American Champion Aircraft Corp 7GCBC, VH-MWY, 19 km west of Camden Aerodrome, New South Wales, on 8 May 2008

Summary

On 8 May 2008, the pilot of an American Champion Aircraft (ACA) 'Citabria', model 7GCBC (registered VH-MWY), was returning to Camden Aerodrome, NSW, after a local area flight, when the upper elevator control cable fractured. The pilot was able to maintain control of the aircraft's pitch attitude using wing flaps, and subsequently landed the aircraft safely, with only minor damage to the propeller.

Laboratory examination of the failed cable found the failure (and an adjacent area of significant damage) to have developed from the progressive fatigue cracking of individual cable wires in locations where the cable passed over guide sheaves. The examination also determined that the cable had not been manufactured to conform with the requirements of the accepted standard for aircraft control cables (MIL-DTL-83420).

From 2005, the aircraft manufacturer changed its internal procedures to require that only cable manufactured and certified to MIL-DTL-83420 be used for new aircraft production. Following the cable failure, the Civil Aviation Safety Authority (CASA) published an Airworthiness Bulletin (AWB), highlighting the issues associated with the use of non-MIL standard cables in aircraft control applications, and recommended that owners and maintainers of American Champion Aircraft ensure that periodic inspections are conducted with appropriate veracity.

Occurrence summary

Investigation number AO-2008-032
Occurrence date 08/05/2008
Location Camden Aerodrome NSW W/19 km
State New South Wales
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 Flight control systems
Occurrence class Serious Incident
Highest injury level None

Aircraft details

Manufacturer American Champion Aircraft Corp
Model 7
Registration VH-MWY
Serial number 1347-2003
Sector Piston
Operation type Private
Departure point Camden, NSW
Destination Camden, NSW
Damage Nil

Operational non-compliance, Perth Airport, Western Australia, on 9 May 2008, PK-GEF, Boeing 737-8CX

Summary

On 9 May 2008, a Boeing Company 737-8CX aircraft, registered PK-GEF, was being operated on a scheduled passenger service between Denpasar, Republic of Indonesia and Perth, WA. On board were two flight crew, six cabin crew and 76 passengers.

The flight crew reported that, once established in the cruise, they reviewed their briefing material and noted that the threshold for runway 21 at Perth was displaced due to runway works.

On approach to land at Perth, the aerodrome controller issued the flight crew with the landing clearance, '... runway 21 displaced threshold, cleared to land'. When the aircraft was about 15 seconds from touchdown, the flight crew questioned the presence of cars on the runway and conducted a go-around.

On the second approach, the flight crew were again issued the landing clearance '... runway 21, displaced threshold, cleared to land'. The aerodrome controller recalled observing the aircraft on what appeared to be an approach to land on the closed section of the runway and instructed the flight crew to go around. The go-around instruction also included information to assist the flight crew in identifying where the aircraft was to be landed. That additional information, together with the high workload being experienced by the flight crew at that time, may have momentarily confused them, with the effect that they did not assimilate and act on the instruction to go around.

As a result of this incident, the airport operator undertook a number of safety actions. Those actions included: the review of its dispatch of Method of Works Plans (MWOP) to relevant stakeholders; the implementation of a more robust MWOP receipt and acknowledge system; and the establishment of a project safety group in support of all critical airside works.

Occurrence summary

Investigation number AO-2008-033
Occurrence date 08/05/2008
Location Perth Airport
State Western Australia
Report release date 09/06/2009
Report status Final
Investigation level Systemic
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Operational non-compliance
Occurrence class Serious Incident
Highest injury level None

Aircraft details

Manufacturer The Boeing Company
Model 737
Registration PK-GEF
Serial number 32363
Sector Jet
Operation type Air Transport High Capacity
Departure point Denpasar Indonesia
Destination Perth WA
Damage Nil

Loss of control – Fairchild Metro III, VH-OZA, 19 km south-east of Sydney Airport, New South Wales, on, 9 April 2008

Interim factual report

Interim factual report released 25 July 2008

On 9 April 2008, a Fairchild Industries Metro III aircraft departing Sydney, NSW was observed on radar to be turning contrary to air traffic control instructions. The pilot reported that he had a '...slight technical fault...'. Recorded radar data showed the aircraft then completed a turn to the left before turning back to the right and disappearing from radar at an altitude of 3,900 ft. Searchers later discovered a small amount of aircraft wreckage floating in the ocean, south of the last recorded radar position. The pilot was fatally injured, and the aircraft was destroyed.

