Main rotor blade skin separation, on 15 March 2007, Mareeba Aerodrome, Queensland, VH-HPI, Robinson R22 Beta II

Summary

While undertaking a demonstration autorotational descent during an instructional flight test in a Robinson R22 Beta II helicopter, the student pilot and flight instructor noted an unusual mechanical noise, followed by the onset of severe vibrations from the main rotor system. After immediately landing the helicopter, it was found that the skin from the underside of one main rotor blade had disbonded from the leading-edge spar over a length of approximately 450 mm from the blade tip.

The skin separation was found to be associated with abrasion and loss of the rotor blade leading edge paint across the bond line between the skin and leading-edge spar. Erosion along the bond line had produced an undercutting effect and a feathering of the skin edge. Associated with random voids and pores in the adhesive that filled the gap between skin and spar recess edges, it was probable that the erosion had produced localised stresses within the adhesive joint, promoting the lifting of the feathered edges and the subsequent peeling separation of the skin.

As a result of a number of similar failures in both R22 and R44 main rotor blades, the helicopter manufacturer published a series of safety alerts, service letters and service bulletins, recommending the regular inspection of the blades for evidence of skin disbonding and the refinishing of blades showing abrasion of the leading-edge paint to, or beyond, the skin bond line. Airworthiness directives from the US Federal Aviation Administration and the Civil Aviation Safety Authority subsequently mandated the initial and repeat inspection of R22 and R44 main rotor blades for this issue. Those airworthiness directives became effective in January 2008.

Occurrence summary

Investigation number 200701625
Occurrence date 15/03/2007
Location Mareeba Aerodrome
State Queensland
Report release date 03/06/2008
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Propeller/rotor malfunction
Occurrence class Incident
Highest injury level None

Aircraft details

Manufacturer Robinson Helicopter Co
Model R22
Registration VH-HPI
Serial number 3408
Sector Helicopter
Operation type Flying Training
Departure point Mareeba, Qld
Destination Mareeba, Qld
Damage Minor

Depressurisation - Tamworth, New South Wales, on 26 February 2007, VH-HPB, Fairchild SA227-DC

Summary

On 26 February 2007, while in cruise at flight level (FL) 190 on a scheduled passenger flight from Inverell, to Sydney, NSW, with two pilots and six passengers, the crew of a Fairchild Industries SA227-DC (Metro) aircraft, registered VH-HPB, reported that the cabin altitude increased rapidly. The crew immediately donned their emergency oxygen masks and descended the aircraft to 10,000 ft. The flight continued to Sydney and landed safely. There were no injuries.

This was the second reported in-flight depressurisation on VH-HPB. The aircraft operator reported a prior event on 12 February 2007.

Following the 26 February 2007 event, the aircraft operator conducted extensive troubleshooting of the aircraft's pressurisation system and door seals in an attempt to isolate the reason for the depressurisation. Following maintenance actions, the aircraft was returned to service.

The operator reported that the aircraft again depressurised in-flight on two more occasions on 20 March and 4 April 2007. Despite further troubleshooting and maintenance actions, the operator was unable to ascertain the reason for the depressurisations. As a result, following the 4 April event, the operator issued a Pilot Operations Notice to all flight crew restricting the operating altitude of the aircraft to a maximum of 12,000 ft. Subsequent to this action, the aircraft depressurised again in-flight on 16 August 2007.

On 16 October 2007, as a result of fleet changes, the aircraft operator ceased operating VH-HPB. The aircraft subsequently completed a Phase check, including a thorough inspection of all pressurisation components and systems. The aircraft was subject to several pressurisation ground runs, however no anomalies with the pressurisation system were found.

