Turbulence event, Adelaide Airport, South Australia, on 15 December 2006, Boeing 737-476, VH-TJH

Summary

At approximately 1416 Central Daylight-saving Time on 15 Dec 2006, the flight crew commenced a take-off roll in a Boeing Company 737-400 aircraft, registered VH-TJH, on a scheduled passenger service from Adelaide, SA to Melbourne, Vic.

At a speed of approximately 50 kts, the crew reported an abrupt, uncommanded left yaw. Corrective action was applied, and the take-off was continued without further incident. The remaining flight was uneventful.

The flight crew subsequently reported that they did not notice any rudder pedal movement coincident with the uncommanded yaw and recalled that there was a gusting crosswind from the left during the take-off.

Data from the aircraft's Flight Data Recorder was recovered and downloaded by the Australian Transport Safety Bureau (ATSB) for review. That review indicated that the input to the aircraft rudder was not uncommanded and that the rudder pedals moved proportionally to the rudder surface deflection at all times. An examination of the aircraft by the aircraft operators' maintenance engineers did not identify any reason for the uncommanded yaw and the aircraft was released back to service. Additionally, there was no other aircraft traffic in the vicinity that may have generated wake turbulence in the immediate timeframe prior to the take-off.

While the nature of the uncommanded yaw could not be positively identified, it is likely that the event was related to an atmospheric disturbance or turbulence during the take-off.

The ATSB continues to monitor such reported uncommanded yaw events and has reported similar events in the past (see occurrence reports 200700035, 200500994 and 199703237 available on the ATSB website).

Occurrence summary

Investigation number 200607627
Occurrence date 15/12/2006
Location Adelaide Airport
State South Australia
Report release date 26/06/2007
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Turbulence/windshear/microburst
Occurrence class Incident
Highest injury level None

Aircraft details

Manufacturer The Boeing Company
Model 737
Registration VH-TJH
Serial number 24433
Sector Jet
Operation type Air Transport High Capacity
Departure point Adelaide SA
Destination Melbourne Vic
Damage Nil

Collision with terrain - 19 km north-east of Collarenebri, New South Wales, on 9 December 2006, VH-CJZ, Air Tractor AT802A

Preliminary report

Preliminary report released 9 December 2006

The aircraft was reported to have impacted the ground during a flight to replenish the hopper for further spraying. The pilot was fatally injured.

Summary

On 9 December 2006, the pilot of an Air Tractor Inc. AT802A aircraft, registered VH-CJZ, was conducting night agricultural spraying operations under the night visual flight rules, at a property 19 km NE of Collarenebri, NSW. In conjunction with a pilot in another agricultural spraying aircraft from the same aircraft operator, the Air Tractor pilot was utilising an airstrip located on the property as a base for the spraying operation. At about 2140 Eastern Daylight-saving Time, the aircraft was returning to the airstrip when it impacted the ground 1.4 km WSW of the landing strip. The pilot was fatally injured. The aircraft was destroyed by impact forces and a post-impact fire.

Earlier that evening, the pilot had made a 20-minute positioning flight from the operator's base at Wee Waa, NSW, to the airstrip. The pilot then conducted two 30-minute spraying flights, with a short period on the ground to replenish the load of chemical fertiliser. The aircraft remained running while that replenishment was conducted. The accident occurred when the pilot was returning to the airstrip at the conclusion of the second spraying flight.

Examination of the aircraft wreckage revealed no evidence of an in-flight fire or any mechanical fault with the aircraft, engine, or systems which may have contributed to the occurrence. The intensity of the post-impact fire, deformation to the integral wing fuel tank structure and ground marks, indicated that there was sufficient fuel on board the aircraft for the operation. There was no evidence that the aircraft struck trees or powerlines.

The reason for the aircraft impacting the ground could not be conclusively determined. It was possible that the pilot may have experienced a medical event that was not evident during the post-mortem medical examination. However, based on the evidence available it is probable that the pilot experienced spatial disorientation and a subsequent loss of control of the aircraft resulting in it impacting the ground.

Occurrence summary

Investigation number AO-2006-002
Occurrence date 09/12/2006
Location 56km E Collarenebri
State New South Wales
Report release date 03/12/2008
Report status Final
Investigation level Systemic
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Collision with terrain
Occurrence class Accident
Highest injury level Fatal

Aircraft details

Manufacturer Air Tractor Inc
Model AT802
Registration VH-CJZ
Serial number 802A-0055
Sector Turboprop
Operation type Aerial Work
Departure point Colley Farms, NSW
Destination Colley Farms, NSW
Damage Destroyed

Loss of control - VH-BTD, Piper PA-31 Navajo, 50 km north of Cairns, Queensland, on 2 December 2006

Summary

During an approach into Cairns Airport, Qld in overcast conditions late on the morning of 2 December 2006, the pilot of a Piper Navajo aircraft, registered VH-BTD, lost control of the aircraft and entered an uncontrolled descent. Control of the aircraft was regained shortly before the pilot became visual below the cloud base, and the pilot continued to Cairns.

