At 1323 Coordinated Universal Time (UTC) (0623 US Pacific Daylight Saving Time), on 9 June 2006, a Piper PA-44-180 Seminole aircraft, registered VH-CZE, departed Santa Barbara, California, USA, for Hilo, Hawaii. The aircraft was one of two Seminoles that were being ferried in-company to Australia under the instrument flight rules. At about 2050 UTC, the pilot in command advised US Air Traffic Services that the left engine had failed, and that the aircraft would have to be ditched as the aircraft was 7 hrs from Hilo but only had 5 hrs of fuel endurance remaining. At about 0145 UTC, the aircraft ditched 980 km north-east of Hilo. The pilot and co-pilot exited the aircraft uninjured and were rescued by a nearby ship. The aircraft sank and was not recovered.
The pilot reported that more fuel was being drawn from the ferry fuel tank than was expected. In addition, a 5 cm x 1 cm scorch mark could be seen just above the landing gear observation mirror on the left inboard engine cowl. Following discussions with the pilot of the accompanying Seminole, the pilot decided to shut down the left engine. Prior to ditching, the pilot restarted the left engine to prevent an asymmetric situation on touchdown.
As a result of this occurrence, the aircraft operator has advised the Australian Transport Safety Bureau that:
In conjunction with their US maintenance provider, they were continuing inquiries with respect to the interaction of the ferry fuel tank system and the fuel selector positions fitted to the aircraft and system management.
They intended to change the ferry flight procedures to use more fuel from the aircraft wing fuel tanks and then periodically top-up those tanks from the ferry fuel tank, using the aircraft fuel contents gauges as a guide.
On 1 June 2006, at about 07011 Central Standard Time2, a Beech Aircraft Corp. A36 (Bonanza) aircraft, registered VH-JDJ, departed Kununurra, WA on a private category visual flight rules (VFR) flight to Bathurst Island, NT. The flight was for the pilot, who was the sole aircraft occupant, to visit clients in regional and remote areas of the country.
At about 0900, an aircraft advised air traffic services (ATS) of a radio distress beacon transmitting on the 121.5 MHz distress frequency. That beacon transmission was confirmed at 0912, when a COSPAS-SARSAT satellite download to an AusSAR3 local user terminal, indicated that a radio distress beacon was transmitting in the vicinity of Bathurst Island.
The Rescue Coordination Centre at AusSAR coordinated the search for the source of the distress beacon transmission. A search aircraft subsequently located aircraft wreckage approximately 1.3 NM north-west of the Bathurst Island aerodrome. The ground party that located the wreckage determined that the pilot had sustained fatal injuries. There was no fire.
A review of ATS recorded radar data identified a VFR aircraft on the direct track between Kununurra and Bathurst Island at an altitude of 5,500 ft4 above mean sea level (AMSL). The aircraft commenced descent from cruise altitude about 30 NM from the aerodrome and, at 0846, arrived overhead at an altitude of 1,400 ft. That was, about 1 hour 45 minutes after the Bonanza departed Kununurra. The recorded radar track was consistent with the aircraft joining the circuit mid-downwind for a landing on runway 15.
The aircraft continued downwind and commenced decent from 1,000 ft just prior to turning onto the base leg of the circuit. The aircraft then turned onto a long final approach for runway 15. The last valid radar return was received at 0848 at an altitude of 600 ft.
The aircraft wreckage was located slightly left of the extended runway 15 centreline, approximately 1,200 m north-west of the runway threshold.
Figure 1 depicts the aircraft's recorded radar position during the final stages of the flight.
Figure 1: Bathurst Island aerodrome, recorded radar track and location of aircraft wreckage
Examination of the wreckage indicated that the aircraft had impacted terrain in a left wing-low, steep nose-down attitude. The accident site was located in scrub-type terrain, moderately populated with trees approximately 10 to 20 m in height (Figure 2).
Figure 2: Accident site and surrounds
The aircraft collided with the upper branches of a tree during the final stages of the decent. Damage to the foliage was consistent with the aircraft descending steeply as it approached the ground. All aircraft components were accounted for at the accident site, and the aircraft was assessed as being intact prior to impact. The landing gear was down, and the wing flaps were retracted (up position) at that time. The propeller sustained relatively minor damage, and the hub of the propeller remained intact.
There was no evidence of bird strike or of a collision with any other object prior to the final impact sequence.