Occurrence summary

Investigation number 200701109
Occurrence date 26/02/2007
Location East of Tamworth,
State New South Wales
Report release date 03/03/2008
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Air/pressurisation
Occurrence class Serious Incident
Highest injury level None

Aircraft details

Manufacturer Fairchild Industries Inc
Model SA227
Registration VH-HPB
Serial number DC-808B
Sector Turboprop
Operation type Air Transport Low Capacity
Departure point Inverell, NSW
Destination Sydney, NSW
Damage Nil

Loss of control, Clyde North, Victoria, on 23 February 2007, Van's Aircraft Inc. RV-4, VH-ZGH

Preliminary report

Preliminary report released 8 May 2007

On 23 February 2007, at approximately 1710 Eastern Daylight-saving Time, a Van's Aircraft Inc. RV-4 aircraft, registered VH-ZGH, took off from Essendon Airport, Victoria, with the owner-pilot and one passenger on board. The flight was to the designated Moorabbin aerobatic area over Clyde North.

At approximately 1740, witnesses reported observing the aircraft descending in a spin after completing an aerobatic manoeuvre. The aircraft engine was heard to gain power during the spin and the aircraft speed rapidly increased. The aircraft was then seen to enter into, what appeared to be, an unstable spiral dive.

At approximately 1,500 ft above the ground, witnesses reported that the engine noise was very high-pitched and loud, and objects were seen to separate from the aircraft. The rapid spiral descent continued and the aircraft was observed to impact the ground almost vertically. The aircraft was destroyed by impact forces and a post-impact fire. The pilot and passenger were fatally injured.

Summary

On 23 February 2007, the owner-pilot of a Van's Aircraft Inc RV-4 aircraft, registered VH-ZGH, was observed conducting aerobatic manoeuvres in the designated Moorabbin aerobatic area over Clyde North. At approximately 1740 Eastern Daylight-saving Time, witnesses observed the aircraft descending in a spin after completing a stall turn. The aircraft then appeared to enter an unstable spiral dive and, at approximately 500 m above the ground, pieces were observed separating from the aircraft. The aircraft was seen to impact the ground almost vertically and was destroyed by impact forces and a post-impact fire. Both occupants were fatally injured.

The investigation found that the pilot probably lost control of the aircraft performing an aerobatic manoeuvre and entered a spin from which he was unable to recover. The investigation also found that the pilot performed manoeuvres in an aircraft that was loaded above the maximum weight limit for aerobatic flight, and with the centre of gravity outside the rear limit.

Occurrence summary

Investigation number 200701033
Occurrence date 23/02/2007
Location Clyde North
State Victoria
Report release date 11/02/2008
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Loss of control
Occurrence class Accident
Highest injury level Fatal

Aircraft details

Manufacturer Amateur Built Aircraft
Model Vans RV-4
Registration VH-ZGH
Serial number S-88
Sector Piston
Operation type Sports Aviation
Departure point Essendon, Vic
Destination Essendon, Vic
Damage Destroyed

Airprox, 28 km south-west Camden Aerodrome, New South Wales, on 14 February 2007, VH-BMX, Cessna 182T, VH-DTX, Cessna 210L

Summary

On 14 February 2007 at about 1127 Eastern Daylight-saving Time, the pilot of a Cessna Aircraft Company 182T (182) was positioning to conduct a sector entry for an area navigation (RNAV) global navigation satellite system (GNSS) arrival procedure to runway 06 at Camden Aerodrome, NSW. The aircraft was approaching the aerodrome from the east. At the same time, the pilot of a Cessna Aircraft Company 210L (210) was approaching Camden from the south-west with the intention of conducting a Camden runway 06 straight-in RNAV (GNSS) approach. The two aircraft had similar estimated times of arrival at the approach commencement waypoint. They were both being operated under the instrument flight rules (IFR), in Class G airspace.

The air traffic controller provided the pilots with mutual radar based traffic information. The pilot of the 210 contacted the controller and was provided with traffic information about the 182. The pilot of the 182 climbed the aircraft to minimise the risk of a collision as he was unsure of the intentions of the pilot of the 210. Recorded radar data showed that, when the aircraft passed, there was 500 ft vertically and 2.1 NM laterally between them.

