On 27 February 2006, at approximately 1427 Western Standard Time, the Cessna Aircraft Company 441 aircraft, registered VH-LBA, was being operated on a charter flight with two pilots and seven passengers from Perth to Mount Weld, WA. During cruise, at Flight Level (FL) 250, the left engine shut down. The crew actioned the 'engine securing phase one checks' from the quick reference handbook and declared a PAN. They then requested and received a clearance to descend to FL200. The crew then actioned the engine restart procedures, successfully restarting the left engine. Air Traffic Control was notified of normal operations and the flight continued to Mount Weld.
Following the occurrence, the flight crew reported that, prior to the engine shutdown, the pilot in command (PIC) had inadvertently depressed the left engine STOP button.
On 18 January 2006, McDonnell Douglas Corporation MD-82, registered PK-LMJ, was operating a flight from Ambon to Makassar, Indonesia. The aircraft was cleared to land on runway 31 and the reported wind direction was 260 degrees at 20 kts. Heavy rain was reported, and the runway was wet. During the landing roll the aircraft veered to the left resulting in a runway excursion.
The National Transportation Safety Committee (NTSC) of Indonesia was responsible for investigating this occurrence. On 27 January 2006, the NTSC requested assistance from the Australian Transport Safety Bureau (ATSB) in the recovery and analysis of information from the flight data recorder (FDR). The Executive Director of the ATSB approved the request.
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 (TSI) Act 2003.
The NTSC is responsible for publishing 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 21 February 2006, at approximately 0630 Eastern Standard Time, a Robinson Helicopter Company Model R44 helicopter (R44), registered VH-HBS, departed Mt Isa, Qld, with two people on board. The helicopter was to position to the Gunpowder airstrip (approximately 100 km to the north) to meet a survey party.
Upon arrival at the airstrip, two other people boarded the helicopter and it departed to begin survey operations in the area between Mt Gordon Mine and Mt Kelly Mine, approximately 30 km to the south-west (Figure 1). During the morning, the helicopter returned to the airstrip at Gunpowder on three occasions to refuel and change personnel on board. It was reported that the helicopter was refuelled to full tanks on each occasion.
Figure 1: Survey area and accident location
It was reported that the helicopter refuelled for the last time at approximately 1300 and departed shortly after with four people on board to continue survey operations in the designated area. The helicopter was expected to rendezvous with the other members of the survey team at approximately 1530. When the helicopter failed to arrive, communication checks with the helicopter pilot and the helicopter operator were conducted and, when no contact with the helicopter was established, search and rescue procedures were initiated. The search continued into the night using a forward looking infrared (FLIR) equipped aircraft. The following morning additional helicopters and aircraft joined the search. At approximately 1100, the burnt wreckage of the helicopter was located on the top of a hill, situated on the edge of the survey area. Rescuers confirmed that all four persons on board had received fatal injuries.
Examination of the wreckage indicated that the helicopter had impacted the terrain heavily, approximately rotor-disc level and in a nose-down attitude. The helicopter came to rest on its right side (Figure 2). The main and tail rotor blades displayed evidence of low rotational energy at the point of impact. Further examination of the main rotor blades revealed compression wrinkling of the upper outer surface of both main rotor blades. All components of the helicopter were accounted for at the accident site.
Figure 2: Aerial view of helicopter wreckage
A severe, fuel-fed, post-impact fire destroyed the cabin and cockpit structure and surrounding flight and engine control systems. The fixed emergency locator transmitter (ELT) and the satellite telephone carried by the pilot were destroyed in the fire. No evidence of the portable ELT, reported to have been carried by the pilot, was found in the wreckage.
The area in which the helicopter was located was not considered to be suitable for a landing area for the R44 helicopter.
Weather conditions in the area were forecast to be fine with light easterly winds. Reported weather conditions in the area were consistent with that forecast.
The pilot held a commercial pilot (helicopter) licence and was appropriately endorsed to fly the R44 helicopter.
The ATSB has recovered the engine and a number of other components for further examination. One of the components recovered is an impact and fire damaged Global Positioning System (GPS) unit. A quantity of data has been successfully recovered from the GPS unit.
