Collision with terrain

On 10 November 2013, while conducting an approach to the Red Lake Airport, at Red Lake, Ontario, Canada, the crew of a Fairchild-Swearingen SA227AC (Metroliner) aircraft declared an emergency. Shortly after, the aircraft struck trees and a powerline before crashing south of the airport. The aircraft was destroyed by the impact and fire. The two crewmembers and three of the passengers sustained fatal injuries. The remaining two passengers escaped with non-life-threatening injuries.

An investigation into the circumstances of this accident is being carried out by the Transportation Safety Board (TSB) of Canada. The TSB investigation can be accessed at www.bst-tsb.gc.ca/eng/, reference A13C0150.

On 5 November 2014 the TSB requested Australian Transport Safety Bureau (ATSB) assistance in gathering information on two recent engine failures involving Australian‑registered Metroliner aircraft, with a view to identifying any commonality with the Red Lake accident. In accordance with paragraph 5.23 of Annex 13 to the Convention on International Civil Aviation Aircraft Accident and Incident Investigation, the ATSB appointed an accredited representative to the TSB investigation. To facilitate this support, the ATSB initiated an external investigation under the provisions of the Transport Safety Investigation Act 2003. The information gathered by the ATSB was provided to the TSB on 11 November 2014.

The TSB is responsible for, and will administer the release of the final investigation report into this accident. Any enquiries regarding the TSB investigation should, in the first instance, be directed to:

Director Investigations - Air
Transportation Safety Board of Canada
200 Promenade du Portage
Place du Centre, 4th floor
Gatineau Québec, K1A 1K8

Tel: +1 819-994-3741
Fax: +1 819-997-2239

General enquiries email: communications@bst-tsb.gc.ca

 

 

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Released in accordance with section 25 of the Transport Safety Investigation Act 2003.

The helicopter was operating a Night VFR medical evacuation flight. The patient to be evacuated was a 15 year old adolescent who had suffered a dislocated elbow.

Initial advice of the requirement for the evacuation was telephoned by the tasking hospital at about 2030 EST and after obtaining weather forecasts and readouts of the present weather in the area of the destination, the aircraft departed for the short flight to the hospital at 2108.

At the hospital, the pilot checked with the medical staff as to the need to conduct the evacuation and was advised that the flight was necessary. After emplaning a doctor the aircraft departed for its destination.

As the flight proceeded the pilot checked the weather conditions at the island with persons at the destination and at a location to the south of the destination. Checks were also made through the Flight Service operator with the meteorological radar service in Brisbane. The weather report received from the destination indicated a complete overcast with a south-easterly wind of 15-20 kts and no rain.

The flight continued along the eastern side of Fraser Island and the pilot reported that he had the lights at the destination in sight. Enroute, over the island, the helicopter was forced to descend to about 1000 feet to remain below the overcast. As the helicopter approached the destination it entered rain and the pilot commenced a descent. The rain became heavier and the pilot lost sight of all but one of the three light sources at the destination. He continued with the descent and decided that because of the conditions he would be unable to conduct a turn to clear the area.

The helicopter subsequently struck a tree and began to vibrate. After it struck another tree the pilot closed the throttle and flared the helicopter, which came to rest upright about 400 m prior to the threshold of the Orchid Beach airstrip.

Weather reports received by the pilot prior to and during the flight indicated that visual flight was possible to the destination. However, the reports also indicated that the heavy showers to the north of the destination were moving to the south.

SIGNIFICANT FACTORS

• There was pressure on the pilot to complete the evacuation.
• The weather conditions in the area of the destination deteriorated rapidly.
• The pilot continued with the flight into non-visual conditions.

The operator had received approval to carry out certain low level operations, including power line inspections, during nominated periods of emergency. The approval was subject to a number of conditions, which included requirements that such flights be authorised by the State Emergency Services and that only persons essential to the operation be carried. As suitably qualified commercial pilots were not normally available, two private pilot members of the aero club who had more than 1000 hours flying experience had been specifically approved to conduct these flights. Before receiving this approval, the pilots had been required to complete specialised low flying training and testing. The procedure used in conducting power line inspection flights was to fly at approximately 200 feet above ground level, maintaining about 90 knots airspeed with one or two stages of flap lowered and with the aircraft tracking left of the line to assist inspection by the observer in the right seat.

The aircraft struck the spur line with its propeller and nose gear. The line did not break and the aircraft was pitched vertically to the ground.

Examination of the wreckage found no evidence of mechanical defect or malfunction which might have contributed to the accident.