Occurrence summary

Investigation number 200700766
Occurrence date 14/02/2007
Location 28km SW of Camden
State New South Wales
Report release date 22/08/2007
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Separation issue
Occurrence class Incident
Highest injury level None

Aircraft details

Manufacturer Cessna Aircraft Company
Model 182
Registration VH-BMX
Serial number 18281262
Sector Piston
Operation type Flying Training
Departure point Wollongong, NSW
Destination Camden, NSW
Damage Nil

Aircraft details

Manufacturer Cessna Aircraft Company
Model 210
Registration VH-DTX
Serial number 21060872
Sector Piston
Operation type Unknown
Destination Camden, NSW
Damage Nil

Crew incapacitation - Busselton Aerodrome, Western Australia, on 13 February 2007, VH-SQF, Beech Aircraft Corporation 58 Baron

Summary

On 13 February 2007 at 1830 Western Daylight-saving Time, a Beech Aircraft Corporation 58 Baron was being used for instrument flight training. The flight was being conducted under the visual flight rules (VFR), with the pilot flying, simulating flight under the instrument flight rules (IFR). A second pilot was on board to act as a safety pilot and to lookout for other aircraft. During the conduct of a Busselton, WA non-direction beacon (NDB) approach, the pilot flying became incapacitated, and the safety pilot assumed control of the Baron. The safety pilot landed the aircraft on runway 21 at Busselton and the incapacitated pilot received treatment from attending ambulance officers. The pilot was a 22-year-old, Grade 2 flying instructor, with 1,422 hours total flying experience. Following a check by a Designated Aviation Medical Examiner and 4 days rest, the pilot was approved to return to work.

The pilot stated that about 12 months previously, he had experienced a similar event and after a number of medical tests that did not find any physical problems, it was established that he had been dehydrated.

Initial medical testing following the event found no health problems and it is possible that the pilot's sustenance and fluid intake was inadequate. The pilot changed his eating and fluid intake habits, including using a water bottle while flying.

The Civil Aviation Safety Authority (CASA) Aviation Medicine section subsequently suspended the pilot's Class 1 medical and requested the pilot undergo further testing. That testing found that the pilot had epilepsy, and CASA revoked the pilot's medical.

Occurrence summary

Investigation number 200700765
Occurrence date 13/02/2007
Location Busselton
State Western Australia
Report release date 15/04/2008
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Flight crew incapacitation
Occurrence class Serious Incident
Highest injury level None

Aircraft details

Manufacturer Beech Aircraft Corp
Model 58
Registration VH-SQF
Serial number TH-1560
Sector Piston
Operation type Flying Training
Departure point Jandakot, WA
Destination Jandakot, WA
Damage Nil

Depressurisation, 140 NM south of Alice Springs, Northern Territory, on 6 February 2007, Beech Aircraft Corporation 300, VH-MLG

Summary

On 6 February 2007, at approximately 1130 Central Summer Time, while operating a passenger charter flight from Melbourne, Vic. to Alice Springs, NT, the pilot of a Beech Aircraft Corporation 300 aircraft, registered VH-MLG, reported feeling his ears 'pop' while at flight level 280 and the aircraft rapidly depressurised.  There were eight persons on board the aircraft.

The pilot reported looking at the aircraft pressurisation panel and noticing that the needles were rapidly moving.  The passenger seated in the right seat (also a pilot) called to the pilot to 'put on oxygen'.  While donning his oxygen mask, the passenger reported that the oxygen hose blew out of the mask when pressurised. He managed to reattach the hose and remain on oxygen.

After checking that the passengers had donned their oxygen masks, the pilot advised air traffic control of the depressurisation and commenced an emergency descent. The aircraft subsequently landed at Alice Springs with no injuries reported.
The pilot reported that it is possible that, while adjusting his seat position prior to top of descent, he inadvertently activated the switch to the DUMP position.

