery from those conditions, particularly in respect of a pilot that does not hold an instrument rating.

Aviation Safety Recommendations

[ R2007014SR029 ] [ R2007014SR030 ]

On 13 June 2007 at about 1335 Eastern Standard Time, a Bell Helicopter B206B helicopter registered VH-JWM (JWM) departed Mackay, Qld on a charter flight to a container ship, located about 180 km offshore. The helicopter was engaged in the transfer of a marine pilot to an offshore ship. On board were the pilot and the marine pilot. The flight was operated under the visual flight rules (VFR). The pilot later reported that at about 1423, while about midway between Mackay and the ship at about 1,500 ft above mean sea level, the helicopter sustained an engine power loss. The pilot reported that the first indication was a slight yaw kick in the helicopter. He reported that he immediately lowered the collective control and configured the helicopter descent profile for an auto-rotation emergency landing. The pilot reported that he broadcast a MAYDAY on both the operator's and air traffic control radio frequencies. The pilot reported that he then reduced the forward airspeed of the helicopter, confirmed the inflation of the pop-out floats on the helicopter's skids, flared the helicopter and landed in the ocean. He reported that at this point, the helicopter was floating on the ocean and the main rotor blades had nearly stopped rotating.

The 2 to 3 m sea swells caused the helicopter to roll to its left and become inverted. The two occupants sat on the overturned helicopter until they could inflate and enter a four-person life raft.

About one and one-half hours after ditching, they recovered by another company helicopter and transported to the Mackay Base Hospital. They sustained only minor injuries. After several weeks floating, the helicopter eventually submerged and was not recovered until 26 September 2007. The damage to the wreckage prevented the investigation from obtaining any additional information in relation to the engine failure.

On 31 May 2007, the pilot of a Beech Aircraft Corp. Super King Air, registered VH-XCB, was conducting an Area Navigation (RNAV) Global Navigation Satellite System (GNSS) non-precision approach (NPA) to runway 36 at Ballarat, Vic. in instrument meteorological conditions (IMC) as part of a check flight for renewal of a command instrument rating. While conducting the approach, the check pilot on board visually determined that the aircraft was displaced outside the permitted lateral tolerances of the published final approach track. The pilot's primary flight display showed that the aircraft was within permitted tolerances and there were no associated messages or alerts.

An examination of the aircraft's navigation equipment by an avionics technician found that the installation was not approved for the procedure and a technical problem prevented the equipment from meeting approval standards.

The operator of the aircraft annotated the aircraft's maintenance release to reflect that the Global Positioning System (GPS) was not approved for use in the conduct of RNAV (GNSS) NPAs.

During the Australian Transport Safety Bureau investigation into the accident at Lockhart River, Qld on 7 May 2005, involving the Metro 23 aircraft registered VH-TFU, it was established that it was possible to receive ground proximity warning system (GPWS) warnings while conducting the Runway 12 RNAV (GNSS) non-precision approach, even when the aircraft was on the correct profile and track. After several reports of crews receiving such warnings, an investigation into the potential safety implications of these 'nuisance' warnings' was commenced. It was found that nuisance warnings could condition flight crews to ignore the warnings in order to complete the approach procedure, rendering the warning system ineffective in preventing controlled flight into terrain.

The safety issue identified as a result of this investigation related to the generation of 'nuisance' GPWS warnings while conducting the Runway 12 RNAV (GNSS) non-precision approach at Lockhart River. Airservices Australia have commenced designing a revised approach using new approach design criteria, and the Civil Aviation Safety Authority has undertaken to flight validate the revised approach when available.

On 26 May 2007 at about 1644 Western Standard Time, a Piper Aircraft Corp PA-28RT-201 aircraft, registered VH-FTT, departed Jandakot Airport for Esperance, WA. On board the private, visual flight rules (VFR) flight were the non-instrument-rated owner-pilot, and two passenger friends.

The flight arrived at Esperance about 1 hour and 40 minutes after last light, and in marginal weather conditions. The aircraft impacted the ground on what appeared to be a right base for runway 11. There were no survivors.

There was no evidence of any technical defect or other failure of the aeroplane, or of its associated systems, prior to the impact with terrain. That, and the normal operation of the approach and landing aids, and apparent activation of the aerodrome lighting, suggested that the most likely factors that contributed to the development of the occurrence related to the operation of the aircraft.

The investigation was unable to conclusively establish the reason for the impact with terrain. The investigation could not exclude the possibility of a sudden incapacitation of the pilot due to a cardiac condition. However, the weather conditions enroute to, and in the vicinity of Esperance were such that the pilot's decision to attempt the flight indicated a low appreciation, or an acceptance, of the associated risks. The attempted approach and landing under those conditions represented a significant level of risk for any flight attempted under the night VFR.

A Raytheon Beech King Air aircraft, registration VH-IWO, was cruising at FL290 on an aero-medical flight from Newman to Fitzroy Crossing, WA with the pilot, a flight nurse and a doctor on board. When approximately 140 NM (259 km) south-south-east of Broome, the right engine inter-turbine temperature indication (ITT) was observed by the pilot to rise without any engine control input. The ITT rise was accompanied by a slight fluctuation in a number of associated engine indications. The pilot reduced power on the right engine.

Shortly after the power reduction, there was a slight right engine surge, with an accompanying rise in ITT. The pilot observed smoke coming from the right engine exhaust. The pilot shut down and secured the right engine and, after briefing the flight nurse and doctor, diverted to Broome Airport where a single-engine landing was completed.