The investigation is continuing and will include:
detailed examination of the engine and recovered components
examination of the helicopter maintenance records
further evaluation of the weather conditions
a review of operational factors
detailed examination of recovered GPS data.
Final report
On 21 February 2006, a Robinson Helicopter Company R44 'Astro' helicopter, registered VH-HBS, was being operated on a series of aerial survey flights approximately 100 km to the north of Mt Isa Airport, Qld. The helicopter was operating from Gunpowder airstrip and had completed three flights by 1254 Eastern Standard Time. The pilot refuelled the helicopter and at 1341 departed for a survey flight with three passengers on board. When the helicopter did not arrive at a pre-arranged rendezvous point, a search was initiated. Searchers found the burnt wreckage of the helicopter the next day. The four occupants were fatally injured.
The helicopter had impacted the ground with significant force in a nose-down, fuselage-level attitude. The main rotor displayed evidence of low rotational energy and coning. Other than impact and fire damage, there were no identified mechanical defects or abnormalities. There was evidence that the engine was rotating at impact, but the amount of engine power being developed was not able to be established.
The previous aerial survey flights were reported to have included low speed flight and occasional hovering. At the estimated helicopter weight and the prevailing air density, the helicopter did not have the performance to hover at the survey altitude, which was estimated to be about 1,000 ft above ground level. The investigation considered that the helicopter probably descended contrary to the pilot's intentions, possibly influenced by a partial engine power loss or downdraft, and induced the pilot to apply collective, which developed into overpitching and ultimately main rotor stall.
The investigation found that the helicopter was being operated at gross weights that exceeded the specified maximum take-off weight. The investigation also found that the operator's procedures did not provide a high level of assurance that a relatively low time pilot could conduct aerial survey operations safely.
A turbine-engined PZL-Warszawa-Okecie M-18A Dromader aircraft, registered VH-FVF (callsign Bomber 223), was conducting fire suppression operations on a bushfire in the vicinity of Mount Ulandra, near Bethungra, NSW. At 1921 Eastern Daylight- saving Time, the aircraft was seen by fire fighters to make a low pass over the fire ground area and commence a left turn. Another fireman reported seeing the aircraft in an almost vertical left bank before losing sight of it. None of the other firemen continued to watch the aircraft but, moments later, they reported that they heard a loud noise. When they looked again, the aircraft had hit the ground. The pilot was fatally injured, and the aircraft was destroyed by impact forces. There was no fire.
The crew of a helicopter engaged in fire bucket operations on the same fire ground reported hearing the Dromader pilot broadcast that he was 'lining up for a drop'. A short time later, the helicopter crew reported that they heard the pilot transmit three short expletives. After unsuccessfully attempting to contact the pilot, they commenced searching and located the wreckage of the aircraft a few minutes later, where fire fighters were already in attendance.
The aircraft had impacted open, rising terrain in a nose-down, slightly right wing-low attitude. Examination of the impact marks and the wreckage indicated that the aircraft had been travelling at low forward speed and with a high rate of descent. The ground around the wreckage was covered with a considerable amount of chemical retardant from the ruptured hopper (Figure 1).
Figure 1: Aerial view of wreckage
The aircraft was manufactured in Poland in 1988 and placed on the Australian register in March 1999. In November 2003, the aircraft was modified from the original design in accordance with an approved Supplemental Type Certificate (STC), number SA09039SC, which permitted the replacement of the original reciprocating (radial) engine and the 4-blade propeller with a Garrett TPE 331-12U gas turbine engine and a Hartzell 5-blade constant speed propeller. The modification also incorporated other changes that included the replacement of the hopper with a larger, 800 US gallon (3,030 L) hopper. Additionally, servo tabs were added to the primary flight control surfaces, flap travel was increased and vortex generators were installed on the wings and tailplane.
The aircraft was operated in the restricted category 1 that permitted flight at weights up to 5,300 kg during agricultural operations, which was 1,100 kg in excess of the certified maximum aircraft weight. Flights at those weights restricted the aircraft's maximum speed and, during fire suppression operations, manoeuvring was limited to a maximum angle of bank of 30 degrees.