Occurrence summary

Investigation number 200700510
Occurrence date 06/02/2007
Location 140 NM south of Alice Springs
State Northern Territory
Report release date 26/05/2008
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Serious Incident
Highest injury level None

Aircraft details

Manufacturer Beech Aircraft Corp
Model 300
Registration VH-MLG
Serial number FL-389
Sector Turboprop
Operation type Charter
Departure point Melbourne, Vic
Destination Alice Springs, NT
Damage Nil

Engine failure, Cecil Park, New South Wales, on 5 February 2007, VH-HYY, Cirrus SR22

Preliminary report

Preliminary report released 5 April 2007

On 5 February 2007, a Cirrus SR22 aircraft, registered VH-HYY, with a pilot and one passenger, was being operated on a private flight from Canberra, ACT to Bankstown NSW. As the aircraft approached the Cecil Park area, the pilot reported to air traffic control that the engine had lost power and that he was attempting a forced landing. Soon after, the aircraft impacted terrain close to the M7 freeway in Cecil Park and both occupants sustained serious injuries.

Summary

On 5 February 2007, a Cirrus SR22 aircraft, registered VH-HYY, with a pilot and one passenger on board, was being operated on a private flight from Canberra, ACT to Bankstown, NSW. As the aircraft approached the Cecil Park area, NSW, the pilot reported to air traffic control that the engine had lost power, and he was attempting a forced landing. Soon after, the aircraft impacted terrain close to the M7 motorway and both occupants sustained serious injuries.

The investigation determined that the engine stopped due to the in-flight loss of a blanking cap from the un-metered fuel pressure test port in the engine fuel system. Testing showed that the engine would not operate with the cap missing.

The investigation determined that, instead of the normal steel cap, a plastic blanking cap had probably been fitted to the test port on the engine during maintenance and had been inadvertently left there, and that the plastic cap had detached from the test port just prior to the accident.

Prior to impact, the pilot activated the Cirrus Airframe Parachute System (CAPS), but the system malfunctioned, and the parachute did not deploy correctly.

Following examination of the CAPS components from this aircraft and further functional testing of production CAPS components in the US, the aircraft manufacturer issued an Alert Service Bulletin incorporating design changes to the CAPS in the worldwide fleet of Cirrus aircraft.

The aircraft and engine manufacturers are also making a number of other changes to their processes and procedures based on lessons learnt from this accident.

The Australian Transport Safety Bureau will forward copies of this report to the relevant state emergency authorities to alert them to the dangers posed by ballistic parachute systems in light aircraft.

Occurrence summary

Investigation number AO-2007-018
Occurrence date 05/02/2007
Location Cecil Park
State New South Wales
Report release date 24/12/2008
Report status Final
Investigation level Systemic
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Engine failure or malfunction
Occurrence class Accident
Highest injury level Serious

Aircraft details

Manufacturer Cirrus Design Corporation
Model SR22
Registration VH-HYY
Serial number 928
Sector Piston
Operation type Private
Departure point Canberra, ACT
Destination Bankstown, NSW
Damage Destroyed

Engine in-flight shut down, 37 km west-north-west of Danks, Victoria, on 5 February 2007, VH-EBY, Boeing 747-338

Summary

On 4 February 2007, the crew of a Boeing Company 747-338, registered VH-EBY, shut down the number 3 engine in flight, due to a fuel related problem.

Approaching the top of descent the crew noticed that the number 3 main fuel tank quantity indicator (FQI) was reading zero and that both fuel boost pump low pressure lights for that tank had illuminated. The crew then shut down the number 3 engine, broadcast a PAN broadcast and continued the flight for an uneventful landing at Melbourne.

An examination of the number 3 main fuel tank after landing, found that it was empty. An 'over-read' malfunction in the number 3 FQI had resulted in the crew believing there was a greater quantity of fuel remaining in the tank than was actually present. The planned quantity of fuel for arrival at Melbourne for the number 3 tank was 2,500 kg. An investigation of the incident conducted by the operator determined that the FQI malfunction was caused by either an electrical malfunction, water contamination or a combination of both.

The FQI fault was rectified and the aircraft returned to service.

