Preliminary report released 19 December 2008

On the morning of 16 October 2008, a Gippsland Aeronautics GA-8 Airvan, registered VH-WRT, being operated on a freight charter flight, was reported missing near Elcho Island, NT. Subsequently, items of wreckage from the aircraft were found in Buckingham Bay. The pilot, who was the sole occupant of the aircraft, was assumed to be fatally injured.

On 24 September 2008, at about 1606 Eastern Standard Time, a Liberty Aerospace Inc. XL2 aircraft, registered VH-CZX, descended through trees and collided with terrain 2 km south of Luddenham, New South Wales. The sole occupant, a student pilot, was fatally injured and the aircraft sustained serious damage.

Air traffic control radar data recordings indicated that the aircraft departed straight and level flight from about 3,000 ft above ground level and descended very steeply at a high rate of descent to below the radar's minimum detection height. Witness observations, aircraft damage and wreckage distribution were consistent with a steep, low-speed collision with terrain.

The investigation was unable to determine the reasons for the departure from straight and level flight or establish the aircraft's movements in the period of time between the loss of radar information and the witnesses' visual observations.

No evidence of any mechanical fault that could have contributed to the accident was found. The weather was benign. A post-mortem examination of the pilot did not identify any pre-existing medical conditions that may have contributed to the accident.

Traces of a cannabis metabolite were present in the pilot's blood, indicating previous use of, or exposure to cannabis. There was no evidence that the pilot was impaired by cannabis at the time of the accident; however, there is extensive evidence that the use of cannabis increases the risk of the impairment of pilot performance.

The investigation did not identify any organisational or systemic issues that might adversely affect the future safety of aviation operations. However, following the accident, the flying school proactively modified its training syllabus to include additional instructional flights on the aircraft type prior to authorising extended solo flights.

On 18 September 2008, a Boeing Company 717-200 (717), registered VH-NXE, was being operated on a scheduled passenger flight from Cairns, Queensland to Alice Springs, Northern Territory. There were 70 passengers, four cabin crew and two flight crew on board. During the manually-flown visual approach by the pilot in command (PIC) to runway 30 at Alice Springs Aerodrome, the stickshaker activated. The pilot flying lowered the nose while continuing the turn onto final. The stickshaker activated again before the flight crew stabilised the approach to within the operator's criteria and landed without further incident.

The investigation found that the stickshaker activated because of a combination of bank angle, high nose-up pitch change rate and airspeed slightly below the approach speed. The aircraft was higher, faster and closer to the aerodrome than was suitable for the direct-to-final approach being attempted. The autothrottle was inadvertently not engaged by the flight crew after the automatic flight system was disconnected earlier in the approach, which contributed to the airspeed reduction. The PIC's response to the stickshaker did not conform to the aircraft manufacturer's procedures.

The investigation also found that the PIC's judgement and monitoring ability were probably adversely affected by personal and work stress and associated fatigue, although the duty roster met the necessary standards. Pilots operating within flight and duty time limitations can still experience fatigue. Responsibility for adequate flight crew wellbeing before flight rests with both operators and their pilots.

The investigation did not identify any organisational or systemic issues that might adversely affect the future safety of aviation operations. However, in response to this occurrence, the operator proactively issued a number of notices to pilots to enhance pilot flight mode annunciator and auto mode awareness in the 717, to highlight the aircraft's buffet protection system and to discuss recent stickshaker events, and to describe the stall recovery procedure in the 717. In addition, the operator amended a number of its command upgrade and recurrent simulator training requirements and worked with the aircraft manufacturer to reduce the incidence of stickshaker events across the operator's 717 fleet.

On 14 September 2008, a Robinson Helicopter Company R44 Raven helicopter, registered VH-RIO, was being operated on a series of scenic flights in the Bungle Bungle ranges area of the Purnululu National Park, which was about 250 km south of Kununurra, Western Australia. At about 1230 Western Standard Time, the helicopter departed the Purnululu Aircraft Landing Area for an 18- minute scenic flight with the pilot and three passengers. When the helicopter did not return by the nominated time, a search was initiated. Shortly after, the burnt wreckage of the helicopter was located. The four occupants were fatally injured.

The pilot had deviated from the regular scenic flight track, speed and profile to operate out of ground effect (OGE) in close proximity to the terrain at a low airspeed or at the hover. The helicopter's estimated OGE hover performance was marginal. It is likely that the high level of engine power required to sustain a hover in the local conditions was not available, or not fully utilised by the pilot, resulting in; an uncommanded descent, overpitching of the main rotor as a result of the pilot's attempts to arrest that descent, and a main rotor RPM decay that significantly increased the rate of descent.