The pilot held a commercial pilot licence, endorsed for the aircraft type, and a valid Class 1 medical certificate. The pilot also held a Grade 1 Agricultural Rating and had been issued a Night Visual Flight Rules Agricultural Rating on 19 December 2004. The test for that rating met the requirements of the Aeroplane Flight Review, the biennial proficiency check required of pilots. The pilot had in excess of 4,000 hours in agricultural flying operations, of which 127 hours were flown in fire suppression operations over a period of six seasons. Although the pilot had only 4.7 hours on the aircraft type, he had flown over 400 hours on the unmodified radial-engine Dromader aircraft type, and had over 600 hours on other turbine-powered aircraft. The pilot had commenced fire bombing operations two days before and was reported to have been well rested and in good health.
The investigation is continuing and will include the following aspects:
analysis of data downloaded from the aircraft's Global Positioning System navigation receiver to determine the actual flight path
testing of the switches controlling the hopper gate
examination of other aircraft components
a review of maintenance documentation and records of modification made to the aircraft
an appraisal of flight characteristics of the modified aircraft during operations at higher gross weights.
Restricted category aircraft are certified by the Civil Aviation Safety Authority to conduct certain special purpose operations.
Summary
At about 1922 Eastern Daylight-Saving Time on 16 February 2006, the pilot of a turbine PZL-Warszawa-Ockie M-18A, Dromader, registered VH-FVF, was fatally injured when the aircraft impacted terrain during fire-bombing operations approximately 20 km south-south-west of Cootamundra, NSW.
The pilot was an experienced agricultural pilot with previous fire-bombing experience. Although he had considerable flying experience on radial-engine Dromader aircraft, and in other turbine agricultural aircraft, his total flying experience in the modified turbine Dromader was 4.7 hours. Prior to commencing fire-bombing duties two days before the accident, the pilot had not recorded any fire-bombing flights in the previous 3 years.
The pilot's limited familiarity with the handling characteristics of the modified and heavily loaded aircraft might not have allowed him adequate recognition of an impending stall. The pilot had not jettisoned the load of retardant when the aircraft stalled. The ensuing loss of control occurred at a height that did not permit recovery before the aircraft collided with the ground. The possibility that the pilot was distracted by a problem with the operation of the fire doors, or some other activity could not be determined.
Subsequently, the state fire authority reviewed its minimum pilot experience levels for aerial fire suppression. The minimum aircraft type experience for fire-bombing pilots was made more specific to the type of aircraft. It also introduced a recency requirement for fire-bombing operations.
During a charter flight from Broome, WA to Cone Bay, WA, the pilot of an amphibious (float and landing gear equipped) Viking Air Ltd DHC-3-T 'Turbo-Otter' aircraft (VH-OTV) reported an unusual movement within the control system, followed by a sudden downward pitching motion, leading to a rapid and uncontrolled descent. With the assistance of the front seat passenger, the pilot was able to arrest the descent and regain control of the aircraft, before making a precautionary landing at Lombadina Station, WA.
An engineering assessment of the aircraft found that the right elevator servo tab had broken away from the control rod and horn at the outboard end. Damage to the elevator trailing edge and tearing of the tab through the mid-span was consistent with gross oscillatory movement (flutter) of the tab after it had become disconnected from the rod and horn.
Aerodynamic flutter within the elevator trim and servo tabs of the DHC-3 aircraft type had been known since the 1960s, however the development of turboprop engine conversions for the aircraft had resulted in an increased potential for tab failure as a result of the increased airspeeds and control surface loads associated with the re-engined aircraft. A series of engineering solutions to the flutter problem had been subsequently developed, and in April 2004, a US Federal Aviation Administration airworthiness directive (AD) mandated the modification of the DHC-3 elevator tab assembly for US registered aircraft.
At the time of the occurrence, VH-OTV had not undergone the elevator tab modifications. The maintenance organisation stated that it was unaware of the FAA actions and had not received any information as to the availability of flutter prevention modifications from the aircraft type certificate holder or the certificate of registration holder.
Safety action taken by the maintenance provider after the occurrence included the implementation of systems to more adequately alert the organisation to the existence of important safety bulletins and airworthiness directives affecting the aircraft. An airworthiness directive for the elevator tab modifications issued by Transport Canada the month before the occurrence, became effective on 31 March 2006 and, on 1 March 2006, the Civil Aviation Safety Authority (CASA) introduced an AD to mandate the prospective Transport Canada requirements from 31 May 2006.
