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Cessna 310R, VH-HCP

Factual Information

At about 1930 Western Standard Time1 on 26 January 2001, a Cessna 310R aircraft, VH-HCP, departed Kiwirrkurra, Western Australia (WA), for Newman. The flight was conducted at night under the visual flight rules (VFR), with one pilot and three passengers on board. The aircraft was operated by the Air Support Unit (ASU) of the WA Police Service and had been used to transport police officers from Newman to Kiwirrkurra earlier that day.

The aircraft arrived in the circuit area at Newman at about 2150 for a landing on runway 23. Witnesses at the aerodrome heard the engines start to 'cough and splutter'. Soon after, the aircraft collided with the ground about 3 km to the east of Newman aerodrome. The four occupants sustained fatal injuries. Impact forces destroyed the aircraft.

The investigation determined that both of the aircraft's engines failed due to fuel starvation,2 prior to impact with the ground. There was no evidence of a technical malfunction or of an in-flight fuel leak. From the information available, the investigation calculated that the aircraft probably had about 165 L of useable fuel at impact. Approximately 30 L of fuel was recovered from the aircraft's auxiliary fuel tanks and it was probable that fuel had leaked from these tanks post-impact.

The investigation identified a number of factors that had contributed to the circumstances of the accident. These factors included operational events on the night of the accident, local conditions associated with the circumstances of the operational events, the defences that were used to manage risk, and organisational conditions that influenced the effectiveness of the defences.

Operational events and local conditions

The investigation identified a number of deficiencies associated with the pilot's pre-flight preparation and conduct of the flight. There was no evidence that he had obtained a weather forecast, considered the need for extra fuel, or submitted the appropriate flight notification and he had exceeded the maximum duty period permitted by the Civil Aviation Safety Authority (CASA) under Civil Aviation Order 48. Also, the flight was not operated in accordance with required procedures for VFR flights conducted at night, with respect to contingencies for runway lighting and provision for flight to an alternate aerodrome. The investigation concluded that these factors suggested that the pilot had probably not identified, or fully considered, the hazards associated with the flight. A number of physiological factors such as fatigue, dehydration, and a lack of recent nutrition could also have affected his performance. The pilot was probably experiencing self-imposed pressure to conduct the flight.

The fuel starvation of the engines was probably the result of inadequate techniques used by the pilot to monitor and manage the consumption of fuel from the aircraft's fuel tanks. This had resulted in a low quantity of fuel in the main fuel tanks at the time the engines failed. The investigation could not determine the sequence of events that led to the low quantity of fuel in the main tanks. It was possible that the pilot had inadvertently omitted to use the auxiliary tanks, had used the auxiliary tanks for an unusually short period of time, or made some other type of error with the tank selections during the flight. Regardless of what fuel tank selections were made during the flight, the pilot had probably not detected the critically low quantity of fuel in the main tanks towards the end of the flight. The investigation could not find any evidence that the pilot had used structured techniques to monitor the quantity of fuel consumed from the aircraft's tanks during the flight. This could have affected his ability to successfully detect and resolve abnormal indications from the aircraft's fuel gauges.

The pilot experienced a difficult set of circumstances in which to respond to the initial and subsequent engine failure. Those circumstances included a lack of significant external visual reference due to the dark night conditions, the limited height available at circuit altitude and the pilot's skill level in handling emergency situations in multi-engine aircraft. He did not maintain control of the aircraft following the engine failures.

The pilot held a commercial pilot (aeroplane) licence and was rated to fly single-engine aircraft at night under the VFR. He did not hold a valid rating to fly multi-engine aircraft at night, although he probably thought that he had been issued with such a rating following a flight test conducted by the ASU chief pilot. However, the chief pilot was not authorised by CASA to conduct flight tests to issue night VFR ratings. The investigation could not find any objective evidence to indicate that the occurrence pilot had received recent training to control a multi-engine aircraft solely by reference to the aircraft flight instruments following a simulated engine failure, or that this ability had been tested prior to, or after the issue of, the (invalid) multi-engine night VFR rating.

Defences and organisational conditions

The investigation concluded that the processes used by the ASU for training in, and supervision of, fuel planning and fuel management were deficient. This probably contributed to the occurrence pilot not using structured procedures and techniques that could have provided him with a greater level of awareness of his fuel situation during the flight.

Deficiencies were also found with the ASU training and checking of night operations. Pilots did not receive recurrent checking of their performance during night operations. The ASU had not fully recognised the risks of remote area night operations and did not have effective defences to manage those risks.

The ASU chief pilot had been provided with minimal training, guidance and professional development to effectively perform his duties. His performance in several safety critical areas was not monitored and resulted in a series of failures in the overall system of safety management at the ASU. Senior management of the WA Police Service assumed that the regulatory relationship between the ASU and CASA provided adequate assurance that the ASU's operations were conducted to an appropriate standard. However, CASA prioritised its surveillance activities, utilising available resources to achieve surveillance targets for operations carrying fare-paying passengers. Organisations holding an aerial work Air Operator's Certificate (AOC), such as the ASU, were allocated a lower priority when planning surveillance tasks and therefore CASA had not performed any significant assessment of the ASU's fixed-wing operation during recent years.

A number of the ASU's safety defences exceeded minimum regulatory requirements. However, the overall safety management system did not have the capacity to ensure the safety of operations in the wide range of circumstances that could reasonably be anticipated. Insufficient management processes existed to ensure that adequate defences were in place at the operational level to provide an assurance of flight safety.

The WA Police Service provided limited guidance for the ASU to develop safety management processes. The ASU management was expected to develop such processes, and a heavy emphasis was placed on the ASU chief pilot to ensure the safety of flight operations. Although he was a key person within the organisation with defined legal responsibilities, he had not been adequately prepared for this role, and the WA Police Service had no procedures to ensure that the chief pilot was supervising operations to an appropriate safety standard. Many of the deficiencies detected with the ASU's system of safety management had existed for many years, but the WA Police Service did not have a system to identify safety deficiencies in operational areas.

As a result of this accident, the ASU implemented a number of changes to the conduct of its operations. These included: the introduction of a new operations manual; a new training and checking manual; revised procedures for management of fuel by the ASU's pilots; appointment of a safety manager within the ASU; implementation of a hazard identification and communication program; and introduction of procedures to supervise remotely-based pilots. The WA Police Service also formally recognised the chief pilot position in the organisational structure of the service and implemented a reform process to improve pilot and crew selections, training, flight risk management, fatigue management, professionalism, external crosschecking and validation of the ASU systems against industry best practice.

Other issues

At the time of the accident, the relevant aviation regulations permitted flight at night under the VFR at times when pilots may have had insufficient external visual reference to control the aircraft using external visual cues. Under such conditions, the pilot would have been required to control the aircraft using the flight instruments. However, the training and currency requirements for VFR operations at night placed minimal emphasis on flight under such conditions. There was no formal advisory material linked to these requirements to help pilots identify higher risk situations or otherwise encouraging the use of various risk mitigation strategies.

The process used by CASA to approve the appointment of the ASU chief pilot did not detect his (or the operator's) limited knowledge of system safety concepts, nor did it provide any assurance that he understood the extent of his role and responsibilities as chief pilot. That also extended to the manner by which the chief pilot received his CASA approval as a training and checking pilot.

Some of the deficiencies associated with the ASU's procedures and management processes may have been able to be detected during the completion of a CASA periodic inspection. The investigation could not determine why those deficiencies were not detected during earlier periodic inspections, during reviews of documentation associated with checklist completion for the reissue of an AOC, and at other times CASA staff had contact with the ASU.

CASA has recently modified its surveillance planning to ensure that all operators are subject to a recertification audit prior to the reissue of an AOC. CASA is also progressively working on its capacity to identify organisations requiring additional surveillance activity on the basis of risk.

CASA has proposed a number of regulatory changes in the area of General Operating and Flight Rules that relate to fuel planning and fuel management.

While acknowledging the significant safety action underway, the ATSB has issued three additional recommendations concurrently with the release of this report. The recommendations cover: the provisions for the disposition of fuel reserves in fuel tanks to be used during the approach and landing; operational requirements and guidance material for pilots conducting VFR flight in dark night conditions; and required qualifications and/or competencies for chief pilots, with particular reference to management and system safety issues.

1 Australian Western Standard Time is UTC +8 hours.

2 Fuel starvation refers to an event where fuel is not being supplied to the engines, but useable fuel is available in at least one of the aircraft's fuel tanks.

Summary

At about 1930 Western Standard Time on 26 January 2001, a Cessna 310R aircraft, VH-HCP, departed Kiwirrkurra, Western Australia (WA), for Newman. The flight was conducted at night under the visual flight rules (VFR), with one pilot and three passengers on board. The aircraft was operated by the Air Support Unit (ASU) of the WA Police Service and had been used to transport police officers from Newman to Kiwirrkurra earlier that day.

Occurrence summary

Investigation number 200100348
Occurrence date 26/01/2001
Location 3 km E Newman, Aero.
State Western Australia
Report release date 23/10/2002
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Fuel starvation
Occurrence class Accident
Highest injury level Fatal

Aircraft details

Manufacturer Cessna Aircraft Company
Model 310
Registration VH-HCP
Serial number 310R0849
Sector Piston
Operation type Aerial Work
Departure point Kiwirrkurra, WA
Destination Newman, WA
Damage Destroyed

Pitts Aviation Enterprises S-1E, VH-SIS

Analysis

Why the aircraft impacted the ground could not be determined.