The loss of control was the result of the pilot's inexperience with respect to the effects of spatial disorientation and with flight in instrument meteorological conditions (IMC).

This occurrence reaffirms the potential for spatial disorientation, if not recognised and recovered from appropriately, to result in the loss of aircraft control.

Occurrence summary

Investigation number AO-2006-153
Occurrence date 02/12/2006
Location 50 km north of Cairns
State Queensland
Report release date 06/05/2009
Report status Final
Investigation level Systemic
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Loss of control
Occurrence class Serious Incident
Highest injury level None

Aircraft details

Manufacturer Piper Aircraft Corp
Model PA-31
Registration VH-BTD
Serial number 31-7912041
Sector Piston
Operation type Charter
Departure point Port Moresby
Destination Cairns, Qld
Damage Nil

In-flight engine failure, 93km north of Perth Airport, Western Australia, on 27 November 2006, Beechcraft King Air 200, VH-XDB

Summary

On 27 November 2006, a Beechcraft King Air 200 aircraft, registered VH-XDB and carrying two crew and six passengers, was on a flight from Mount Hale to Perth, Western Australia. Shortly after commencing the decent into Perth airport, the right engine failed catastrophically.

An engineering examination of the failed Pratt and Whitney Canada PT6A-41 turboprop engine was performed and revealed that the first stage 'sun' and 'planet' gear set within the propeller reduction gearbox had decoupled from the power turbine. The decoupling allowed the power turbine to overspeed, which resulted in destruction and shedding of the turbine blades. Several blade fragments punctured the outer gas generator case.

A metallurgical examination of the failed first-stage gear set revealed that a mismatch in service histories between the sun gear and planet gears was the most likely contributor to the failure. The engine manufacturer had been alert to the occurrence of reduction gearbox distress due to gear mismatching at overhaul.

Following this incident, the aircraft operator initiated a review of their system of maintenance with respect to monitoring of life-limited engine components, for all PT6A engines in their fleet.

Occurrence summary

Investigation number AO-2006-007
Occurrence date 27/11/2006
Location 93km N of Perth Airport
State Western Australia
Report release date 24/06/2009
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 Incident
Highest injury level None

Aircraft details

Manufacturer Beech Aircraft Corp
Model 200
Registration VH-XDB
Serial number BB-533
Sector Turboprop
Operation type Air Transport Low Capacity
Departure point Mt Hale. WA
Destination Perth, WA
Damage Minor

Reported runway excursion, RAAF Richmond, New South Wales, UR-BXQ, IL76 TD

Summary

On 22 November 2006 at 0817 Eastern Summer Time, an Ilyushin Design Bureau IL-76TD (IL-76) aircraft, registered UR-BXQ, was reported to have entered the runway 28 stop way before becoming airborne while departing from runway 28 at Royal Australian Air Force Base Richmond, NSW. The aircraft was departing on a charter flight to Manila, the Philippines with 10 crew members on board.

A number of witnesses at various locations on the airport reported that the main wheels of the IL-76 did not lift off the ground until after the aircraft entered the stop way. However, the pilot in command of the IL-76 stated that the aircraft became airborne at about 250 m before the end of the runway.

From the available witness and flight crew reports, and the physical and recorded evidence, the investigation was unable to determine whether the aircraft entered the runway 28 stop way. The investigation could not reconcile the discrepancy between the recollection of events provided by the witnesses to the occurrence, and that of the pilot in command.

Occurrence summary

Investigation number 200607054
Occurrence date 22/11/2006
Location Richmond, Aerodrome
State New South Wales
Report release date 04/05/2007
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Miscellaneous - Other
Occurrence class Serious Incident
Highest injury level None

Aircraft details

Manufacturer Ilyushin Design Bureau
Model IL-76
Registration UR-BXQ
Serial number 1023410360
Sector Jet
Operation type Charter
Departure point Richmond, NSW
Destination Manila, Philippines
Damage Nil

Aircraft loss of control, Palmers Island, New South Wales, on 2 November 2006, VH-AAL, Bell 206A

Summary

On 2 November 2006, the pilot of a Bell Helicopter Company 206A helicopter, registered VH-AAL, departed Coffs Harbour, NSW, on a private flight to a property located at Palmers Island, near Yamba, NSW. On board the 206A were the pilot and one passenger in the front left seat.