Occurrence summary
Investigation number
200600837
Occurrence date
15/02/2006
Location
Lombadina, (ALA)
State
Western Australia
Report release date
25/01/2008
Report status
Final
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
De Havilland Canada/De Havilland Aircraft of Canada
On 24 January 2006 at 0644 Western Standard Time, a Boeing Company 737-800 (737) aircraft, registered VH-VXR, was lined up on the threshold of runway 06 at Perth Airport, WA, when the aerodrome controller (ADC) issued the crew a clearance for the aircraft to take off. The crew reported that at about the same time, a British Aerospace Plc 146-300 (146) aircraft, registered VH-NJN, crossed runway 06 in the vicinity of taxiway Charlie. The 737 copilot, the non-flying pilot, advised the ADC that '…we'll just wait for the 146 crossing the runway'. The crew delayed the aircraft's take-off until the 146 had vacated and was taxiing away from the runway.
The ADC and Coordination controller considered that a runway separation standard would exist prior to the 737 commencing take-off. The 737-crew reported that they were concerned at the taxi speed of the 146 and delayed the commencement of their take-off until it had vacated the runway.
The incident highlighted the use of a Manual of Air Traffic Services (MATS) procedure for a situation for which it was not designed. The use of the adapted procedure by controllers has possibly reduced safety when used for runway crossing situations.
As an outcome from the investigation Airservices Australia has advised the Australian Transport Safety Bureau that it intends to:
review the use of take-off/landing clearance procedures during runway crossing situations, by aircraft and vehicles
review runway crossing procedures with a view to assessing the need for a specific runway standard for situations involving aircraft or vehicles crossing a runway during landing/take-off operations
review the use of memory prompts or aids by tower controllers in situations involving aircraft taxiing across a runway during landing/take-off operations.
On 12 February 2006, the pilot of a Robinson Helicopter Company R44 Raven II Newscopter, registered VH-WYS, was conducting aerial filming of a banner towing helicopter in the vicinity of Williamstown, Vic. On board with the pilot were a photographer in the front left seat and a gyro-stabilised camera operator in the rear left seat.
While in a turn at low airspeed, and with a quartering tailwind, the helicopter began an uncommanded yaw to the right. The pilot attempted to regain control, but the helicopter continued to rotate to the right and descended approximately 1,800 ft before control was regained. The helicopter was flown to a nearby beach and landed.
The reported ambient conditions and nature of the loss of control were consistent with the pilot report that the helicopter had suffered a loss of tail rotor effectiveness (LTE). It was possible that the onset of vortex ring state had contributed to the high rate of descent during the pilot's recovery from the LTE.
On 5 February 2006, at approximately 1725 Eastern Daylight-saving Time, a Cessna Aircraft Company 208 floatplane, registered VH-KLP, departed from Strahan, Tasmania on a chartered tourist flight over Frenchman's Cap with the pilot and ten passengers.
When the aircraft was over Frenchman's Cap at an altitude of 4,500 ft above mean sea level, the pilot observed that a chip detector light on the master caution warning panel had illuminated. The pilot decided to land the plane as soon as possible. During the diversion, five minutes after the chip detector light illuminated, a loud noise was heard and the engine lost power. The pilot immediately feathered the propeller and carried out a forced landing on Lake Burbury.
The pilot reported that the aircraft landed heavily, and its forward speed could not be controlled. The aircraft came to a stop on a mud bank on the edge of Lake Burbury with its floats clear of the water. There were no reported injuries.
The engine was removed, disassembled and inspected, revealing damaged components with characteristics consistent with electrical discharge damage. The source of the electrical discharge damage was a starter-generator that was replaced due to a malfunction 18.7 hours prior to the engine failing. This was the forty-third reported starter-generator electrical discharge damage event reported to have taken place on PT6A series engines world-wide since 1992.
As a result of this investigation several safety recommendations have been issued to the aircraft manufacturer, the engine manufacturer, the Civil Aviation Safety Authority, Transport Canada and the US Federal Aviation Administration.