Preliminary report

Preliminary report released 20 June 2008

On 9 April 2008, a Fairchild Industries Metro III aircraft departing Sydney, NSW was observed on radar to be turning contrary to air traffic control instructions. The pilot reported that he had a '…slight technical fault…'. Recorded radar data showed the aircraft then completed a turn to the left before turning back to the right and disappearing from radar at an altitude of 3,900 ft. Searchers later discovered a small amount of aircraft wreckage floating in the ocean, south of the last recorded radar position. The pilot was fatally injured, and the aircraft was destroyed.

Summary

On 9 April 2008, at 2325 Eastern Standard Time, a Fairchild Industries Inc. SA227-AC (Metro III) aircraft, registered VH-OZA, departed Sydney Airport, New South Wales on a freight charter flight to Brisbane, Queensland with one pilot on board. The aircraft was subsequently observed on radar to be turning right, contrary to air traffic control instructions to turn left to an easterly heading. The pilot reported that he had a 'slight technical fault' and no other transmissions were heard from the pilot.

Recorded radar data showed the aircraft turning right and then left, followed by a descent and climb, a second right turn and a second descent before radar returns were lost when the aircraft was at an altitude of 3,740 ft above mean sea level and descending at over 10,000 ft/min. Air traffic control initiated search actions and search vessels later recovered a small amount of aircraft wreckage floating in the ocean, south of the last recorded radar position. The pilot was presumed to be fatally injured, and the aircraft was destroyed.

Both of the aircraft's on-board flight recorders were subsequently recovered from the ocean floor. They contained data from a number of previous flights, but not for the accident flight. There was no evidence of a midair breakup of the aircraft.

The investigation determined that it was highly likely that the pilot took off without alternating current electrical power supplied to the aircraft's primary flight instruments, including the pilot's artificial horizon and both flight recorders. It is most likely that the lack of a primary attitude reference during the night take-off led to pilot spatial disorientation and subsequent loss of control of the aircraft.

A significant safety issue was identified in respect of the aircraft operator's training and checking of its pilots. As a result of audits conducted following the accident, the Civil Aviation Safety Authority imposed a number of conditions on the operator's air operator's certificate that were reportedly actioned by the operator.

Occurrence summary

Investigation number AO-2008-026
Occurrence date 09/04/2008
Location Sydney Airport SE 19 km
State New South Wales
Report release date 16/05/2011
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 Fairchild Industries Inc
Model SA227
Registration VH-OZA
Serial number AC-600
Sector Turboprop
Operation type Charter
Departure point Sydney, NSW
Destination Brisbane, Qld
Damage Destroyed

Aircraft proximity event, VH-VOQ and VH-VQS Launceston Aerodrome, Tasmania, on 1 May 2008

Summary

On 1 May 2008 at about 2216 Eastern Standard Time, an Airbus Industrie A320 aircraft, registered VH-VQS, was conducting the runway 32L (left) instrument landing system missed approach procedure at Launceston Aerodrome, Tasmania. During the climb, the A320 came into close proximity with a Boeing Company 737 that was manoeuvring at 3,100 ft above mean sea level about 5 NM (9 km) to the north-west of the aerodrome. The lateral separation between the aircraft reduced to within 3 NM (5 km) and zero vertical separation as the A320 climbed through 3,100 ft. No Traffic Alert and Collision Avoidance System alerts were generated during the occurrence.

Both aircraft were operating scheduled passenger services from Melbourne, Victoria and had arrived at Launceston outside the normal operating hours of the Launceston air traffic control tower. Separation between the aircraft was therefore the responsibility of the respective flight crews. In this instance, a breakdown in the communication and interpretation of the respective flight crews' separation planning contributed to the proximity event.