It is possible that the air temperature and humidity affected the pilot's performance, however, the extent of any such affect could not be assessed.

The pilot's new parachute pack would have changed his position relative to the cockpit controls. A possible consequence was that, if the pilot used that relationship as a reference during manoeuvres, without adjusting for the parachute pack, the position of the flight control surfaces would also have changed when compared with previous flights performing the same manoeuvres. That could have resulted in the aircraft being operated outside the parameters previously established by the pilot for particular manoeuvres, such as by descending unintentionally.

Although the aircraft impacted the ground while tracking to the north-west, when the observer lost sight of it behind a ridge the aircraft was tracking in a south-easterly direction at a very low height. It is possible that the pilot discontinued the knife-edge manoeuvre and reversed the direction of flight while hidden from view by the ridge.

Summary

Sequence of events

The pilot of a Pitts aerobatic aircraft arranged to fly to a training area to the south of Archerfield in company with a friend in a Yak aerobatic aircraft. They planned to practise aerobatics for about 30 minutes. The area selected was over a pine forest with a duplicated high-tension power line traversing the forest. North of the power lines the trees had been cleared and grass to about 500 mm high was the only significant vegetation in the area. The terrain was gently sloping up towards the north-west. The pilots agreed to operate on either side of the power line with the Pitts operating to the north of the line.

When the pilot of the Yak aircraft completed his sequence he attempted, unsuccessfully, to contact the Pitts pilot by radio. He also could not see the aircraft. When he flew closer to the power line he observed a small fire and realised that the Pitts aircraft had crashed. The pilot then contacted the Archerfield Air Traffic Controller to alert emergency services.

A resident located north-east of the accident site had observed the Pitts aircraft flying manoeuvres parallel to the power line. During one manoeuvre conducted to the north-west and away from the observer, the aircraft appeared to be flying straight, with the wings vertical, as if in a manoeuvre known as a "knife-edge". The upper side of the fuselage was directed away from the power line. The aircraft appeared to be descending but the person was aware that the aircraft was moving away and thought that the apparent descent may have been an illusion. After a vertical climb and descent involving rolling manoeuvres, the aircraft again flew in a straight line with the wings vertical. On that occasion the aircraft was tracking to the south-east and toward the observer, and the upper fuselage was again oriented away from the power line. The observer stated that the aircraft appeared to be descending, and passed from sight behind a low ridge. He did not see the aircraft again and sometime later saw smoke rising from behind the ridge.

Aircraft examination

The aircraft impacted the ground in a wings-level attitude at a speed estimated at more than 100 kts, while travelling in a north-westerly direction. At the time the aircraft was descending at about 30 deg nose down, and appeared to have been in balanced flight and at a low "g" loading. The impact was considered not survivable. The aircraft did not bounce, coming to an extremely rapid stop in the sandy soil. The fire would have broken out immediately, as a result of the ruptured fuel tank and disruption of the electrical system. The aircraft was destroyed by impact forces and the post-impact fire.

The engine was dissassembled and inspected. The crankshaft had moved rearward by about 6 mm relative to the crankcase, a further indication of an abrupt stop. The lack of damage to the cylinders indicated that the propeller and crankshaft had taken most of the deceleration loads, transmitting them through the crankcase to the airframe. There was no indication of mechanical failure prior to impact. The available information suggested that the engine was operating at low to moderate power at impact.

The Pilot

The pilot held a private pilot's licence to fly aeroplanes. His Class Two medical certificate was valid until June 2001. He had commenced flying training in January 1983 and obtained an aerobatic rating in March 1995. The rating was progressively upgraded, and in November 2000 the pilot was approved to conduct aerobatics to a minimum height of 100 ft.

The pilot purchased the Pitts aircraft in September 1997 and had flown it almost exclusively since then. His most recent biennial flight review, which included aerobatic flying, was conducted in May 1999.

Although he normally flew without a parachute, on the accident flight the pilot was wearing a new parachute pack for the first time. The pack thickness was about 4 cm.

Weather conditions

At the time of the accident the sky was clear of cloud, and the wind was a light south-westerly. The pilot of the Yak aircraft assessed that the temperature was in the mid-thirties [Celsius]. The temperature and humidity at the accident site were considered by an experienced pilot to be such that conditions in the cockpit of the Pitts aircraft would have been oppressive.

Aerobatic manoeuvres

One of the manoeuvres the pilot was intending to practise was a "knife-edge" manoeuvre where the aircraft was flown straight and level while banked 90 degrees left or right. That manoeuvre was referred to as a stick-position manoeuvre, because the positioning of the control column and rudder pedals must be precise to place the aircraft in the correct attitude and flight path. Practice and familiarity are the primary means of ensuring accuracy.

In the immediate vicinity of the crash site there were no prominent visual indicators for the pilot to judge the height of the aircraft above the ground. The vegetation was low and devoid of trees, and the terrain was not sufficiently sloping to provide the pilot with good height cues.

Examination of terrain contours and the location of the observer indicated that the aircraft was probably below 30 ft above ground level at the time it was lost from sight behind a ridge.

Occurrence summary

Investigation number 200100347
Occurrence date 28/01/2001
Location Logan Village
State Queensland
Report release date 17/01/2002
Report status Final
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 Pitts Aviation Enterprises
Model S-1
Registration VH-SIS
Serial number W69
Sector Piston
Operation type Sports Aviation
Departure point Archerfield, QLD
Destination Archerfield, QLD
Damage Destroyed

Beech Aircraft Corp A23A, VH-BZO

Factual Information

Wreckage examination

The airframe had come to rest in an upright attitude, aligned about 250 degrees M, about 12 m north of the initial impact point. The wings, fuselage and empennage were in the normal places relative to each other. The fuselage had been destroyed by impact forces and post-impact fire. The wings displayed extensive post-impact fire damage. The empennage was relatively intact but had suffered some post-impact fire damage.

The engine had separated and come to rest inverted about 3 m west of the airframe and about 10 m north of the initial impact point. The axis of the engine was perpendicular to the axis of the airframe. The lower engine mount brackets had been severed and the engine mounts deformed, indicating an impact from the left side. The propeller had separated from the engine when the engine shaft failed due to excessive bending and torsion, and was buried 15 cm below the surface about 1 m from the initial impact point. Inspection of the propeller revealed one blade bent in the chordwise direction with the tip 14 cm aft of the normal position, indicating that it was developing power at the time of impact.

The flight control surfaces did not show any witness marks to indicate their pre-impact positions. The flight controls were cable operated and were found to be correctly and securely attached to their respective control surfaces. However, some cables had been torn off at the controls in the cockpit area. The flap extension lever was found in the stowed position. There was no evidence of the locking tongue having been forced over the slots. This indicated that the flaps had been retracted before impact.

The fuel system and components showed various degrees of fire damage. The remains of the fuel lines were in the expected locations and remained securely attached to their respective components. Both fuel caps were found mounted in the fuel filler ports and with their locking mechanisms closed. The examination of the fuel system did not reveal any pre-impact defect that would have prevented normal operation of the system. The extent of the fire attested to a significant fuel load on board.

Due to the intensity of the fire, no fuel remained in the wreckage. Two sets of fuel samples were taken from tank number four at Canberra Airport. The samples were assessed and found to be consistent in colour and appearance with 100LL Avgas, of normal density, and free from water. Several aircraft had refuelled from the same bowser earlier in the day. None of the pilots of those aircraft reported any fuel-related problems.

The engine was removed and stripped for inspection. The examination did not reveal any pre-impact defect that would have prevented the engine from operating normally.

Pilot

The pilot held a Private Pilot Licence (Aeroplane) and was endorsed for single-engine aircraft below 5,700 kg maximum take-off weight (MTOW). He was 34 years of age and held a current Class 2 medical certificate with no special requirements.

The pilot had obtained his licence on 7 April 2000 and reportedly had accrued less than 100 hours flying experience. A precise figure could not be obtained as the pilot's logbook, which was recovered from the aircraft wreckage, had been almost destroyed by fire.

The pilot had begun his flying training some time previously, but the completion of his Private Pilot training was delayed. He subsequently completed his Private Pilot training with a Canberra-based flying training and charter operator. At the time of the accident, the pilot was purchasing both the Musketeer and the training and charter company. Between 5 January 2000 and 23 April 2000, the pilot completed 25 training flights, totalling 30.9 hours, of which 25.8 hours were dual and 5.1 hours were solo. The pilot passed his General Flying Proficiency Test on 7 April 2000 and subsequently completed eight navigation training flights totalling 16.9 hours dual and 5.0 hours solo.

An instructor assessed the pilot's flying skills as sound, but added that the pilot tended to be over-confident. Another instructor said that although the pilot's aircraft handling met the required standard, he tended to be casual and to chat during flight. He added that the pilot did not always concentrate sufficiently on the task in hand, and did not always prepare fully for cross-country flights.

A witness said that all four aircraft occupants had arrived at the pilot's home in Canberra, after driving from Brisbane in two vehicles, in the early hours of the morning on the day of the accident. En route, they had visited a private home at Umina on the NSW Central Coast, departing there at about 2130 hours Eastern Standard Time (EST), and had probably arrived in Canberra about 0130. The witness observed the pilot up and about at 0630 EST on the day of the accident.