Examination of the right engine revealed extensive damage caused by the separation of one of the compressor turbine blades at mid span.

As a result of this occurrence, the engine manufacturer has modified the alerting feature in the case of the interruption of the supply of electronic trend monitoring (ECTM) information to customers from its automated ECTM program.

At about 1030 Eastern Standard Time on 23 May 2007, a Piper Aircraft Inc. PA-32-260 aircraft, registered VH-PYD (PYD), departed Horn Island, Queensland, for a visual flight rules charter flight to Warraber Island, Queensland, with the pilot and three passengers onboard. Approximately 25 NM from Warraber Island, the aircraft experienced difficulties with the powerplant and was forced to ditch into the waters of the Torres Strait. Having received only minor injuries, the occupants exited the aircraft before it sank. The occupants were located and rescued within an hour of the ditching.

Shortly after commencing the descent into Warraber Island, the pilot noticed that the engine speed had increased beyond the normal range. Several unsuccessful attempts were made to reduce the engine speed, and within a short time the engine stopped producing power. Without engine power, the aircraft was not able to maintain altitude and given the aircraft's distance from land was forced to ditch into the water.

Because the aircraft was not recovered, the factors that resulted in the powerplant failure could not be determined; however, it was probable that they were related to a problem with the forward most crankshaft bearing.

In addition to the favourable sea, the pilot's recently acquired knowledge from the company's emergency procedures training likely contributed to the successful ditching.

On 17 May 2007, a de Havilland Dash 8, registered VH-TQP, and a Beechcraft Baron D55, registered VH-ILS, were operating in the vicinity of the Port Macquarie CTAF(R) Aerodrome. At the same time, the pilot of an Aeroprakt A22 Foxbat, registered 24-4422, was taxiing to conduct circuits from runway 21. The Foxbat was operating under the visual flight rules (VFR).

The pilot of the Baron initiated a go-round from short final approach to runway 03 as the Foxbat took off from runway 21. The crew of the Dash-8 subsequently conducted a go-round from final as the pilot of the Foxbat also turned onto final for runway 21 in front of the Dash-8.

A short time later, the pilot of the Foxbat landed without further incident. A club instructor inspected the Foxbat's radio after engine shutdown and found that the radio volume was at a low setting.

On 8 May 2007 at about 1858 Eastern Standard Time, a Boeing Aircraft Company 767-338 (767), registered VH-OGI, was inbound to Sydney, NSW from Melbourne, Vic. on descent to 6,000 ft and a SAAB Aircraft Company 340B (SAAB), registered VH-OLL, was departing Sydney for Moruya, NSW on climb to FL140. The distance between the aircraft reduced to 1.5 NM horizontal and 400 ft vertical separation. Separation standards as specified in the Manual of Air Traffic Services (MATS) required the provision of either 3 NM horizontal or 1,000 ft vertical separation between the aircraft. There was a breakdown of separation.

The apparent distraction of the controller by his involvement in a non-operational control room discussion would probably have adversely affected his mental 'air picture' and traffic planning. That included unintentionally clearing the flight crew of the SAAB to climb through the assigned level of the inbound 767, rather than the routinely assigned intermediate altitude of 5,000 ft. The traffic manager's preoccupation with administrative duties meant that the monitoring and control of the distraction risk and operational activities in the control room was ineffective.

Action by the controllers to issue traffic information to the flight crew of the 767 and a radar vector and altitude limit to the flight crew of the SAAB quickly re-established the required separation standards.

Although no safety issue was identified as a result of this investigation, in its submission in response to the draft report, Airservices Australia (Airservices) advised of its development of an Air Traffic Control (ATC) Reform initiative. The aim of that initiative was to improve the structure and processes used by Airservices to verify ATC operational performance. At the time of writing this report, the initiative was in the design phase, with implementation planned for early 2009.

On the night of 3 May 2007, a Raytheon Aircraft Company 390, registered N7088S, was enroute to Townsville Airport, Qld on the final leg of a private instrument flight rules (IFR) flight from Avalon, Vic via Sydney, NSW and Brisbane, Qld. The aircraft carried four passengers and a pilot. At about 0049 EST on 4 May, the pilot landed the aircraft on runway 01 while it was closed due to works in progress. There was no damage to the aircraft or injuries to personnel.

On 29 April 2007, a notice to airmen (NOTAM) had been issued which required that pilots requiring the use of runway 01 provide 30 minutes prior notice to the works safety officer (WSO) on duty at the airport. The pilot of N7088S later reported that although he had reviewed the list of NOTAMs for the airport prior to the flight, he did not recall noting the runway closure and did not notify the WSO of his planned arrival. The WSO had been notified of the planned arrival of another aircraft and had selected the runway lighting ON in anticipation of its arrival. At the time of the occurrence, the instrument landing system approach aid for runway 01 was available and the airport's pilot activated lighting and airfield frequency response unit were unavailable.

For a period of several minutes while on approach and final, the pilot was not contactable by radio on either the Brisbane Centre frequency or the Townsville common traffic advisory frequency. During this time the duty supervisor at Brisbane Centre notified the WSO of the approaching aircraft. Workers on the runway noticed the approaching aircraft and vacated the runway before the aircraft landed.

The investigation identified several safety factors that contributed to the occurrence, including pre-flight planning, radio selection and operation, ground works management, and air traffic control. The airport operator, the pilot, and Airservices Australia initiated a number of safety actions in response to some of the issues identified.