The aircraft's Continental IO-520 engine had accumulated approximately 62 hours time in service since its last overhaul. The engine was recovered from the accident site for further examination. That examination found no evidence of catastrophic failure of any of the engine's components. The engine's ignition system was tested and found to be capable of normal operation. The fuel-injection nozzles for each cylinder were clear of any obstruction and capable of normal operation.
The aircraft was equipped with an EDM 700 engine data monitoring system that monitored a number of parameters of the engine operation. That instrument was recovered for further examination.
The aircraft was equipped with main and auxiliary fuel tanks. The main fuel tanks were located in each wing, and each had a capacity of 140 litres (L) useable fuel. The auxiliary tanks were located on the tip of each wing, and each had a capacity of 75 L. The cockpit fuel selector had 5 positions: 'OFF', 'L. MAIN', 'R. MAIN', 'R. TIP' and 'L. TIP'. The auxiliary tanks were also equipped with a tank cross feed and an 'ON' 'OFF' cross-feed selector.
During the impact sequence, the right auxiliary fuel tank detached from the right-wing tip. Although the tank was intact, it did not contain a significant quantity of fuel. The left auxiliary fuel tank remained attached to the left-wing tip. Although that tank sustained impact damage, it remained substantially intact and did not contain a significant quantity of fuel.
The left main tank was intact. Approximately 65 L of fuel was recovered from that tank and a sample was retained for testing. The right main tank was breached along the leading edge of the wing and the fuel line from that tank sustained impact-related damage and was fractured in the vicinity of the wing root5. All of the fuel tank caps were secure and there was no evidence that any fuel had been lost overboard during flight.
The aircraft fuel selector was found in the R. TIP position and the cross feed for the auxiliary tank was found in the OFF position. A separate fuel gauge was capable of indicating the quantity of fuel in the aircraft's tip tanks. A switch located beside that gauge allowed the pilot to display the quantity of fuel in either of the tip tanks. That switch was found in the L. TIP position. A number of components from the aircraft's fuel system were recovered for further examination/testing. Those components included the cockpit fuel selector and selector valve, cockpit fuel quantity gauges and the fuel tank float and sender units.
The aircraft was last refuelled at Halls Creek on 30 May 2006. Fuel company records indicated that one of the aircraft's swipe cards was used to purchase 268 L of aviation gasoline. Other aircraft had also refuelled from the same fuel source that day. The aircraft's records indicated that, at the time of the accident, the Bonanza had operated approximately 3.6 hours since refuelling at Halls Creek. Flight planning documents recovered at the accident site indicated that, when fully fuelled, the pilot had planned the aircraft's endurance as 7.3 hours.
A number of local residents and other pilots reported that visual meteorological conditions (VMC) prevailed in the vicinity of Bathurst Island at the time of the accident.
The pilot held an unrestricted Private Pilot (Aeroplane) Licence and had accumulated approximately 526 hours total aeronautical experience.
The investigation is continuing and will include the:
examination of the engine data monitoring equipment
testing of recovered components
review of operational factors associated with the flight.
First light at Kununurra on 1 June was 0652 CST (0522 Western Standard Time).
The 24-hour clock is used in this report to describe the local time of day, Central Standard Time (CST), as particular events occurred. Central Standard Time was Coordinated Universal Time (UTC) + 9.5 hours.
Australian Search and Rescue - in general terms, AusSAR coordinates the response to aviation SAR incidents across Australia.
Altitude information is encoded by the aircraft's radar transponder to the nearest 100 ft.
During the subsequent salvage of aircraft components on behalf of the insurance company, a quantity of about 20 L of fuel was reported to have drained from the right main tank.
Summary
On 1 June 2006, at about 0848 Central Standard Time, a Beech Aircraft Corp A36 Bonanza aircraft, registered VH-JDJ, was approaching to land at Bathurst Island aerodrome.
Air traffic services radar data recorded the aircraft overflying the aerodrome and that the pilot joined the circuit on left downwind for a landing on runway 15. The aircraft impacted terrain 2.4 km north-west of the aerodrome. The pilot, who was the sole occupant of the aircraft, sustained fatal injuries.
The aircraft was assessed as being intact prior to the impact with terrain and no anomaly was identified with the aircraft that could have affected its normal operation.
Data recovered from an onboard engine data recording system was consistent with an interruption of the fuel flow and the loss of engine power about 42 seconds before impact. The pilot may have been attempting to perform an emergency landing to a nearby clearing when control of the aircraft was lost.