Neither the autopsy nor the toxicology reports on the pilot revealed any medical condition that would have impaired his ability to operate the aircraft.

Weather

The weather conditions at the time of the accident were:

Surface wind: 035/04-06 kts (Max headwind component 0.5 kt, max crosswind component 6 kt)
Visibility: 40 km
Temperature: 25.3 degrees C
Dew point: 12.5 degrees C
QNH: 1014.0 hPa
Cloud: 2 octas cumulus, base 5,000 ft
 

These conditions produced a density altitude of 3,400 ft on the ground at the aerodrome. The aerodrome elevation is 1,888 ft above mean sea level (AMSL).

Aircraft weight and balance

Based on a fuel load of 115 L and weights of the aircraft occupants as determined by the autopsies, the aircraft gross weight at take-off was calculated as 2,375 lb. The maximum permitted gross weight for takeoff was 2,400 lb. The aircraft centre of gravity was near the middle of the permitted range.

Aircraft performance

According to performance charts, the aircraft was capable of take-off and climb from runway 30 with 15 degrees of flap selected, and climb at maximum gross weight under the prevailing environmental conditions. However, with a density altitude of 3,400 ft and the aircraft gross weight just below MTOW, the pilot would have needed to monitor take-off and climb performance closely.

Stall warning system

The aircraft was equipped with the normal stall-warning system: a vane mounted in the wing leading edge that moved upward, triggering an aural warning, when the wing's angle of attack approached the stalling angle.

Before departing on the aircraft's delivery flight to Canberra 14 days before the accident, the pilot who carried out the delivery flight tested the system on the ground and found it to operate when the vane was raised manually. The day following the delivery flight, the accident pilot carried out a flight carrying three passengers, one of whom reported that the warning system had operated briefly a couple of times on that flight.

Another pilot who had flown the aircraft on two occasions said that during the flare prior to touchdown, the aircraft had stalled and firmly contacted the ground. On neither occasion did he remember hearing the stall warning operate.

The serviceability of the stall-warning system on the day of the accident could not be determined due to impact and fire damage.

Possible effects of terrain

The 570 m (1,880 ft) elevation contour line passes through the middle of the aerodrome but higher terrain lies to the west, north-west and north. Along the extended runway centreline, the terrain rises to 630 m (2,060 ft). To the left and right of the extended centreline the terrain rises to 662 m (2,170 ft) and 840 m (2,760 ft) respectively.

Visual illusions can occur in flying and result from a pilot's incorrect interpretation of what is seen. A pilot's susceptibility to visual illusions will depend largely on the amount and nature of his/her flying experience, although other factors such as fatigue tend to increase susceptibility.

When flying visually, a pilot judges the aircraft's attitude by the relationship between the nose of the aircraft and the horizon. This is then crosschecked with the aircraft instruments to confirm the aircraft is performing as expected. The various phases of visual flying such as climbing, descending and turning are accomplished by adjusting engine power and aircraft attitude. However, a pilot also receives indications of attitude and performance from his/her senses which can be deceptive.

Gently rising terrain ahead of a low-flying aircraft can lead a pilot flying visually to misjudge the horizon, thinking that it is higher than its true position. If the pilot uses this false horizon as a pitch-attitude reference, the aircraft nose attitude will be higher than normal, resulting in a reduction in airspeed. If a pilot does not monitor the airspeed closely, or does not apply power to compensate for the steeper angle, the aircraft can slow, unnoticed, to its stall speed.

Rising terrain can also mislead a pilot into believing that the aircraft is not climbing at the required rate. If the pilot then selects a higher nose attitude without reference to performance instruments, and does not apply additional power, the airspeed will reduce.

The maximum altitude attained was about 300 ft above the aerodrome elevation. The accident site was located at the base of rising terrain. Looking directly ahead, the pilot would have observed terrain rising to an elevation slightly below the altitude at which the aircraft stalled. Either side of the aircraft's heading, the terrain was higher still. Although it cannot be confirmed, the pilot might have been misled by the rising terrain and raised the aircraft's nose above the normal climb attitude.

Possible distractions

As the aircraft was taxiing for takeoff, the Surface Movement Controller (SMC) transmitted the Musketeer's airways clearance to the pilot, which he read back confidently and correctly. Twenty-six seconds later, the SMC heard about 30 seconds of open microphone transmission, indicating that the transmitting station was experiencing problems with an aircraft seat. The SMC then called the transmitting station, informing it that its intercom was being transmitted on SMC frequency. Although the source of the transmissions could not be confirmed, the indications pointed to the Musketeer. Exactly 2 minutes later, the Aerodrome Controller (ADC) gave the Musketeer its takeoff clearance; in his readback, the pilot sounded unsure of himself and made a couple of errors.

As the aircraft was climbing after takeoff, the ADC passed traffic information to the pilot, informing him of an inbound helicopter in his 12 o'clock. The pilot acknowledged and replied that he was looking for traffic. That was the last radio transmission from the aircraft; about 30 seconds later, the aircraft impacted the ground.

Significant Factors

  1. The aircraft stalled at an altitude from which a recovery was not effected.

Analysis

Environment

The density altitude of 3,400 ft and the aircraft's gross weight (just below the maximum permitted) combined to adversely affect the aircraft's acceleration and climb performance. This was evident from the witness reports stating that the aircraft's angle of climb seemed to be shallower than normal for single-engine light aircraft departing on runway 30. The brief loss of altitude before the right wing dropped was probably the result of the pilot raising the flaps.

As the aircraft was lower than the normal climb profile, rising terrain ahead might have affected the pilot's assessment of the aircraft's nose attitude with respect to the horizon or its rate of climb with respect to terrain, leading him to select a higher nose attitude than he would have selected otherwise.

Pilot

Although precise figures for the pilot's total experience and his experience on type could not be determined, he was known to be relatively inexperienced. However, he had completed several previous flights in the Musketeer, including at least two flights with a passenger in a rear seat.

The four aircraft occupants had arrived back in Canberra at about 0130 on the day of the accident after driving in two vehicles from Brisbane. The pilot had risen by 0630. He could not have had more than 5 hours sleep in bed after arriving home. However, it cannot be assumed that he did all the driving; the other vehicle occupant might have driven the final trip from Umina to Canberra, permitting the pilot to obtain some sleep during that time.

Although it could not be confirmed that the Musketeer was the source of the open microphone transmissions on SMC frequency, some of the phraseology heard at the time supported this conclusion. In the event, the pilot might have had his confidence shaken, resulting in the errors in his readback of his take-off clearance.

After receiving the traffic information about the inbound helicopter directly ahead, the pilot may have been devoting considerable attention to looking for the helicopter, allowing his concentration on flying the aircraft to lapse.

The reason for the stall could not be established.

Stall warning system

Although it could not be confirmed, it is possible that the stall warning system did not operate, thus denying to the pilot the aural warning of an approaching stall.

Summary

The Beech Musketeer aircraft was being operated on a private pleasure flight. On board were the pilot and three passengers.

The aircraft took off from runway 30 and began climbing at a shallow angle, which a witness reported was below the normal climb profile. When the aircraft reached a point about 100 m beyond the upwind threshold of the runway, the tower controller informed the pilot of inbound traffic directly ahead of the aircraft. At that time, the tower controller also noticed that the aircraft was exhibiting `wobbles' and became concerned for its safety. Witnesses reported that the aircraft slowly climbed to about 300 ft and then seemed to lose altitude. The aircraft then continued tracking outbound in a shallow climb on runway heading, before the right wing dropped. The aircraft then rolled to the right, assumed a steep nose-down attitude and began rotating. After one turn, the aircraft impacted the ground in a steep nose-down inverted attitude. A fireball engulfed the aircraft immediately after impact. The four occupants received fatal injuries.

The accident site was located in an open paddock covered with dry grass, about 1.3 km from the upwind threshold of runway 30 and about 200 m left of the extended centreline. The wreckage was contained within an area about 30 m by 20 m, consistent with the nature of the impact. However, before being extinguished, the post-impact fire burned out an area about 130 m by 80 m.

Occurrence summary

Investigation number 200100346
Occurrence date 28/01/2001
Location 1.3 km NW Canberra, Aero.
State Australian Capital Territory
Report release date 12/10/2001
Report status Final
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 Beech Aircraft Corp
Model 23
Registration VH-BZO
Serial number M-1075
Sector Piston
Operation type Private
Departure point Canberra, ACT
Destination Khancoban, NSW
Damage Destroyed

Bell 206B(III), VH-PHG

Safety Action

Local Safety Action

During the period since the accident, the helicopter operator, in conjunction with the electricity power supply company, has devised and instigated a formal training program for power company employees who wish to undertake aerial powerline inspections as part of their company duties. The operator reported that the operations manual was being amended to reflect that change and to correct other deficiencies identified during the investigation. The operator plans to report back to the ATSB on completion of those changes. The training and procedures will now also have an audit process in place to ensure best practice is maintained.