The investigation also found that the operator's refuelling procedures were not able to accurately verify the base line quantity of fuel on board, or to alert the flight crew or line engineers to the consequences of an erroneous fuel quantity indicator system indication. The investigation reviewed the refuelling procedures for the operator's other fleet types to ensure serviceability of those installations. As a result of this occurrence, the operator is implementing a series of safety actions, including amending its refuelling procedures and conducting a risk assessment of its fuel management policies and procedures.

Occurrence summary

Investigation number 200700368
Occurrence date 05/02/2007
Location 37km WNW Danks
State Victoria
Report release date 30/06/2008
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Fuel starvation
Occurrence class Incident
Highest injury level None

Aircraft details

Manufacturer The Boeing Company
Model 747
Registration VH-EBY
Serial number 23823
Sector Jet
Operation type Air Transport High Capacity
Departure point Jakarta, Indonesia
Destination Melbourne, Vic
Damage Nil

Engine power loss - 15 km south-east of Gold Coast Airport, Queensland, on 4 February 2007, VH-DIC, Piper PA-30 Twin Comanche

Preliminary report

Preliminary report released 15 March 2007

On 4 February 2007, the owner pilot of a Piper Aircraft Co PA 30 Twin Comanche aircraft, registered VH-DIC, was conducting a private flight from the Gold Coast aerodrome. The pilot was the sole occupant. Approximately 11 minutes after takeoff, at 1622 Eastern Standard Time, the pilot declared an emergency reporting an engine failure and some 15 seconds later that he was also experiencing problems with the left engine. Approximately 13 minutes after departure, the aircraft impacted the water about 100 m from Kingscliff beach, adjacent to the suburb of Casuarina, New South Wales. The pilot sustained fatal injuries.

The aircraft wreckage, including most of the lower centre fuselage, wings, and both engines and propellers, were recovered 2 days after the accident. The right propeller was recovered with the blades in the feathered position. The left propeller blades were recovered in the normal operating range with bending consistent with power being applied at the time of the accident.

The pilot held a commercial pilot license and at the time of the accident, had accrued approximately 2,544 hrs total flying time. He purchased the accident aircraft in 1996, and had accrued approximately 940 hrs in that aircraft.
At the time of the accident, the weather was generally fine.

Summary

On 4 February 2007, the owner-pilot of a Piper Aircraft Co. PA-30 Twin Comanche aircraft, registered VH-DIC, was conducting a private flight from Gold Coast Airport, Qld. The pilot was the sole occupant. Approximately 11 minutes into the flight, at 1622 Eastern Standard Time, the pilot declared an emergency reporting an engine failure and some 15 seconds later that he was also experiencing problems with the 'left engine'. Approximately 13 minutes after departure, the aircraft impacted the water about 100 m off Kingscliff beach, adjacent to the suburb of Casuarina, NSW. The pilot received fatal injuries.

Two days following the accident, the aircraft wreckage including most of the lower centre fuselage, wings, and both engines and propellers, was recovered and examined. The right propeller was recovered with the blades in the feathered position. The left propeller was recovered with the blades in the normal operating range with bending consistent with power being applied at the time of the impact with the sea.

The investigation determined that most probably the right engine stopped operating, followed by an unexplained power loss of the left engine. The aircraft airspeed then decreased below the minimum controllable airspeed during the emergency landing before power suddenly returned to the left engine causing the aircraft to pitch nose up and bank sharply to the right and impacting the water.