On 04 May 2006, Boeing 737-281, registered PK-YTQ, was operating a flight from Jakarta to Ujung Pandang, Indonesia. During the take-off roll at Jakarta a main landing gear tyre delaminated and parts of the tread were released damaging hydraulic components. Shortly after takeoff, a malfunction of the hydraulics system was indicated to the flight crew. The crew elected to return to base. During the landing roll, the aircraft brakes and thrust reversers were reportedly not effective and the aircraft overran the end of the runway.
The National Transportation Safety Committee (NTSC) of Indonesia was responsible for investigating this occurrence. On 19 May 2006 the NTSC requested assistance from the Australian Transport Safety Bureau (ATSB) in the recovery and analysis of information from the flight data recorder and cockpit voice recorder.
In accordance with clause 5.23 of Annex 13 to the Convention on International Civil Aviation, the ATSB appointed an Accredited Representative to assist the NTSC and initiated an investigation under the Transport Safety Investigation Act 2003.
The NTSC is responsible for releasing a final investigation report regarding this occurrence.
National Transportation Safety Committee Ministry Of Transportation Republic Of Indonesia Transportation Building 3rd Floor Jalan Medan Merdeka Timur No. 5 Jakarta Pusat 10110 Indonesia
On 29 May 2006 at about 0805 Eastern Standard Time, a Boeing Company 737-7Q8 aircraft (737) passed within 400 ft vertically of an Aero Commander 680-FL (Aero Commander) aircraft. At that time there was less than the minimum 3 NM radar separation standard or the 1,000 ft vertical separation standard between the two aircraft.
The 737 departed Melbourne Airport tracking to the north and then to the north-east of Melbourne on a runway 27 DOSEL 3 standard instrument departure (SID). The Aero Commander became airborne off runway 35 at Essendon. The pilot of the Aero Commander was instructed to track overhead Melbourne Airport and climb to 3,000 ft. From overhead Melbourne Airport, the pilot was instructed to fly a heading of 310 degrees magnetic.
The pilot of the Aero Commander advised the departures controller that he had the 737 in sight. However, there was a breakdown of separation standards because the departures controller did not comply with the requirements of the Manual of Air Traffic Services (MATS) when he assigned separation responsibility to the pilot of the Aero Commander.
On 29 May 2006, an Australian registered and operated Boeing Co. 747-400 was taxiing at New York, John F Kennedy (JFK) Airport. During the aircraft's final turn into its allocated parking bay, the right wingtip contacted a blast fence, resulting in damage to the outboard end of the right wing. An investigation was conducted by the US Federal Aviation Administration in conjunction with the US National Transportation Safety Board and the Australian Transport Safety Bureau.
The ATSB has completed its technical analysis report of the flight recorder data from the Boeing Co. 737-204, registration PK-YTH, on behalf of the Indonesian National Transportation Safety Committee (NTSC). The aircraft was operating a flight from Banjarmarsin to Balikpapan, Indonesia when it was involved in an incident during the landing at Sepinggan Airport at Balikpapan.
The National Transportation Safety Committee (NTSC) of Indonesia is responsible for investigating this occurrence. The NTSC requested assistance from the Australian Transport Safety Bureau (ATSB) in the recovery and analysis of information from the flight data recorder and cockpit voice recorder. In accordance with clause 5.23 of Annex 13 to the Convention on International Civil Aviation, the ATSB appointed an Accredited Representative to assist the NTSC and initiated an investigation under the Transport Safety Investigation Act 2003.
The ATSB's Technical Analysis Report has been sent to the NTSC to assist its ongoing investigation. The NTSC is responsible for releasing a final investigation report regarding this occurrence.
National Transportation Safety Committee Ministry Of Transportation Republic Of Indonesia Transportation Building 3rd Floor Jalan Medan Merdeka Timur No. 5 Jakarta Pusat 10110 Indonesia
On 27 April 2006 at about 1530 Eastern Standard Time, a Cessna Aircraft Company U206G (206) aircraft was being operated on a non-scheduled passenger flight from Warraber Island to Mabuiag Island, in Torres Strait. On board were a pilot, six passengers and luggage. Shortly after touchdown during the landing on runway 15 at Mabuiag Island, the aircraft commenced to veer to the left. The pilot was unable to maintain the aircraft on the runway and it continued to veer left, skidding sideways on the grass verge through a fence and into a lagoon. The pilot and passengers were able to safely vacate the aircraft.