The Network Service Division, in consultation with the helicopter operator, has completed work on a reference document, "Western Power Guidelines for Power Line Inspection/Patrols by Helicopter, 30 January 2002" which is one step in addressing ATSB Recommendations R20010204 and R20010205. In a meeting with the ATSB, the Principal Engineer for the Network Service Division stated that the new document will now be a mandatory standards reference document for any training manuals/courses devised for power company employees intending to undertake powerline inspection and patrol by helicopter. The document will also be a mandatory reference for any helicopter operators as part of the Network Service Division's contract tender process for powerline inspections.

Significant Factors

  1. The pilot turned the helicopter across the powerlines into an area that had not been assessed for hazards.
  2. The turn placed the spur line in the direct flightpath of the helicopter.
  3. The combination of the overcast conditions and the pale colour of the harvest stubble created a condition of low contrast between the powerlines and the surrounding background.
  4. The helicopter was flown at a height that was not sufficient to ensure obstacle clearance.
  5. Although the operator and the pilot had operated in accordance with the existing aviation regulatory requirements, the training that the pilot received to meet those requirements, was inadequate for the task of powerline inspections.
  6. The operator's training and operational procedures for powerline inspections were inadequate.
  7. There were no visual cues or hazard markers present to give an indication to the presence of a hazard in the helicopter flightpath.
  8. The organisational processes within the Network Service Division did not adequately equip its employees to undertake crewmember roles for helicopter powerline inspection operations.

FINAL RECOMMENDATIONS

As a result of the investigation the Australian Transport Safety Bureau issues the following recommendations.

R20010202

The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority review the need to develop and mandate competency standards for low-level aircraft operations, including powerline inspection by helicopters.

R20010203

The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority consider instituting an education program for the industry highlighting the impending changes to operational standards to be introduced under Civil Aviation Safety Regulation (CASR) Part 61 and its associated elements, in order to give sufficient lead time for early adoption and implementation.

R20010204

The Australian Transport Safety Bureau recommends that Electricity Supply Association of Australia Ltd (ESAA), in conjunction with its members, develop formal Operations and Procedures Manuals to be used by Australian Electrical Supply Businesses employing helicopters to accomplish low level powerline inspection or maintenance tasks. These manuals should have an appropriate quality control audit procedure to ensure that industry accepted best practice is maintained.

R20010205

The Australian Transport Safety Bureau recommends that Electricity Supply Association of Australia (ESAA) in conjunction with its members and in consultation with helicopter operators identified as successful tenderers for low level powerline survey work, adopt or purchase an acceptable training package to be undertaken by power supply company employees prior to tasking on helicopter power line inspections. This training package should include but not be limited to:

  • Safety hazards when working in and around helicopters
  • In flight communication procedures which includes crew resource management (CRM), hazard identification and crew alerting procedures.
  • Identification of fatigue in the workplace.
  • Re-currency training.

R20010206

The Australian Transport Safety Bureau recommends that Electricity Supply Association of Australia Ltd (ESAA), in conjunction with its members and Standards Australia, review the current standard on powerline marking. This review should consider identifying the location of low level flight hazards such as spur junctions on power transmission lines by the fixing of markers to give visual warnings to aeroplanes or helicopters approaching from either direction while engaged in powerline inspection or maintenance operations.

R20010207

The Australian Transport Safety Bureau recommends that Electricity Supply Association of Australia (ESAA) in conjunction with its members develop a requirement for employees identified by Australian Electrical Supply Businesses as candidates for aerial low level powerline inspection duties to undergo medical tests including eye tests. These tests should be of a standard commensurate with their expected duties to be performed as a member of a crew.

Factual Information

History of the flight

The pilot of the Bell 206 helicopter had been tasked to conduct a powerline inspection for the local electricity power supply company (power company). The helicopter took off from Jandakot Airport at 0500 Western Standard Time and arrived at Northam one hour later. Two personnel from the power company boarded the helicopter at Northam, one acting as observer and the other as the powerline inspector. The pilot occupied the front right seat, the observer the left front seat and the powerline inspector occupied the left rear seat. The helicopter then transited to the Bonnie Rock area to commence the inspection. The inspection progressed in a westerly direction from Bonnie Rock to Beacon with the helicopter flying parallel to, and on the northern side of, the main powerline.

At approximately 0800, the pilot discontinued the powerline inspections and flew the helicopter to Koorda for refuelling. After refuelling, the crew commenced the inspection of the powerline between Beacon and Bencubbin townships, flying south on the western side of the main powerline. At 1100 the pilot again discontinued the powerline inspection and flew the helicopter to Koorda for refuelling and lunch.

During the lunch break the work progress was discussed and, because less than 200 poles remained in the powerline inspection to Bencubbin, the crew decided to reverse the direction of the inspection and fly from Koorda to Bencubbin. At 1230 the helicopter departed Koorda and flew to Bencubbin, where they resumed the inspection at approximately 1300. The pilot then flew a parallel course on the eastern side of the main powerline from Bencubbin tracking north to where the earlier inspection had finished.

Approximately 3 kms north of Bencubbin, the observer saw what he thought to be an anomaly with a "beehive" structure (insulator device) atop one of the poles. The pilot then banked the helicopter to the left to conduct a 180-degree turn over the main powerline to return to the beehive. He then established the helicopter in a hover on a southerly heading on the western side of the main powerline. The inspection revealed that the anomaly was in fact bird droppings and nothing of concern.

Intending to resume the inspection, the pilot transitioned the helicopter from the hover to forward flight. The powerline inspector reported that he believed the pilot intended to complete another 180-degree left turn, again crossing the main powerline to resume the northerly track on the eastern side.

The inspector told investigators, that after the helicopter pitched nose down and accelerated into forward flight, "the helicopter's engine began sounding as though it was labouring, as if the helicopter was struggling under a heavy load". He then looked out of the left side of the helicopter and saw the first pole of the spur line. The helicopter then struck the ground and was destroyed by impact forces and the subsequent fire. The pilot and observer received fatal injuries, and the inspector received serious injuries.

Pilot information

The pilot gained a Private Pilot (Helicopter) Licence in February 1980, a Commercial Pilot (Helicopter) Licence in February 1981 and a Senior Commercial (Helicopter) Licence in April 1987. He then accrued many hours both in Australia and overseas on a variety of single and twin-engine helicopter types and gained experience in logging, low-level aerial survey, medical evacuation, fire fighting and external sling load work. He obtained a command multi-engine helicopter instrument rating in October 1991, having accrued a total of 4,495 hours as pilot in command at that time. He then accrued large helicopter experience, which included offshore oil rig crew transfer and operations in the North Sea, Canada and Mozambique. In July 1994 he qualified for, and was issued with, an Air Transport Pilot (Helicopter) Licence.

The pilot undertook low-level recurrency flight training 3 months prior to being employed by the operator. The pilot who conducted the recurrency training said that training was oriented to offshore operations and that the instruction given did not cover powerline inspections. When the pilot commenced casual flying for the operator, he successfully completed a check flight on the Bell 206 helicopter type with the operator's Chief Pilot. The flight did not include any specific training and checking regarding powerline survey or inspection operations. The Chief Pilot later stated that "he only hired pilots with low-level flying endorsements and he believed that, in accordance with the [Civil Aviation] regulations, that training qualified them for his company's operational requirements".

At the time of the accident, the pilot had accrued about 7,830 hours total helicopter flying experience of which 3,468 hours were on the Bell 206. The pilot had a Class 1 medical certificate. He was required to wear vision-correction spectacles while flying and was doing so at the time of the accident.

The pilot had not been on duty for the three days prior to the day of the accident. There was no indication that he was experiencing any personal or medical problems that may have adversely affected his performance.

Observer/Inspector information

The power company employee occupying the rear seat acted as the powerline inspector, and inspected the powerlines in consultation with the observer while referring to maps to assist in identifying the location of defects, as well as the location of known hazards. The employee in the front left seat acted as the observer, scanning for powerline anomalies, assisting the pilot in command by scanning for hazards in the intended flight path, as well as maintaining radio communications with the power company base at Northam. The observer required vision correction for reading only. At the time of the accident, the observer was not wearing spectacles and did not require them for distance sight. Neither employee had undergone any formal training to enable them to carry out their in flight roles in helicopter powerline inspections, despite there being a requirement to do so in the operator's operations manual. The operations manual stated that, "Operating crew means any person having duties on board an aircraft in connection with the flying or safety of the flight of that aircraft."

There was no indication that either power company employee was experiencing any personal or medical problems that may have adversely affected the performance of their respective duties.

Observer/Inspector training

The operations manual also provided guidance in the form of Special Instructions on the training required for non-operator personnel to permit them to conduct the role of operating crew for other operations such as aerial photography. However such training guidance was not provided for low-level powerline inspections.

The Network Service Division of the power company for whom the operator was working did not have a published requirement for such training. The power company reported that the two employees were selected as a consequence of their seniority within the company and their familiarity with the powerlines in the area. At least one of the employees had personally been involved in the construction of the powerline network being surveyed. The two employees had received a basic safety briefing from the helicopter operator, which included information on how to approach an operating helicopter and seat belt fastening and exit details.

Meteorological information

The temperature at the time of the accident was about 35 degrees C with surface winds being generally light from the west. It was also humid, with a band of cloud in the area having a base of between 4,000 to 6,000 feet. Some convective shower activity may have been developing in the area at the time. Rescuers said that due to the combination of the overcast conditions and the pale colour of the harvest stubble, there was little contrast between the powerlines and the surrounding background.