As a result of the investigation into this occurrence, two minor safety issues were identified:

• There was no Australian requirement for endorsement and recurrent training conducted on Robinson Helicopter Company R22/R44 helicopters to specifically address the preconditions for, recognition of, or recovery from, low main rotor RPM.
• There was a lack of assurance that informal operator supervisory and experience-based policy, procedures and practices minimised the risk of pilots operating outside the individual pilot's level of competence.

In response, the aircraft operator has since formalised the operating parameters applicable to pilots conducting scenic flights. In addition, the Civil Aviation Safety Authority will be reviewing the training requirements affecting R22/44 helicopters. The Australian Transport Safety Bureau has issued a Safety Advisory Notice to encourage operators to address the risk of their pilots operating outside the individual pilot's level of competence.

Response to Bungle Bungle inquest findings

A Western Australian Coroner recently released findings into a 2008 fatal Robinson R44 Raven helicopter accident near Purnululu in the Bungle Bungle Ranges in Western Australia.  The findings highlight a number of safety concerns that require review by the aviation industry in relation the safety issues raised by the ATSB in its report released on 7 July 2010.

These issues cover:

• Recovery from Low Main Rotor RPM;
• Formalisation of Operator, Policies, Procedures and Practices

Circumstances of the accident

On 14 September 2008 a Robinson R44 Raven Helicopter, VH-RIO, crashed near Purnululu in the Bungle Bungle Ranges in Western Australia.  All four occupants were fatally injured.  The ATSB investigation advised that it was likely that due to the local conditions the helicopter was in a situation where the necessary engine power was either unavailable, or not fully utilised by the pilot, to sustain a hover.   The crash site indicated there had been significant main rotor RPM decay and a high rate of descent.

Safety Issues

The ATSB found the following safety issues as part of the investigation:

1. Recovery from Low Main Rotor RPM

There was no Australian requirement for endorsement and recurrent training conducted on Robinson Helicopter R22/R44 helicopters to specifically address preconditions for, recognition of, or recovery from, low main rotor RPM.

At the time of the release of the ATSB report, CASA had advised that it was reviewing the requirements for initial pilot training and endorsement and recurrent training on all helicopters, including a review of the Helicopter's Flight Instructor's Manual.

While noting that CASA was undertaking this review, the Coroner made a recommendation for CASA to address the safety issue raised by the ATSB.

In response to the safety issue CASA has advised the ATSB as follows:

"CASA is intending to produce an Instructor Pack for Awareness Training (AT) on the key hazards as specified in FAA SFAR 73.  This AT would be generic in nature, but would address specific discussion points on matters relevant to specific types, including but not limited to R22/R44."

2. Operator policy, procedures and practices

During the course of the investigation the ATSB also considered it necessary to draw the attention of all operators in the industry to the potential lack of assurance that informal operator supervisory and experienced-based policy, procedures and practices minimise the risk of their pilots operating outside the individual pilot's level of competence.

Operators were encouraged to take action where considered appropriate.

The ATSB continues to advocate that all operators in the industry should consider their procedures for appropriately tasking pilots.  Backing this, the Coroner noted the specific risks associated with low flight, including conducting aerial photography.

ATSB investigations and Coronial Inquiries

Inquests are separate to ATSB investigations.  In this matter the respective authorities largely agree on what the safety issues are that the industry needs to take account of.

The ATSB's report can be downloaded by clicking on the link: AO-2008-062.  Feedback can be provided via the website.

The Coroner's report can be obtained from the Coroner's Court of Western Australia.  Contact details are available at: http://www.coronerscourt.wa.gov.au.  Queries regarding the Coroner's findings should be directed to the Coroner's Court of Western Australia.

Response to Inquest Findings

NSW Deputy State Coroner MacMahon recently handed down findings into a 2008 fatal Cessna U206A aircraft accident 56 km north north-east of Scone Airport.

The Coroner accepted the findings of the Australian Transport Safety Bureau (ATSB) in relation to how the accident occurred and made findings substantially in accordance with those of the ATSB.

The safety factors identified in the ATRSB report and the Coroner’s findings highlight the risks to for VFR pilots encountering IMC, the important of flight planning and obtaining sufficient information as to prevailing weather conditions for VFR pilots.

ATSB Investigations and Coronial Inquiries

Inquests are separate to ATSB investigations. In this matter the respective authorities largely agree on what the safety issues are that the industry needs to take account of.

The ATSB's report can be downloaded by clicking on the link: AO-2008-063 Feedback can be provided via the website.

The Coroner's report can be obtained from the Coroner's Court of New South Wales. Contact details are available at: www.coroners.lawlink.nsw.gov.au Queries regarding the Coroner's findings should be directed to the Coroner's Court of New South Wales.