On 2 February 2006 at approximately 1308 Eastern Daylight-saving Time, a US registered Boeing Company 747-422 (747) aircraft was taxiing for departure at Melbourne Airport, Vic. At the same time, a Boeing Company 767-338ER (767) aircraft was stationary on taxiway Echo and waiting in line to depart from runway 16. The tail section of the 767 was protruding into taxiway Alpha while it was stationary on taxiway Echo awaiting a clearance to enter the runway.
The pilots of the 747 received a clearance to taxi, which included a taxi route from the international apron to the holding point on taxiway Bravo, for a departure from runway 16, via taxiways Uniform then Alpha. The pilot in command of the 747 deviated from the taxi clearance issued by the surface movement controller and turned the 747 right into taxiway Echo, to pass behind the 767. The left wing tip of the 747 collided with the right horizontal stabiliser of the 767 as the 747 crew attempted to manoeuvre behind the 767.
The taxiway dimensions and markings at Melbourne Airport complied with international standards and were suitable for use by the aircraft types involved in the occurrence.
The 747 crew was aware of the 767, and chose to pass behind it rather than wait on taxiway Alpha until the 767 was no longer obstructing the taxiway. The decision by the pilot in command of the 747 to deviate off the centreline of taxiway Alpha and taxi behind the 767 did not comply with the taxi clearance issued by the SMC. It was based on his assessment that it was safe to do so. The pilot in command of the 747 misjudged the distance between the wingtip of the 747 and the right horizontal stabiliser of the 767, which resulted in the collision.
On 2 February 2006, a Bell Helicopter Company 206B (III) aircraft, registered VH-MFI, was being operated in the area east of Parkes, NSW on a noxious weed identification survey at low-level, for a local council. At about 0930 Eastern Daylight-saving Time, the helicopter was observed to strike a powerline about 130 ft above ground level (Figure 1), in a location known as 'The Dungeons', approximately 23 km east of Parkes. All three occupants were fatally injured.
Figure 1: Powerline running between arrow heads
Examination of the wreckage revealed that the helicopter struck the powerline with the left landing gear skid (Figure 2).
Figure 2: Landing skid wire contact marks
This led to the tail boom and tail rotor assembly being severed from the fuselage by the main rotor (Figure 3), as a result of which the helicopter entered an uncontrolled descent from which recovery was not possible. The helicopter was destroyed by impact forces and post-impact fire.
Figure 3: Severed tail rotor section
A witness reported that the helicopter appeared to be operating normally until it struck the powerline. The pilot was qualified to undertake the flight and the helicopter was being operated within the manufacturer's prescribed weight and centre of gravity limits.
The investigation is continuing and will include examination of:
low-level operational planning by the council and the helicopter operator
low-level obstacle information databases, and the accessibility of database information to low level operators, aircrew, and contractors.
Summary
On 2 February 2006, a Bell Helicopter Co 206B (III), registered VH-MFI arrived at Parkes Aerodrome from Dubbo, NSW in preparation for an aerial noxious weeds survey, including the requirement for a closer inspection of the eastern border area of the Parkes Shire Council. At an estimated 0923 Eastern Daylight-saving time, the pilot took off for the estimated 7 to 8 minutes flight to the survey area. Also onboard the helicopter were two council weeds control officers.
Witness reports indicated that, at about 0930, the helicopter struck a powerline that crossed the Parkes to Orange road.
The occupants of the helicopter were fatally injured, and the helicopter was destroyed by impact forces and a post-impact, fuel-fed fire. There was no damage to the powerline or associated facilities and structures.
As a result of this investigation, the Civil Aviation Safety Authority (CASA) indicated that it was considering the development of a Civil Aviation Order (CAO) with the effect that anyone carrying out low-level operations would have to satisfy relevant low-level flying standards.
The Australian Transport Safety Bureau (ATSB) issued two recommendations as a result of this investigation, including: the possible enhancement of the content of CASA's Approval to conduct Low-flying Instruments and the possible development of a Civil Aviation Advisory Publication or Advisory Circular for application in the conduct of low-level operations. In addition, the ATSB has commenced initial discussions with a number of agencies and associations in order to examine the feasibility of the establishment of a national database of information on the location of known powerlines and tall structures for access by pilots, operators and managers of aerial campaigns.