Flight following

The helicopter was fitted with VHF communications equipment, including dedicated air to ground radio for communications with non-aviation related ground parties. The power company routinely provided flight following from its Northam township base and, although no formal communication schedule was in place, the crew of the helicopter called the Northam base at irregular intervals. Those broadcasts were primarily to inform the power company of their intentions including when a section of a task was completed, an anomaly was found, or a task was discontinued for rest breaks or refuelling.

At the time of the accident, an employee at the Northam base noticed that the circuit breaker for the Bencubbin three-phase line had tripped and, considering that a helicopter operating in the area might be in trouble, isolated that breaker to prevent an automatic reset. After he had unsuccessfully attempted to contact the helicopter by radio, he raised the alarm within the company. The alarm was also raised in Bencubbin township by a passing motorist who was flagged down by the survivor waving from the field.

Wreckage and impact information

The helicopter had collided with a spur line running west, almost at right angles to the main powerline. The spur line consisted of two 12mm, three-strand, high-tensile steel wires. The force of the collision shifted the pole adjacent to the main line approximately 100mm in its foundation steel supports. The next three poles to the west of the accident site were pulled down. The wires of the spur line were strung between poles that were set 310m apart in the first span. Four spans of the spur line each approximately of 300m in length were downed. Under normal tension those wires were approximately 7.2m above the ground at mid-span rising to 9.9m at the poles. The downed support pole to the west of the spur "T" junction was set in the field adjacent to a fence. The poles and wires blended with a line of trees and some shrubbery extending in that direction.

Impact marks indicated that during the accident sequence the wires were trapped by the left skid, and pulled tight in the direction of flight until the tension caused the left skid tube assembly to fail at the forward and rear, cross-tube to skid-tube, attachment points. The left landing skid tube was then thrown rearward by the recoiling action of the conductor wire.

The helicopter appeared to have rolled to the left, probably due to the restraining force of the wire on the left skid, and became inverted before impacting the ground. Several strikes of the main rotor severed the tail boom immediately in front of, and immediately behind, the horizontal stabilisers. The main rotor mast failed below the static stops, liberating the main rotor. The fuselage impacted the ground inverted on a heading of about 215 degrees and came to rest 80 metres south of the spur line. The helicopter was not fitted with a wire strike protection system (WSPS) and there was no requirement that a WSPS be fitted for this type of work.There was no indication that the helicopter was incapable of operating normally before the collision with the powerline.

Survival

The helicopter cabin contained five seating positions; two single seats in the forward cockpit and three seats in a bench arrangement in the rear. The front seats were fitted with both lap and shoulder restraints. The rear bench seats were fitted with lap seat belts only. The inverted attitude of the helicopter just before it impacted the ground exposed the right front seat and its occupant to the full force of the impact. Consequently, the accident was considered to be non-survivable for the pilot. The results of the postmortem revealed that the front left seat occupant was fatally injured from a combination of impact forces and the ensuing fire.

The inspector occupying the rear left seat was thrown clear of the helicopter during the impact sequence. Lap seat belts for the rear seats were found in the wreckage trail with charred webbing and the buckles still fastened. Evidence indicated that an anchor point for the rear left seat belt failed during the ground impact and subsequent breakup sequence.

Emergency locator transmitter

The helicopter carried a fixed emergency locator transmitter (ELT) mounted in an approved manner within the forward cabin area. The inverted attitude of the helicopter at impact was outside the design mounting criteria for the ELT and most probably resulted in the failure of the ELT to transmit prior to being consumed by the post accident fire.

Organisation and management

The Electrical power supply company

The power company had two distinct divisions requiring helicopter support. The Transmission Division of the company was responsible for the maintenance of the high voltage transmission lines, usually carrying voltages in excess of 66 kilovolts. The Network Service Division was responsible for distribution lines carrying all voltages lower than 66 kilovolts.

a. Transmission Division

Due to the highly specialised requirements of helicopter powerline inspection work and the high voltages involved, the tender documents for helicopter support of activities for the Transmission Division were very detailed. The documents contained the requirements and scope of work required, general conditions, special conditions, quality control requirements and technical drawings of electrical transmission tower installations. In turn, the successful tenderer submitted to the power company, copies of Safety Management Plans, a Quality Plan, pertinent extracts from the helicopter company training manual, a computerised inspection and patrol software program and a Powerline Procedures Manual.

b. Network Service Division

The Network Service Division, for which the accident helicopter was operating, did not require a formal tender process for the helicopter line survey work, nor was the process formally aligned to any published criteria. Helicopter operators with whom the Network Service Division had established a relationship over several years were normally contracted to provide the service. The relationship was such that the subdivision was able to call upon those helicopter operators at very short notice if an urgent task arose.

The Network Service Division's principal engineer reported that they also assumed that, as the helicopter operator was approved to hold an Air Operator's Certificate for the type of work they required (low-level operations), their requirements and obligations to provide a safe environment for their employees had been met. The engineer also reported that they believed that the approved helicopter operator would bring the relevant expertise to the job and supply any specific training for the power company employees that might be required to meet the task.

The operator

The operator was permitted, under the Air Operator's Certificate (AOC) issued by the Civil Aviation Safety Authority (CASA), to conduct charter and aerial work operations including powerline inspections. The operator had been engaged in powerline inspection work for the Network Service Division of the power company for a period of approximately 10 years.

The Chief Pilot was also the operator's Managing Director and AOC holder. The line pilots, including the pilot involved in the accident, were employed by the operator, on a casual basis. The Chief Pilot did not conduct Check and Training because the operator was not approved by CASA to do so. When a requirement for Check and Training arose, the company would arrange a sub-contractor to carry out the work on its behalf by a CASA approved Check and Training pilot.

The operator's operations manual was a document using a modular design. It was co-authored by the Chief Pilot and an individual specialising in authoring regulatory documents. The manual had scope to tailor to any operator requirements as evidenced by "Reserved" sections within the separate modules. A section was reserved for a Flight Safety Program, but had not been activated at the time of the accident. Additionally, the operator said that a formal Flight Safety Program had not been instituted due to the company's small size. However, the Chief Pilot stated that training and risk assessment were verbally delivered to the pilot prior to each task and that he was debriefed after completion of the task. Several other stipulated Special Instruction requirements for activities listed in the AOC section of the operator's operations manual were also not activated at the time of the accident.

The operations manual detailed the requirements and instructions for specialised operations such as Aerial Photography, Aerial Spotting, Aerial Survey (including powerline inspections), Dropping and External (Underslung) Loads.

Operating Standards

The investigation found that the only published guidance and operating standard in Australia for any helicopter powerline work, was the Electricity Supply Association of Australia Ltd (ESAA) document "Guidelines for use of helicopters for live line work", August 1995. That publication was recommended by ESAA as a reference text for minimum industry standards for work in the vicinity of live power lines. Although the publication was not comprehensive, it was considered by some members of the electrical and aviation industries to be a good basis from which to develop standards, particularly for work on and in the vicinity of high voltage powerlines. While it was recognised that the guidelines were intended for working on, and in the vicinity of, energised powerlines, it was also considered that some of the general principles for helicopter operation, safety and training could easily be adapted and applied to operations and training manuals for low voltage line inspection of the type being conducted at the time of the accident.

The Transmission Division of the power company responsible for the high voltage distribution had knowledge of that publication and reference was made to it in the specialist tender documents issued to its prospective helicopter contractors. However, the helicopter operator and the Network Service Division responsible for the low-voltage network were not aware of the existence of the ESAA publication at the time of the accident and therefore did not consider it as a possible reference text.

Regulatory references and requirements associated with operating at low levels in the vicinity of powerlines were found in Civil Aviation Orders (CAOs). The CAOs addressed agricultural and mustering operations. All helicopter pilots engaging in agricultural and mustering operations were required to undergo training and testing in accordance with the CAOs, before gaining a rating. Similar references and requirements did not exist for pilots undertaking low-level powerline work.

The operator's Chief Pilot said that he told company pilots to maintain a minimum height of 5m above the power poles while they were engaged in powerline surveys. Although the minimum safe clearance figure of 5m was recommended in the ESAA document "Guidelines for use of helicopters for live line work", August 1995, the document was not a reference text for the operator at the time of the accident and the recommended safe distance was not promulgated in the operator's operations manual. In addition, the operations manual did not provide guidance on structured crew communications and phraseology, the responsibilities of each crewmember, and individual crew actions in the event of an emergency during powerline inspections. In addition, the manual did not provide guidance on turn-back techniques or the avoidance of many of the hazards unique to powerline inspections.

Hazard Identification

After comments by some pilots regarding the positioning of pole-marker numbering at the base of certain poles, the Transmission Division had commenced a program to position pole numbers at the top of poles. That was accompanied by marker ball placement on certain lines (over 80 kilovolts) to identify hazards to flight.

The Network Service Division had no such program in place to identify, by physical means, hazards to flight on any of the lower voltage networks. No other visual cues, such as yellow disc or orange ball markers at the spur line junction, were in place that would have assisted the pilot or his front seat observer conducting the aerial survey to recognise that they were in the vicinity of a hazard. In addition, the crew was only calling the pilot's attention to hazards that were on the flightpath side of the main line. A copy of the specific map identifying the powerline positions was on board, and was being referenced by the inspector on the day of the accident. During the investigation the Chief Pilot remarked that "the observer was known on occasion to rely on his memory in areas he knew well".