Occurrence summary

Investigation number AO-2008-030
Occurrence date 01/05/2008
Location Launceston
State Tasmania
Report release date 30/06/2010
Report status Final
Investigation level Systemic
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 The Boeing Company
Model 737
Registration VH-VOQ
Serial number 33798
Sector Jet
Operation type Air Transport High Capacity
Departure point Melbourne Vic.
Destination Launceston Tas.
Damage Nil

Aircraft details

Manufacturer Airbus
Model A320
Registration VH-VQS
Serial number 2515
Sector Jet
Operation type Air Transport High Capacity
Departure point Melbourne Vic.
Destination Launceston Tas.
Damage Nil

Fuel-related event, 16 km south-east of Townsville Airport, Queensland, on 9 April 2009

Summary

On 9 April 2008, the crew of a McDonnell Douglas Helicopter Company MD369ER helicopter registered VH-PLU, experienced a substantial loss of engine power while conducting low-level powerline stringing operations. The helicopter impacted the ground and was seriously damaged. The two occupants were seriously injured.

The investigation determined that the pilot in command was operating the helicopter with a fuel tank quantity that did not guarantee continuous operation of the engine at the flight attitudes experienced during the powerline stringing operation.

As a result of the accident, the operator revised its fuel management procedures for powerline stringing operations.

Occurrence summary

Investigation number AO-2008-025
Occurrence date 09/04/2008
Location Townsville
State Queensland
Report release date 29/06/2009
Report status Final
Investigation level Systemic
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Fuel starvation
Occurrence class Accident
Highest injury level Serious

Aircraft details

Manufacturer McDonnell Douglas Corp.
Model 500
Registration VH-PLU
Serial number 0384E
Sector Helicopter
Operation type Charter

Ditching - Brampton Island, Queensland, on 03 April 2008

Summary

On 3 April 2008, a Piper PA-32-300 Cherokee Six aircraft, registered VH-ZMP, lost engine power shortly after take-off from Brampton Island, Qld and ditched into the sea. The pilot and the four passengers evacuated the aircraft before it sank and were later recovered by rescue helicopter. The engine power loss was consistent with fuel starvation.

Following the event, the aircraft operator amended Cherokee Six fuel procedures to require a minimum of 30 L of fuel in the selected fuel tank for any take off.

Occurrence summary

Investigation number AO-2008-022
Occurrence date 03/04/2008
Location Brampton Island
State Queensland
Report release date 20/03/2009
Report status Final
Investigation level Systemic
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Fuel starvation
Occurrence class Accident
Highest injury level Minor

Aircraft details

Manufacturer Piper Aircraft Corp
Model PA-32
Registration VH-ZMP
Serial number 32-7440019
Sector Piston
Operation type Charter
Departure point Brampton Island Qld
Damage Destroyed

Examination of the feasibility of the establishment of a single source or database of known powerlines and tall structures

Summary

There were 52 fatalities throughout Australia as a result of wirestrike accidents in the period 1994 to 2006. During that period, there was an average of just under 11 reported wirestrike accidents each year and the average number of fatalities was four per annum.

Despite the application of risk strategies to mitigate the consequences of a wirestrike, those consequences can often be expected to be catastrophic. In that case, a large investment is made by operators, pilots and other parties involved in low-level operations to minimise the likelihood of a wirestrike. That includes by ensuring awareness of all known low-level hazards, including powerlines and tall structures, before commencing, and during the conduct of low-level operations.

During a series of recent ATSB investigations into fatal and other wirestrike accidents, a number of different sources of information on the location of known powerlines and tall structures was identified. However, despite the apparent utility and safety benefits inherent in the availability to pilots, operators and low-level campaign managers of a single source or database of the location of known powerlines and tall structures, initial discussions with aviation authorities on the potential development of such a resource were non-productive.

However, Australian Transport Safety Bureau (ATSB) investigators commenced initial discussions with Geoscience Australia (GA) and the Energy Networks Association (ENA) to examine the feasibility of the establishment of such a database. Those discussions determined that GA was amenable to working with other relevant agencies in order to promulgate that data for use by pilots and other parties. ENA indicated that the proposal to establish a national database would be considered as part of its 2008 priority issues.

The ATSB will advise of further developments in its discussions with GA and ENA on its website at 6-monthly intervals.

Occurrence summary

Investigation number AI-2008-019
Occurrence date 02/04/2008
Location Not applicable
State Other
Report release date 02/04/2008
Report status Final
Investigation level Systemic
Investigation type Safety Issue Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Other
Highest injury level None

Collision with terrain, Pitts S-2A, VH-NUK, 7 km north-east of Camden, New South Wales, on 18 March 2008

Preliminary report

Preliminary report released 16 May 2008

On 18 March 2008, at approximately 1115 Eastern Daylight-saving Time (EDT), a Pitts S-2A aircraft struck two trees before impacting the ground beside the Northern Road, 7 km NE of Camden, NSW, fatally injuring the occupant of the rear cockpit.