On arrival in the vicinity of Palmers Island, the pilot commenced a downwind turn into a strong quartering tailwind and the helicopter began an uncommanded right yaw. The pilot attempted to regain control, but the helicopter continued to yaw and to descend until it impacted the ground. The pilot and passenger sustained serious injuries and the helicopter was destroyed.

There was no evidence found of any mechanical or systems failures that may have contributed to the accident. The reported local conditions and nature of the loss of control were consistent with a loss of tail rotor effectiveness (generally referred to as LTE).

While a serviceable emergency locator transmitter was fitted to the helicopter, it had not been 'armed' prior to the flight and did not activate as a result of the impact.

Occurrence summary

Investigation number 200606570
Occurrence date 02/11/2006
Location Palmers Island
State New South Wales
Report release date 17/12/2007
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 Serious

Aircraft details

Manufacturer Bell Helicopter Co
Model 206
Registration VH-AAL
Serial number 606
Sector Helicopter
Operation type Private
Departure point Coffs Harbour, NSW
Destination Palmers Island, NSW
Damage Destroyed

Runway incursion, Brisbane Airport, Queensland, on 15 November 2006, VH-VYK, Boeing 737-838, Car 22, Airside operations vehicle

Summary

On 15 November 2006, a Boeing Company 737-838 (737) aircraft was established on a visual approach to runway 01 at Brisbane, Qld. The Brisbane aerodrome controller (ADC) had issued a clearance for a vehicle driver to enter runway 01 to locate and remove debris that had been blown onto the runway strip. The ADC subsequently issued the pilot of the 737 with a landing clearance while the vehicle was still on the runway, anticipating that the vehicle would vacate prior to the 737 landing.

The ADC reported that he may have momentarily forgotten about the vehicle. An unidentified transmission, believed to have been made by the pilot of another aircraft waiting for departure, warned the ADC of the vehicle's presence. The ADC instructed the vehicle driver to vacate the runway and reissued a landing clearance to the pilot of the 737. There was a runway incursion.

Recent thunderstorm activity had resulted in unidentified debris being blown onto the active runways, requiring multiple entries for airside operations vehicles into the runway strip to locate and remove the debris.

The thunderstorm activity led to a situation where the ADC experienced a busy and complex workload for an extended period of time without a rest break. The ADC did not initially issue instructions to the vehicle driver, or adequately monitor the situation, to ensure that the vehicle vacated the runway strip so that separation was assured with the 737.

The investigation found a common misconception about the classification and reporting of runway incursion events. The ICAO runway incursion definition of an 'incorrect presence' does not preclude a presence being incorrectly authorised by an air traffic control clearance.

Occurrence summary

Investigation number 200606874
Occurrence date 15/11/2006
Location Brisbane Airport
State Queensland
Report release date 31/01/2008
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Loss of separation
Occurrence class Incident
Highest injury level None

Aircraft details

Manufacturer The Boeing Company
Model 737
Registration VH-VYK
Serial number 34183
Sector Jet
Operation type Air Transport High Capacity
Departure point Cairns QLD
Destination Brisbane QLD
Damage Nil

Engine in-flight shutdown, 580 km south-west of Adelaide, South Australia

Summary

On 2 November 2006, at 1228 Central Summer Time a Boeing Company 767-338 aircraft, registered VH-OGL, departed Melbourne, Vic, on a scheduled passenger flight to Perth, WA. During the cruise climb, the crew reported that the Engine Indication and Crew Alerting System (EICAS) message displayed 'R OIL FILTER'. The crew initiated a descent and reduced the right engine thrust lever to idle. As the EICAS message remained illuminated, the crew shut-down the right engine, as required by the checklist, and diverted the aircraft to Adelaide, SA.

The operator's engineering personnel inspected the right engine magnetic chip detectors and found no evidence of debris. They also replaced the right engine oil scavenge filter and conducted an idle leak check. As no anomalies were found, the aircraft was returned to service.

Occurrence summary

Investigation number 200606594
Occurrence date 02/11/2006
Location 580 km south-west of Adelaide
State South Australia
Report release date 18/12/2006
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Abnormal engine indications
Occurrence class Incident
Highest injury level None

Aircraft details

Manufacturer The Boeing Company
Model 767
Registration VH-OGL
Serial number 25363
Sector Jet
Operation type Air Transport High Capacity
Departure point Melbourne, VIC
Destination Perth, WA
Damage Nil

Loss of control - 9 km south-east of Raglan, Queensland, on 31 October 2006, VH-ZGZ, Piper PA-31-350

Preliminary report

Preliminary report released 31 October 2006

On 31 October 2006 at 1955 Eastern Standard Time, PA31-350 aircraft, registered VH-ZGZ, was on descent to Gladstone Airport, Qld when its radar track disappeared from the air situation display in the Brisbane Air Traffic Control Centre. Subsequently, the aircraft was found to have impacted terrain approximately 9 km south-east of Raglan, Qld. The pilot and two passengers were fatally injured. The aircraft was destroyed by impact forces and post-impact fire.