Analysis

Due to the lack of any formal guidance or procedures, the obstacle clearance calls being made by the observer included only obstacles on the flight path side of the powerlines. The spur line was not in the direct path of the helicopter, so it was unlikely that the observer would have called it as a hazard before the decision was made to turn back to check the "beehive" insulator assembly.

The investigation could not ascertain why the pilot made the decision to turn left across the powerlines instead of turning away from them. Such a turn would have placed the helicopter on the eastern side of the powerline, before backtracking over previously flown terrain and obstacles. Because the two power company employees were seated on the left side of the helicopter, the pilot may have been attempting to maintain their unobstructed view of the powerlines, as was his previously demonstrated flight practice. However, when the pilot turned the helicopter left across the powerline, he was turning "blind" and probably could not see the main powerline or the poles during the execution of the turn.

The long distance between the spur line support poles, in conjunction with the ambient light conditions and almost featureless surrounding terrain, would have made the spur line difficult to see from the air. The lack of a warning call identifying the spur line as a hazard, the turn across the powerlines, the flat light conditions, and the lack of hazard marking, meant that the pilot was probably unaware of the spur line's existence. Appropriate crew training should have included emphasis on lookout for junction points on the line, to be able to anticipate and identify the presence of the hazard to the pilot.

Training and operating standards

Observers/Inspectors

In performing the observing and inspection tasks, some responsibility was transferred to the power company employees for the safe operation of the helicopter and, as a result, both were acting as operating crew as defined in the operations manual. As these roles were never formerly acknowledged and defined, the operator and the power company differed as to the exact job description and consequent responsibilities expected of each power company employee. It was apparent that over time, the line inspection task from the front seat also took on observer aspects such as obstacle identification for safe flight and ground communications.

Despite their roles as operating crew, the employees had not been offered, nor received any formal training or checking by the operator or their employer. That lack of training made it unlikely that they would have been aware of all the considerations involved, and associated with, the decision by the pilot to cross over the powerline.

Pilot

Although the operator and the pilot had operated in accordance with the existing aviation regulatory requirements, the training that the pilot received to meet those requirements, was inadequate for the task of powerline inspections.

The operator's operations manual did not provide adequate guidance on several facets of powerline inspections, such as how the operating crew was to interact and minimum clearance distances from powerlines. A trigger for the inclusion of such guidance may have been gained by reference to the ESSA document "Guidelines for use of helicopters for live line work", August 1995.

Flight safety program

The operator had not instituted a formal Flight Safety Program. Such a program would have included risk management processes and may have assisted the operator in identifying deficiencies in the operations manual, including those found associated with the training and procedures employed for the conduct of powerline inspections.

Electrical power supply company

The organisational processes within the electrical power supply company did not ensure that the two subdivisions were operating to similar or consistent standards; nor did the two subdivisions have similar requirements or standards from contracting companies. Consequently, the Network Service Division had not identified the need for, and had not adequately ensured that, the training of its employees to undertake crewmember roles within the helicopter was sufficient. In addition, the Network Service Division processes did not ensure that the operating procedures of the helicopter company met appropriate standards for this type of specialised work.

Flight following

The practice of flight following between the helicopter and a monitoring base was not formalised and generally amounted to infrequent radio communications initiated by the observer. Because there was no procedure being followed to make or monitor routine calls, there was nothing to trigger a formal response following an occurrence.

Summary

The pilot of the Bell 206 helicopter had been tasked to conduct a powerline inspection for the local electricity power supply company (power company). The helicopter took off from Jandakot Airport at 0500 Western Standard Time and arrived at Northam one hour later. Two personnel from the power company boarded the helicopter at Northam, one acting as observer and the other as the powerline inspector. The pilot occupied the front right seat, the observer the left front seat and the powerline inspector occupied the left rear seat. The helicopter then transited to the Bonnie Rock area to commence the inspection. The inspection progressed in a westerly direction from Bonnie Rock to Beacon with the helicopter flying parallel to, and on the northern side of, the main powerline.

Occurrence summary

Investigation number 200100252
Occurrence date 18/01/2001
Location 3 km N Bencubbin
State Western Australia
Report release date 05/03/2002
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Wirestrike
Occurrence class Accident
Highest injury level Fatal

Aircraft details

Manufacturer Bell Helicopter Co
Model 206
Registration VH-PHG
Serial number 2820
Sector Helicopter
Operation type Aerial Work
Departure point Koorda, WA
Destination Northam, WA
Damage Destroyed

Boeing 737-476, VH-TJX

Summary

On 18 January 2001, VH-TJX, a Boeing 737-476 aircraft, encountered microburst windshear at 0729 EST while conducting a go-around from runway 19 at Brisbane during an intense thunderstorm. The aircraft was operating a scheduled fare-paying passenger service from Sydney to Brisbane.

As the aircraft passed 1,000 ft during the landing approach, it encountered rain and some isolated hail. The approach lights for runway 19 were visible to the crew, and the pilot in command elected to continue the approach. At about 500 ft, the weather deteriorated rapidly, and the aircraft encountered hail and turbulence. The pilot in command discontinued the approach and applied go-around engine thrust. The aircraft commenced to climb normally at about 3,600 ft/min, however, shortly after the go-around was initiated, the climb performance substantially reduced to less than 300 ft/min due to the effects of the microburst downdraft and from flight through heavy rain. The pilot in command applied maximum engine thrust to improve the aircraft's climb performance, and advised the Aerodrome Controller that the aircraft had encountered severe windshear.

The crew then diverted the aircraft to Maroochydore, where it landed without further incident.

The Bureau of Meteorology (BoM) issues severe thunderstorm warnings to the public when their intensity is expected to produce dangerous phenomena, such as hail with a diameter of more than 2 cm, wind gusts in excess of 90 kph (48.5 kts), flash floods, and tornadoes. BoM issued severe thunderstorm warnings for the Brisbane area to the public at 0552 and 0654. At 0635, BoM issued a warning for Brisbane aerodrome, forecasting the presence of thunderstorms with possible hail and gusts exceeding 41 kts between 0700 and 0900. At 0715 BoM issued a lightning alert for Brisbane aerodrome. There was no requirement for Airservices Australia to receive such aerodrome warnings or lightning alerts from the BoM, and they did not do so.

The Brisbane aerodrome forecast, issued by BoM at 2021 on 17 January, contained information that thunderstorms with associated gusts of 42 kts were expected in the vicinity of Brisbane aerodrome until 0300 on the 18 January. At 0213 on 18 January, BoM issued an amended forecast for Brisbane aerodrome. The amended forecast was valid until 0400 on 19 January, and contained no information to suggest that thunderstorms were likely in the vicinity of Brisbane aerodrome throughout the forecast period.

At 0613, TJX commenced 'pushback' at Sydney, and became airborne at 0622 for the flight to Brisbane. The crew relied on the 0213 amended aerodrome forecast issued by BoM, and was not aware of the 0552 public weather warning concerning the severe thunderstorms south of Brisbane.

At 0630, BoM issued a routine aerodrome report for Brisbane aerodrome that superseded the amended aerodrome forecast that was issued at 0213. The trend type forecast appended to the routine aerodrome report included information that thunderstorms and rain showers were forecast during the period 0700 to 0900. The controllers received that forecast at 0636 but did not pass it to the crew of TJX at any stage.

The aviation-related forecasts for Brisbane aerodrome did not refer to thunderstorms from 0213 until 0630, and the 0630 forecast did not contain information about the phenomenon associated with severe thunderstorms that was included in the public forecasts or in the 0635 aerodrome warning. BoM's forecasting staff used different criteria for the issue of public weather warnings and aerodrome terminal forecasts. Public weather warnings were issued for the Brisbane metropolitan area whenever radar or other evidence indicated that severe thunderstorms were present in, or expected to enter, the designated warning area. The Brisbane aerodrome terminal forecast was a statement of meteorological conditions expected for a specified period in the airspace within a radius of five nautical miles of the centre of the aerodrome. The public weather and aviation products could therefore at times present different information.

The air traffic controllers at Brisbane relied on information contained in aerodrome forecasts, routine aerodrome weather reports, and trend type forecasts issued by the Bureau of Meteorology for Brisbane aerodrome. The controllers also relied on weather radar images from the BoM weather radars. The information provided to controllers from those images was to be used in conjunction with other weather information, including that derived from airborne and other observations, to assist pilots with decision making.

For some time before the occurrence, air traffic controllers in the Brisbane aerodrome control tower were concerned about the visual appearance of the approaching thunderstorm, and its image on their weather radar display. However, the terminology and language used by air traffic controllers did not convey their concerns about the intensity of the thunderstorm to the crew of TJX until the aircraft was on final approach. The Manual of Air Traffic Services required controllers to pass hazard alert information as soon as practical to aircraft likely to be affected by known hazards.

Had the controllers been provided with the aerodrome warnings and lightning alerts, that additional information may have assisted them in determining if a thunderstorm hazard alert should have been issued to the crews of approaching aircraft.

In this occurrence there was no effective mutual exchange of information between the controllers and the crew. Had the controllers provided relevant information about the storm to the crew, the crew may have been in a better position to determine whether it was advisable to discontinue the flight towards an area of hazardous weather.

