Abstract

At about 0840 on Wednesday 4 August 2010 a safeworking incident occurred within the Junee station yard limits when a locomotive was moved from one road to another without authority while a Track Occupancy Authority (TOA) was in force. No injuries or damage resulted.

The investigation identified the following:

• non-conformances to the rules in regard to communication by the train drivers and protection of the fixed worksite
• deficiencies in the rules relating to lines of communication and protection of infrastructure booked out of service.

The investigation concluded that it was unlikely the safeworking incident would have resulted in a breach of the worksite at Junee station yard.

On 5 August 2010, the crew of a Fairchild Industries Inc. SA227-AC aircraft, registered VH-TAG, were cleared for a visual approach to runway 30 at Williamtown aerodrome, New South Wales (NSW) by air traffic control (ATC). The flight was a scheduled passenger service from Canberra, Australian Capital Territory (ACT), with two crew and 18 passengers onboard.

After landing, the crew was instructed by ATC to taxi to holding point Alpha, runway 30. During the taxi, the crew received an amended clearance to taxi to holding point Bravo, runway 30.

On approaching holding point Bravo, the crew checked the runway for other aircraft and taxied beyond the holding point. The crew was instructed by ATC to hold short of runway 30. The crew immediately stopped the aircraft and advised ATC that the aircraft had crossed the holding point, but was about 5 m away from the edge of the runway.

Shortly after, the crew observed a Boeing F/A-18 Hornet aircraft takeoff. About 10 seconds later a second Boeing F/A-18 Hornet took off on runway 30.

The crew discussed the incident and determined that they had not received a clearance to cross runway 30.

This incident highlights the importance of pilots utilising all of their available resources to confirm if the appropriate clearance has been received from ATC. Furthermore, if there is some doubt as to the location of other aircraft operating in the area, contact ATC or the pilot of the other aircraft to establish their position.

On 30 July 2010, an Aerospatiale Industries AS.350BA (Squirrel) helicopter, registered VH-HVT, was being flown up a valley between Healesville and Narbethong, Victoria (Vic.). There was low cloud in the area, which was sitting on a ridgeline the helicopter needed to cross. The pilot reported that he hovered the helicopter near the ridgeline, about 10 ft (3 m) above the tree canopy and on the edge of the cloud base for about 2 to 3 minutes, hoping for a break in the cloud sufficient to allow passage.

The pilot reported that he decided it was not possible to cross the ridgeline and commenced a right turn to return via the same route. About two thirds of the way through the turn, when the helicopter was travelling at between 10 and 15 kts, it struck a branch that was protruding above the tree canopy. The branch broke the helicopter's right side chin bubble and brushed against the side of the helicopter. The pilot assessed the damage and decided to continue the flight back to Essendon, Vic. The helicopter landed at Essendon without further incident.

An inspection of the helicopter found that the branch had scraped against the flat side of one of the tail rotor blades. A closer examination of the blade found a small void in the composite core of the blade. The blade was subsequently repaired and returned to service.

On 16 July 2010, the pilot of a Cessna Aircraft Company 210M on a passenger charter flight was preparing to land at Mount Borradaile Station, Northern Territory (NT). The pilot reported that it was quite windy during the approach, with the aircraft being blown off course. At about 300 ft above the airstrip, a small bird struck the windshield and briefly distracted the pilot. The pilot continued the approach. Just prior to touch-down the aircraft was picked up by a gust of wind. After the pilot corrected this, the aircraft touched down, but bounced three times.

The pilot assessed that there was not enough landing strip left to recover and initiated a go-around. The pilot pushed the throttle forward and raised the flaps to 15 degrees. As the aircraft took-off from the strip, the pilot retracted the undercarriage. The aircraft failed to climb and settled back onto the strip, skidding for about 30 m on its belly, before coming to rest prior to the end of the strip. The pilot and passengers were uninjured; however, the aircraft sustained minor damage.

On exiting the aircraft, the pilot realised that the pitch and mixture controls had not been placed in the full forward position resulting in insufficient power for the go-around.

This occurrence highlighted the potential impacts of distractions on the safety of operations. The following report (available at www.atsb.gov.au) provides further information:

• Dangerous distraction: An examination of accidents and incidents involving pilot distraction in Australia between 1997 and 2004 (2006)

The ATSB has completed its technical examination of a cockpit-mounted Global Positioning System (GPS) unit from Hughes Engineering Lightwing SP-2000 aircraft, registered 24-7057. The aircraft was involved in a fatal accident on 4 April 2010 at Tartrus Station, Queensland.

Recreational Aviation Australia Inc (RA-Aus) is assisting the Queensland Police in their investigation of this accident. RA-Aus requested assistance from the Australian Transport Safety Bureau (ATSB) in the recovery and analysis of information from the GPS unit, which had been recovered from the aircraft wreckage by RA-Aus investigators. To protect the information recovered from the GPS unit and the investigative work undertaken to assist RA-Aus, the ATSB initiated an investigation under the Transport Safety Investigation Act 2003.

In summary, while the GPS unit was found to be functional, the ATSB's examination of the device found that the unit's track and data recording functionality had not been enabled, and as a result, there was no data relating to the accident able to be recovered.

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Released in accordance with section 25 of the Transport Safety Investigation Act 2003.

On 13 July 2010, a Cessna Aircraft 210M aircraft, registered VH-TIJ, with two people on board was engaged in geophysical survey operations about 100 km south of Kalgoorlie, Western Australia (WA). Shortly after commencing a grid survey at low level, the aircraft collided with terrain in a shallow descent at around 140 to 150 kts in a wings level attitude. The pilot and survey equipment operator received serious injuries and the aircraft sustained serious damage.

The equipment operator raised the alarm and maintained contact with the rescue coordinators throughout the operation. He may have reduced the extent of his injuries had he been wearing his upper body seatbelt restraint. The emergency locator beacon fitted to the aircraft failed to activate.

As a result of this accident and a previous industry accident in December 2009 involving a different operator and owner, the geophysical survey company have been investigating the fitment of a 4-point harness into the operator's seat, and movement of the equipment such that the operator could still complete his/her work.

They further advised that they have already placed 4-point harnesses in the pilot's seat in their other aircraft and expect engineering work to be completed to allow modification of the operator position soon.

The aircraft operator advised that they were undertaking work on the radio altimeters fitted to survey aircraft to add an aural warning function to the existing warning light to enhance pilot awareness of when the selected aircraft operating height has been acquired.

The aircraft was fitted with a ME406 emergency locator beacon that was designed to be activated by impact forces. No activation was recorded probably because a necessary jumper link had not been installed. The Civil Aviation Safety Authority (CASA) has undertaken to raise industry awareness of the circumstances of this beacon non-activation through publication of an article in the next Flight Safety Australia Magazine. This article will highlight correct emergency locator transmitter (ELT) installations and possible pitfalls of not following approved methods and designs.

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)