Summary

On 18 March 2008, at approximately 1115 Eastern Daylight-saving Time, a Pitts S-2A aircraft struck two trees before impacting the ground beside the Northern Road, 7 km north-east of Camden, NSW, fatally injuring the occupant of the rear cockpit.

The occupant of the rear cockpit (the candidate), an experienced aerobatic pilot, was undergoing a routine flight review with an instructor. In the instructor's judgment, the candidate flew well during the flight review until a practice forced landing (PFL) manoeuvre just before the accident.

During the PFL, the candidate stopped responding to instructions and commands, so the instructor took control of the aircraft. A powerful nose-up force began acting on the control column and, despite the instructor's efforts to control the aircraft, it entered an incipient aerodynamic stall. The instructor recovered the aircraft from the stall but, as consequence of the nose-up force, this came too late to prevent a collision with trees.

No evidence of any mechanical problem with the aircraft was found. Postmortem examination of the candidate found he had severe heart disease.

Expert medical opinion considered it likely that the candidate suffered an incapacitating event as a result of his heart disease, and that the incapacitating event probably led to him exerting a force on the control column. The nose-up force prevented complete control by the instructor, delayed recovery from the stall, and led to the impact with trees.

Occurrence summary

Investigation number AO-2008-021
Occurrence date 18/03/2008
Location Camden Airport E/6 km
State New South Wales
Report release date 10/02/2009
Report status Final
Investigation level Systemic
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Flight crew incapacitation
Occurrence class Accident
Highest injury level Fatal

Aircraft details

Manufacturer Pitts Aviation Enterprises
Model S-2
Registration VH-NUK
Serial number 2116
Sector Piston
Operation type Private
Departure point Bankstown Airport, NSW
Destination Bankstown Airport, NSW
Damage Destroyed

Collision with terrain, VH-KUZ, Airvan GA8, Kalumburu, Western Australia, on 26 February 2008

Summary

On 26 February 2008, at about 1655 Western Daylight-saving Time, the pilot of a Gippsland Aeronautics Pty Ltd GA-8 Airvan, registered VH-KUZ, with two passengers on board, commenced take-off at Kalumburu Aerodrome, WA. Witnesses reported that the aircraft started to drift to the left of the runway prior to becoming briefly airborne. The aircraft settled back onto the runway strip, veering further left across the runway strip. The aircraft subsequently ran up an embankment, through low scrub, and then through small trees beyond the runway strip. The impact with the trees flipped the aircraft onto its back, where it came to rest, facing the opposite way to the direction of take-off. The aircraft was seriously damaged, and the pilot and two passengers received minor injuries.

Occurrence summary

Investigation number AO-2008-015
Occurrence date 26/02/2008
Location Kalumburu Aerodrome
State Western Australia
Report release date 23/06/2009
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 Minor

Aircraft details

Manufacturer Gippsland Aeronautics Pty Ltd
Model GA8
Registration VH-KUZ
Serial number GA8-07-110
Sector Piston
Operation type Charter
Departure point Kalumburu, WA
Destination Kununurra, WA
Damage Substantial

Procedures-related event, Launceston Airport, Tasmania, on 12 March 2008, VH-VQY, Airbus A320-200

Summary

On 12 March 2008, an Airbus A320-200 aircraft, registered VH-VQY, was being operated on a scheduled passenger service from Launceston, Tas. to Sydney, NSW. While the crew were preparing for the flight, the control tower closed, and the airport lighting switched over to a pilot activated lighting system. The aircraft subsequently departed without the airport lighting being turned on. A number of situational factors were probably associated with the crew not activating the airport lights before the departure. Several similar incidents have previously occurred in Australia and overseas.

Occurrence summary

Investigation number AO-2008-020
Occurrence date 12/03/2008
Location Launceston Airport
State Tasmania
Report release date 25/06/2009
Report status Final
Investigation level Systemic
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Incident
Highest injury level None

Aircraft details

Manufacturer Airbus
Model A320
Registration VH-VQY
Serial number 2299
Sector Jet
Operation type Air Transport High Capacity
Departure point Launceston, Tas.
Destination Sydney, NSW
Damage Nil