Interim report

Interim report released 25 May 2007

On 31 October 2006 at 1955 Eastern Standard Time, PA31-350 aircraft, registered VH-ZGZ, was on descent to Gladstone Airport, Qld when its radar track disappeared from the air situation display in the Brisbane Air Traffic Control Centre. Subsequently, the aircraft was found to have impacted terrain approximately 9 km south-east of Raglan, Qld. The pilot and two passengers were fatally injured. The aircraft was destroyed by impact forces and post-impact fire.

Summary

On 31 October 2006, a Piper Aircraft Corporation PA-31-350 Chieftain aircraft, registered VH-ZGZ, was being operated on a private category instrument flight rules (IFR) flight from Emerald to Gladstone, Qld. On board the aircraft were the pilot in command and two passengers. After departing Emerald at 1807 Eastern Standard Time, the flight proceeded apparently normally until the aircraft disappeared from radar while passing about 4,500 ft on descent into Gladstone. It was subsequently determined that the aircraft had crashed 9 km SE of Raglan, approximately 39 km west of Gladstone. The aircraft occupants received fatal injuries.

Conditions in the area of the accident were dark with some rain. Thunderstorms had been forecast but there was no thunderstorm or lightning activity in the area where radar contact was lost.

Recorded radar and voice transmission information indicated that the aircraft was performing normally before it suddenly diverged left from a steady descending flight path and entered a spiral dive.

On-site examination confirmed that the aircraft impacted the ground at high speed in a steep, left spiral descent. The aircraft structure was complete at impact. It was established that at impact, both engines were operating at between 2,200 and 2,400 RPM and both propellers were in the normal operating pitch range. There was evidence that the gyroscopic instruments were functioning. The destruction to the wreckage precluded examination of the electrical and fuel systems, the flight controls, and the autopilot.

A series of maintenance issues involving the aircraft's engines occurred in the period before the accident. However, there was evidence that these had been resolved before the accident flight.

The pilot's experience on the aircraft type was limited, as was his night and instrument flight experience. The dark and very likely cloudy conditions that existed in the area where the aircraft suddenly diverged from its flight path meant that recovery to normal flight could only have been achieved by sole reference to the aircraft's flight instruments. The difficulty associated with such a task when the aircraft was in a steep descent was likely to have been significant.

Occurrence summary

Investigation number AO-2006-001
Occurrence date 31/10/2006
Location Raglan
State Queensland
Report release date 27/01/2009
Report status Final
Investigation level Systemic
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 Piper Aircraft Corp
Model PA-31
Registration VH-ZGZ
Serial number 31-7752006
Sector Piston
Operation type Private
Departure point Emerald QLD
Destination Gladstone QLD
Damage Destroyed

Engine power loss, 28 km north-east of Coolah, New South Wales, on 31 October 2006, VH-KTR, Bell 206 B3

Summary

On 31 October, at approximately 1152 Eastern Daylight-saving Time, the pilot of a Bell 206 B3 helicopter, registered VH-KTR, was undertaking aerial feral animal culling operations with a feral animal shooter onboard. The pilot was lining the helicopter up for the shooter, when the engine power suddenly reduced to near idle. The shooter was able to throw his rifle out of the helicopter and brace for impact, in accordance with the Feral Animal Aerial Shooting Training (FAAST) procedures.

The helicopter descended into trees and came to rest supported by trees on the side of a steep hill. The occupants reported that the engine was still running after the helicopter came to rest, however, only at about idle power. The pilot then shut the engine down via the throttle. The pilot sustained facial and eye injuries while the shooter had minor injuries.

Examination and testing of the engine and components, and the fuel system was unable to determine what led to the sudden loss in power.

By following FAAST procedures, it is likely that the shooter reduced the danger to the pilot and to himself.

Occurrence summary

Investigation number 200606510
Occurrence date 31/10/2006
Location Coolah
State New South Wales
Report release date 17/01/2008
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 Serious

Aircraft details

Manufacturer Bell Helicopter Co
Model 206
Registration VH-KTR
Serial number 2490
Sector Helicopter
Operation type Aerial Work
Damage Destroyed