The crew's decision to continue the approach may have been influenced by their sighting of the aerodrome when they were on the downwind leg, and the runway 19 lighting system while on final approach. In previous weather-related occurrences, crews have attempted to land because they had visual contact with the runway environment. Investigation of those occurrences found that crew decisions to continue the approach and landing may have been more compelling than the deteriorating weather they were approaching.

The occurrence was regarded as a serious incident in accordance with Annex 13 to the Convention on International Civil Aviation. It again highlights that thunderstorms and convective activity in terminal areas are a significant issue in Australian and international aviation. It also illustrates the significant adverse effect of heavy rain on aircraft performance. The hazards associated with those weather conditions are not solely confined to the presence of severe thunderstorms, and should not be underestimated.

Whenever thunderstorm activity is forecast, there is a potential for microburst windshear and heavy rain. Aircraft in the landing, take-off, missed approach or go-around phases of flight are particularly vulnerable in or near thunderstorms. The effects of microburst windshear and, to a lesser extent, the aerodynamic penalties imposed by flight through heavy rain, can place an aircraft in a potentially-high-risk situation.

This serious incident also highlights that without extensive Doppler weather radar capabilities, and in the absence of appropriate systems designed to detect hazardous wind shear in Australia, there is a need for collaborative decision making among forecasters, controllers, pilots and operators during periods of intense or severe convective weather.

Media Release

Occurrence summary

Investigation number 200100213
Occurrence date 18/01/2001
Location Brisbane, Aero.
State Queensland
Report release date 20/09/2002
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Serious Incident
Highest injury level None

Aircraft details

Manufacturer The Boeing Company
Model 737
Registration VH-TJX
Serial number 28150
Sector Jet
Operation type Air Transport High Capacity
Departure point Sydney, NSW
Destination Brisbane, QLD
Damage Nil

Boeing 747-400, VH-OJT

Safety Action

Local safety action

The Honolulu Air Traffic Control Facility completed mandatory team briefings for all personnel on the circumstances of this occurrence. All operational personnel were briefed on maintaining awareness, scanning, and vectoring with increased emphasis placed on operational supervision.

Summary

A Boeing 747-400 was enroute from Los Angeles to Melbourne, cruising at FL320 in a south-westerly direction on airway R576 in the Oakland Flight Information Region. A McDonnell Douglas MD-11 departed Honolulu and was climbing in an easterly direction to FL350. The aircraft were on converging tracks.

The Honolulu Air Traffic Control Facility was responsible for providing positive separation between the aircraft. The radar separation standard was 5 NM lateral, or 1,000 ft vertical.

A controller subsequently recognised that, without intervention, the tracks of the two aircraft would come within 5 NM when less than the required vertical separation existed. The controller instructed the MD-11 crew to "...fly heading 020 ..." to change the aircraft's track. The crew responded by broadcasting "... Air 205, now right, right heading...". The controller did not clarify the required turn direction, and then instructed the B747 crew "...fly 180, vectors on traffic". Those instructions were passed 60 seconds and 49 seconds respectively, prior to the aircraft passing each other.

The B747 crew correctly read back the instruction to fly 180 degrees. Immediately after receiving that instruction, the crew received a traffic advisory alert from the aircraft's traffic alerting and collision avoidance system (TCAS). The alert was followed by a TCAS annunciation of a resolution advisory (RA) to descend. The crew advised air traffic control, "... heading 180 and TCAS descent", as they descended the aircraft, in accordance with standard operating procedures. The crew had the MD-11 in sight for the duration of the incident.

Analysis of the continuous data recording plot indicated that the MD-11 did not commence the left turn until after the aircraft had passed. There was no indication that the B747 turned onto a heading of 180 degrees. A minimum of 700 ft vertical separation existed when there was less than 5 NM between the aircraft. An infringement of separation standards had occurred.

The MD-11 crew apparently misunderstood the instruction to fly heading 020 as "right" heading 020 degrees. A right turn would have been confusing to the crew as the aircraft was tracking approximately 090 degrees. The direction of turn onto a new heading would normally be flown via the shortest arc distance; in this case, a turn onto a heading of 020 degrees would normally involve a left turn. Thirty-three seconds later the MD-11 crew sought confirmation that a left turn to heading 020 degrees was required.

The crew of the B747 may not have turned as instructed due to their response to the TCAS alert, and their visual observation of the conflicting traffic. It could not be established whether standard separation would have been achieved if one or both crews had turned their aircraft when instructed to do so.

There was no evidence that the controller applied the principle of separation assurance in the control of these aircraft. Rather, the controller had relied on aircraft performance to achieve separation.

Occurrence summary

Investigation number 200100135
Occurrence date 15/01/2001
Location 106 km NE Maui, (OGG), (VOR)
State International
Report release date 17/12/2001
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 747
Registration VH-OJT
Sector Jet
Operation type Air Transport High Capacity
Departure point Melbourne, VIC
Destination Honolulu, Hawaii
Damage Nil

Aircraft details

Manufacturer McDonnell Douglas Corp.
Model MD-11
Sector Jet
Departure point Honolulu, Hawaii
Destination Unknown
Damage Nil

Embraer EMB-820-C, VH-HVA

Analysis

There was insufficient evidence to determine the factors that led to the out of trim condition. The aircraft was correctly loaded and well within the centre of gravity envelope. Appropriately qualified maintenance personnel could find no fault with the trim system after a comprehensive check and the aircraft handled normally on the subsequent sectors. The possibility of a mis-set trim was explored and cannot be excluded. The pilot stated that all the appropriate checks before take-off were carried out. The before-take-off checks included setting the trim.

A checklist can be viewed in human factors terms as an additional interface between the human and the machine. That interface controls the method and sequence of the aircraft's configuration. Regardless of the type or method used, the disciplined use of cockpit checklists by pilots is an essential element in flight safety. Distractions and interruptions can break the checklist process and may result in a checklist error or omission. This may be critical in single-pilot operations where the checklist is often the last line of defence against configuration errors. Having ensured that the appropriate training and checking has been carried out, an operator's safety management is dependent on the degree of discipline and professionalism applied to each phase of the operation by the pilot.

Summary

The pilot, who was of slight build, was tasked with conducting a regular public transport flight, with 6 passengers, from Gunnedah to Sydney (Kingsford Smith) airport. The aircraft, an Embraer EMB-820-C (licence built Piper PA31 Chieftain), had a valid maintenance release with no significant outstanding entries. Pre-flight preparation was normal and unrushed and an on-time departure was accomplished. The weather for the departure was fine with light wind.

Before initiating take-off from runway 11, the pilot, who was appropriately licensed, endorsed and base checked to fly the EMB-820-C aircraft, carried out engine run-ups and pre-take-off checks. The pre-take-off checks included selecting 15 degrees of flap and setting the elevator trim. The pilot's normal trim setting procedure was to wind the trim wheel all the way to the forward limit and then wind it back 5 to 6 complete turns. Consultation with industry pilots experienced on the aircraft type revealed that 3 to 4 turns was common. They indicated that pilots of lesser physical stature have found the aircraft type is easier to rotate with the elevator trim set to a nose-up position for take-off, however that would result in more re-trimming of the aircraft once airborne and during flap retraction. Low-wing aircraft have a tendency to pitch up slightly during flap retraction. Additionally, as an aircraft climbs out of ground effect, changed downwash over the tailplane produces a further pitch-up tendency.

The pilot reported that the take-off run and rotation appeared normal, however, as the flaps were retracted the elevator load increased. The pilot was only able to preserve a safe climb attitude by using both hands to maintain forward pressure on the control column. The pilot did not use the electric trim in normal day-to-day operations and did not consider using it to relieve the elevator load on that occasion. Believing the problem was either elevator trim or aircraft centre of gravity related, the pilot requested the passengers seated at the rear to move toward the front of the aircraft in order to lighten the load on the controls. A male passenger positioned himself in the unoccupied right control seat and, as the control forces were still high, the pilot requested that the passenger momentarily apply forward pressure on the control column. The pilot then took one hand from the controls to manually trim the aircraft and reduce the power.

The aircraft continued to Sydney without further incident and showed no abnormal handling characteristics on the subsequent sectors. A comprehensive inspection of the aircraft did not reveal any discrepancies with the elevator trim system and a review of the aircraft logbooks indicated no recent reported problems or disturbance of the trim system for rectification work. It was calculated that, at take-off, the aircraft weight was 39 Kg below the maximum take-off weight and the centre of gravity was slightly forward of the mid-point between the forward and aft limits.

Prior to the incident flight the pilot had positioned the aircraft to Gunnedah from Coonabarabran. The aircraft, which had no passengers or freight, was landed with full flap and in that configuration would have required almost full-back (nose-up) trim. Although not included in the after-landing checks of the operator's approved Piper Aircraft Corporation paper checklist, it was normal practise for most pilots to re-set the trim when clear of the runway. The Pilot's Operating Handbook expanded checklist recommended that course of action. The expanded checklist was used for training and as a supplement to normal and abnormal checklists. It was not meant to be referred to in flight.