Occurrence summary

Investigation number 200700358
Occurrence date 04/02/2007
Location 15 km SE Gold Coast Airport
State Queensland
Report release date 17/04/2008
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Propeller/rotor malfunction
Occurrence class Accident
Highest injury level Fatal

Aircraft details

Manufacturer Piper Aircraft Corp
Model PA-30
Registration VH-DIC
Serial number 30-1775
Sector Piston
Operation type Private
Departure point Gold Coast airport, Qld
Destination Gold Coast airport, Qld
Damage Destroyed

Engine failure - 28 km west-south-west of Warialda, New South Wales, on 2 February 2007, VH-HRT, Bell 407

Preliminary report

Preliminary report released 20 April 2007

On 2 February 2007, at about 1530 hours Eastern Daylight-saving Time, a Bell Helicopter Company model 407 (B407) medical helicopter with a pilot, a crewman, a doctor and a paramedic on board departed Tamworth, NSW enroute to a car accident. At about 1610 hours the pilot broadcast on both the area and common traffic advisory frequency (CTAF) radio frequencies that they were inbound to Warialda at 15 nautical miles south-west and on descent from 6,500 ft above mean sea level. The pilot later reported that soon after the broadcast, the engine chip detector advisory illuminated on the master caution panel. He reported that approximately 5 seconds later, he heard a loud noise, and the helicopter developed a severe high frequency vibration with a complete loss of engine power. The pilot then broadcast a distress advisory on the Area and CTAF frequencies with position, altitude, passenger information and the problem. During the ensuing auto-rotation emergency landing, the helicopter landed heavily and rolled onto its side. None of the occupants were injured, but the helicopter was destroyed.

Interim report

Interim Factual report released 18 September 2007

On 2 February 2007, at about 1530 Eastern Daylight-saving Time, a Bell Helicopter Company model 407 (B407) medical helicopter with a pilot, a crewman, a doctor and a paramedic on board departed Tamworth, NSW enroute to a car accident. At about 1610, the pilot broadcast on both the area and common traffic advisory frequency (CTAF) radio frequencies that they were inbound to Warialda at 28 km south-west and on descent from 6,500 ft above mean sea level. The pilot later reported that soon after the broadcast, the engine chip detector advisory capsule illuminated on the master caution panel. He reported that approximately 5 seconds later, he heard a loud noise, and the helicopter developed a severe high frequency vibration with a complete loss of engine power. The pilot then broadcast a distress advisory on the area and CTAF frequencies with position, altitude, passenger information and the problem. During the ensuing autorotation emergency landing, the helicopter landed heavily and rolled onto its side. None of the occupants were injured, but the helicopter was destroyed. The investigation determined that the engine sustained an in-flight catastrophic failure of the engine accessory gearbox. The failure of the gearbox was determined to be a fracture and separation of a section of the helical torquemeter gear, which resulted in complete loss of engine power.

Summary

On 2 February 2007, at about 1530 Eastern Daylight-saving Time, a Bell Helicopter 407 (407) emergency medical helicopter with a pilot, a crewman, a doctor and a paramedic on board departed Tamworth, NSW enroute to a car accident. At about 1610, the pilot broadcast on both the area and common traffic advisory frequency (CTAF) radio frequencies that they were inbound to Warialda at 28 km south-west and on descent from 6,500 ft [above mean sea level].

The pilot later reported that soon after the broadcast, the engine chip detector advisory capsule illuminated on the master caution panel. He reported that approximately 5 seconds later, he heard a loud noise, and the helicopter developed a severe high frequency vibration with a complete loss of engine power. The pilot then broadcast a distress advisory on the area frequency with position, altitude, passenger information and the problem. During the subsequent autorotation emergency landing, the helicopter landed heavily and rolled onto its side. None of the occupants were injured, but the helicopter was seriously damaged.

The investigation determined that the engine sustained an in-flight catastrophic failure of the engine gearbox. The gearbox failure was due to the fracture and separation of a section of the helical torquemeter gear, which resulted in the complete loss of engine power.

Occurrence summary

Investigation number 200700357
Occurrence date 02/02/2007
Location 28km WSW Warialda
State New South Wales
Report release date 05/05/2008
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Engine failure or malfunction
Occurrence class Accident
Highest injury level None

Aircraft details

Manufacturer Bell Helicopter Co
Model 407
Registration VH-HRT
Serial number 53042
Sector Helicopter
Operation type Aerial Work
Departure point Tamworth, NSW
Destination Warialda, NSW
Damage Substantial