The pilot reported that the aircraft was configured with full flap for the approach and that the aircraft touched down at about 65 kts near the runway threshold. He retracted the flaps on touchdown and as he applied maximum braking, the aircraft turned to the left and started to skid. He applied gentle right rudder in an attempt to straighten the aircraft, but it continued to slide to the left. The aircraft ran off the sealed runway surface and it continued to slide on the grass.
The operator reported that an inspection of the aircraft following its recovery from the lagoon did not reveal any mechanical or system anomalies that may have been a factor in the accident.
The pilot reported that he probably did not apply equal braking effort to both the left and right main landing gear brakes during the landing. While the braking technique may have been a factor, it is more likely that the pilot's limited experience in crosswind conditions and on the aircraft types were the main factors that led to the runway excursion.
On 19 April 2006, a Fairchild Industries Inc SA227-DC (Metro) aircraft was being operated from Newman, WA to Perth, WA at flight level (FL) 200. A Boeing Company 717-200 (717) was being operated from Karratha, WA to Perth at FL320. Both aircraft were in controlled airspace and were on tracks that converged.
The crew of the 717 had been provided with a clearance to descend to FL210 by the air traffic controller managing the airspace the aircraft were operating in. This level provided the required minimum vertical separation standard of 1,000 ft with the Metro.
As the crew of the 717 were approaching FL225 the traffic alert and collision avoidance system (TCAS) provided a traffic advisory relating to the Metro. A few seconds later the crew received a TCAS 'reduce descent rate' resolution advisory (RA). The crew advised the controller 'we've got a TCAS resolution advisory we're leaving F210 on descent'. The controller responded by instructing the crew of the 717 to maintain FL210.
Later analysis of Airservices Australia recorded radar data and audio recordings demonstrated that the crew of the 717 had descended to, and maintained, FL210. There was no infringement of separation standards.
The crew of the 717 maintained a high rate of descent approaching their assigned level, which resulted in the TCAS 'reduce descent rate' resolution advisory. The controller did not recognise the rate of descent of the 717, together with the relative positions of the two aircraft, may have generated a RA.
On 21 April 2006, a Brisbane Airport surface movement controller (SMC) issued a clearance for the driver of an aircraft tow vehicle to cross an active runway in front of a Boeing Company 737 aircraft which had been lined up on the runway ready for departure. The crew of the 737 aircraft had been issued with a take-off clearance by the aerodrome controller (ADC) and subsequently commenced take-off. The SMC and ADC services were being provided on separate radio frequencies.
The crew of the tow vehicle later reported that they were still within the runway strip when the 737 aircraft passed behind them airborne. The flight crew of the 737 had observed the tow vehicle crossing the runway during the take-off roll but had assessed that the vehicle would be clear of the runway prior to them reaching its observed position and decided to continue the take-off. The SMC later reported that he had wrongly believed that he had coordinated and received a clearance for the tug to cross the runway from the ADC.
As a result of this occurrence Airservices Australia has made changes to the coordination of runway crossing clearances, including the content, form and readback requirements and has mandated the use of movement strips for the SMC position at Brisbane. It reported that it has continued with efforts to reduce the number or required runway crossings, in consultation with the airport owner and is also in the early stages of a project to procure an Advanced Surface Movement Guidance System (A-SMGCS). Airservices Australia is also actively considering and pursuing the concept of having all runway crossings occurring on the ADC frequency as recommended by the International Civil Aviation Organization.
On 4 April 2006 a Bell Helicopter Company 206B III helicopter was being operated on a survey of powerlines in the St Albans area of New South Wales with a pilot, two power supply company personnel and a photographer on board. At about 1000 Eastern Standard Time, the pilot observed a previously unseen single-strand telecommunication cable support wire rubbing against the copilot's door and attempted to manoeuvre the helicopter clear of the wire. The helicopter lost directional control and commenced spinning to the right. However, the pilot cleared the wires and attempted a landing in an adjacent paddock. The helicopter came to rest on its right side and was severely damaged. One of the power supply company personnel received serious head injuries and the remaining occupants received minor injuries.
Safety action undertaken as a result of this accident included:
by the power supply company, who acted to:
immediately suspend helicopter inspections
appoint an internal accident investigation team that would make recommendations for the recommencement of helicopter operations
engage an aviation risk management consultant to assess the hazards affecting the company's aerial surveillance operations and to assist the internal investigation team
implement a number of safety actions that were recommended by the internal investigation team.
the removal by the telephone company of the single-strand telecommunication cable support wire that was struck by the helicopter.