Occurrence summary

Investigation number 200100035
Occurrence date 02/01/2001
Location Gunnedah, Aero.
State New South Wales
Report release date 09/11/2001
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Incorrect configuration
Occurrence class Incident
Highest injury level None

Aircraft details

Manufacturer Embraer-Empresa Brasileira De Aeronautica
Model EMB-820
Registration VH-HVA
Serial number 820C-045
Sector Turboprop
Operation type Air Transport Low Capacity
Departure point Gunnedah, NSW
Destination Sydney, NSW
Damage Nil

Grounding of the container ship Bunga Teratai Satu

Final report

Summary

The Malaysian flag container ship Bunga Teratai Satu sailed from Singapore on 26 October 2000, bound for Sydney via the inner route of the Great Barrier Reef with a cargo of 857 containers. A licensed pilot was embarked to conduct the navigation through the inner route between Goods Island and Cairns.

At 0554 AEST on 2 November 2000, Bunga Teratai Satu disembarked the pilot at Yorkeys Knob, off Cairns, at the southern limit of the compulsory pilotage area.

At 0600, 'full away' was rung and the vessel resumed its passage to Sydney on a course of 120° (true). A programmed way-point, at position 16° 52.8' S, 146° 02.3' E, was reached at 0700. At this way-point, the course was supposed to be altered to 164° (true) to round Fitzroy Island and take the vessel to the west of Sudbury Reef. However, no course alteration was made.

The ship was reporting under the Great Barrier Reef Ship Reporting System, REEFREP, administered from Reefcentre, Hay Point. This system requires ships transiting the inner route to report at certain positions within the inner route. To help enforce compliance with pilotage and reporting requirements the normal entry points to the inner route are monitored by radar. In the limited areas covered by radar, the system fulfils a secondary, monitoring role, to improve safe navigation.

Bunga Teratai Satu had been acquired as a target at Reefcentre when it entered the area covered by the Green Island radar system at about 0430. From about 0715 to 0725, the Reefcentre operator was attempting to re-establish lost targets on the Hammond Island radar display covering the western area of Torres Strait. Just before 0716 Bunga Teratai Satu entered the restricted zone (2 miles off Sudbury Reef) but the Reefcentre operator did not notice the alarm message as he worked on other tasks.

At about 0723, the ship struck the north end of Sudbury Reef at a speed of over 20 knots on a heading of 120°. It was about 1 3/4 hours after low water and the vessel's bow rode some 100 metres onto the reef leaving the stern in approximately 12 metres of water.

Nobody was hurt as a result of the grounding and no oil or other pollutant escaped from the ship. The grounding resulted in mechanical damage to the reef and the yet-to-be assessed effects of the ship's anti-fouling paint.

The Australian authorities issued detention orders while the ship's situation was being assessed. Bunga Teratai Satu remained fast on the reef until it was eventually refloated with the aid of tugs at about 0930 on 14 November 2000.

The investigation found that the significant unsafe act that resulted in the grounding was the inattention of the mate on watch aboard Bunga Teratai Satu, who was distracted by his wife's telephone call to their family overseas.

However, a number of other contributing factors led to a breakdown in the defences and protections that may have prevented the ship from grounding.

Conclusions

These conclusions identify the different factors contributing to the grounding of Bunga Teratai Satu and should not be read as apportioning blame or liability to any particular individual or organisation.

1. The significant unsafe act that resulted in the grounding was that the mate allowed himself to become distracted, for a period of about 15 minutes, from the navigation of the ship by a telephone conversation between his wife, who was on the ship's bridge wing, and his family overseas.

2. From about 0645 to 0715 the mate had become preoccupied with arranging and making private telephone calls while the ship was in cellular phone range of the coast, rather than monitoring the ship's course, speed, position and his other watchkeeping duties.

3. The manner in which the mate maintained his watch on 2 November 2000 lacked appropriate motivation and fell well below proper professional standards.

Based on the evidence available, the following underlying, or 'latent', factors are considered to also have contributed or are relevant to the incident:

4. The ship's GPS cross-track error alarm was neither loud enough nor strident enough to attract urgent attention.

5. The absence of an appropriate level of Bridge Resource Management on the vessel allowed a basic error by oneperson to result in a serious accident.

6. The Reefcentre operator was aware that Bunga Teratai Satu was in the area of the Green Island radar coverage, but the loss of radar signal of vessels in Torres Strait caused him to focus solely on the Hammond Island display and to concentrate on re-entering the information into the Traffic Information Module.

7. The frequency of annunciation of Traffic Information Module alarms and associated radar alarm systems had led to the desensitising of Reefcentre operators to the whole TIM alerting system.

8. However, given the setting of the restricted area off Sudbury Reef at two miles and the speed and circumstances prevailing on the bridge of Bunga Teratai Satu, it is unlikely that any advice provided by the Reefcentre operator under the Reefcentre procedures would have prevented the grounding.

In relation to the perception that the radar system was not reliable:

9. The radar units operated consistently within the design availability criteria.

Occurrence summary

Investigation number 162
Occurrence date 02/11/2000
Location Sudbury Reef
State Queensland
Report release date 31/05/2001
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Marine
Marine occurrence category Grounding
Occurrence class Incident
Highest injury level None

Ship details

Name Bunga Teratai Satu
IMO number 9157662
Ship type Container
Flag Malaysia
Departure point Singapore
Destination Sydney, NSW

Grounding of the Australian flag training vessel Wyuna

Final report

Summary

On 19 October 2000, the Australian Maritime College vessel Wyuna was being used to train students in night pilotage exercises in the Tamar River.

The exercises had commenced before dawn that morning, resuming at 2000 under the master's supervision. An outward passage and an inward passage were satisfactorily completed, and a second outward passage was started.

The tide was ebbing. The sky was overcast with moderate rain, the wind was SSE at force 4/5 and the visibility was moderate to good. During the early stages of the passage out, the master observed that the vessel was overshooting course alteration points. On both occasions he verified Wyuna's position and brought the vessel back on track.

After clearing Northwest Bank beacon, the master became disorientated and confused Northwest Bank Beacon for Shear Rock Beacon. He instructed the student on the con to set a course to take Wyuna clear of the river, but the vessel was set on course for Shear Rock. At 2305, Wyuna struck Shear Rock.

The master stopped the engines and checked the electronic chart display, which showed the vessel on Shear Rock. The tide was setting the ship across the rock but, about 2 minutes later, the ship was afloat once more, being carried northward across the channel.

The master let go the port anchor with a shackle1 and a half of chain, but this did not arrest the ship's drift and, at 2315, the ship grounded once more, on Middle Bank. The chief engineer reported that there was no apparent damage to machinery, so the master used the engines to prevent the ship from going further aground and, at 2317, Wyuna steamed back into the channel.

The master took the ship back to anchor at Bell Bay while continuing to check the vessel for any damage. No oil or water was lost from the ship, but numbers 10 and 11 double bottom tanks were making water through sprung seams and rivets.

_____________
1 A shackle is about 27 metres.

Occurrence summary

Investigation number 161
Occurrence date 19/10/2000
Location Tamar River
State Tasmania
Report release date 27/03/2002
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Marine
Marine occurrence category Grounding
Occurrence class Incident
Highest injury level None

Ship details

Name Wyuna
IMO number 54393907
Ship type Training Vessel
Flag Australia
Departure point Tamar River

Lifeboat incident on board Washington Trader

Final report

Summary

At 2036 on 5 August 2000, the Philippines flag, panamax bulk carrier, Washington Trader arrived at the anchorage at the Abbot Point coal loader in Queensland. The ship was in ballast and intending to load a full cargo of coal for export to Japan.

While at anchor on 6 August, the master decided to take the opportunity to conduct an emergency steering and fire drill, followed by an abandon ship drill using the ship's totally enclosed lifeboats. At 1600, the crew commenced the abandon ship drill. As there had been a full lifeboat drill some seven weeks previously, the drill involved a boat muster, followed by the lowering of the unmanned lifeboats to deck level.

By 1612, the boat muster had been completed and both lifeboats prepared for lowering. The master ordered the starboard lifeboat to be lowered first and this was completed without incident.

The master then ordered the port boat to be lowered. The mate, who was the officer in charge of the port boat, started lowering the boat by operating the brake release lever on the davit winch. When the boat was approximately halfway to the deck, the master saw the after end of the boat swing and jerk twice followed by the after-fall detaching from its on-load release hook. When the after fall detached, the boat's stern fell and swung forward, and the boat was seen to jerk twice more followed by the forward on-load release hook releasing its fall. The boat then fell stern first approximately 15 m to the water below.

After the incident, the lifeboat was brought back alongside. There was obvious damage to the stern of the lifeboat and a jacobs ladder was rigged to allow the mate to enter the boat to inspect the damage. He found that the boat was flooded and severely damaged at the stern with the canopy broken and set in. He also found that the after deck around the on-load release hook had been damaged by the impact.

After initial unsuccessful attempts to recover the lifeboat, it was secured alongside overnight. It was recovered early the next morning using the auxiliary lifting shackles on the on-load release hook units. The lifeboat was re-stowed in its davit and secured with additional lashing.

Occurrence summary

Investigation number 160
Occurrence date 06/08/2000
Location Abbott Point
State Queensland
Report release date 10/01/2003
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Marine
Marine occurrence category Lifeboat
Occurrence class Incident
Highest injury level None

Ship details

Name Washington Trader
IMO number 9211602
Ship type Bulk carrier
Flag Philippines
Departure point Kawasaki, Japan
Destination Abbot Point, Queensland
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