On 7 October 2014, a Robinson R44 helicopter, registration ZK-HBQ, collided with terrain in the Kahurangi National Park, near Nelson, New Zealand.

The New Zealand Transport Accident Investigation Commission (TAIC) is conducting an investigation into the circumstances of the accident. As part of its investigation, TAIC requested technical assistance from the Australian Transport Safety Bureau (ATSB) in the recovery of data from a damaged GPS unit recovered from the wreckage. To protect the information supplied by TAIC to the ATSB and the ATSB's investigative work to assist TAIC, the ATSB initiated an investigation under the Transport Safety Investigation Act 2003.

The ATSB successfully recovered data from the GPS unit and has provided the data to TAIC to assist with their investigation.

Enquiries relating to the accident investigation should be directed to TAIC at: www.taic.org.nz

 

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Released in accordance with section 25 of the Transport Safety Investigation Act 2003.

On 9 April 2014, a Quest Aircraft Company Kodiak 100 registered PK-SDF collided with terrain during take off from Doyo Baru Airstrip, Jayapura, Papua Indonesia. The accident destroyed the aircraft and fatally injured the two occupants.

The National Transportation Safety Committee (NTSC) of Indonesia is responsible for investigating this accident. The aircraft was fitted with advanced cockpit instrumentation that included a flight data logging function. Although subjected to significant fire damage, the cockpit instrumentation and associated avionics were recovered by on site investigators and transported to the NTSC facilities for further examination. Examination of the instruments revealed remnants of non-volatile memory devices that were fitted to the cockpit displays.

The NTSC requested specialist assistance from the Australian Transport Safety Bureau (ATSB) to attempt the recovery of flight data from the non-volatile memory chips fitted to the cockpit instrumentation.

In accordance with clause 5.23 of Annex 13 to the Convention on International Civil Aviation (ICAO Annex 13) the ATSB appointed an Accredited Representative to assist the NTSC and initiated an investigation under the Australian Transport Safety Investigation Act 2003.

Examination of the instrument display components indicated they had suffered significant heat exposure resulting in the memory device packaging melting. The examination revealed parts of the memory device were present in the display components, however the memory chip could not be located. Consequently no accident flight data could be recovered to assist the NTSC investigation team. Preliminary results were conveyed to the Head of Aviation Sub Committee and a final report provided in November 2014.

The National Transportation Safety Committee of Indonesia is responsible for releasing a final investigation report regarding this occurrence. Contact details for the NTSC are:

National Transportation Safety Committee Office

Ministry Of Transportation Republic Of Indonesia
Transportation Building 3rd Floor
Jalan Medan Merdeka Timur No. 5
Jakarta Pusat 10110
Indonesia

Phone : +62 21 384 7601
Fax : +62 21 351 7606
Email : knkt@dephub.go.id

 

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Released in accordance with section 25 of the Transport Safety Investigation Act 2003.

What happened

On 27 October 2014, at about 1030 Eastern Daylight-savings Time (EDT), a Cessna 172 aircraft, registered VH-ZZD departed Ballarat, Victoria, for Luskintyre, New South Wales, on a private flight under the visual flight rules. The pilot refuelled at Wangaratta, Victoria, and took a break for refreshments at Temora, New South Wales. As he neared Kandos, New South Wales, the pilot elected to track directly to Luskintyre, rather than follow his planned route which took him over a number of towns further north.

The direct track between Kandos and Luskintyre was over heavily treed and undulating terrain, leaving the pilot unable to positively visually fix his position. As he continued in an easterly direction, the pilot grew increasingly concerned about the possibility of infringing controlled airspace further to the east. Rather than risk infringing controlled airspace, the pilot decided to make a precautionary landing to ascertain his position. The pilot commented that precautionary landing options were very limited, but he ultimately selected a paddock that was clear of obstacles, and while relatively short, it offered an uphill landing run to assist in stopping the aircraft.

During his approach to land on the selected paddock, with full flap selected, the pilot found himself overshooting the selected aim point. Concerned that he would not be able to land safely, the pilot elected to discontinue the approach and commenced a go-around. As the go-around proceeded however, the aircraft collided with a line of trees on rising terrain beyond the far end of the selected paddock. The aircraft was substantially damaged, and the pilot received serious injuries. The aircraft wreckage was discovered by a local resident around 2 hours after the accident, independent of other search and rescue activities.

Pilots unsure of their position or requiring navigational assistance, are encouraged to seek Flight Following services from ATC. In this case, contact with ATC may have allayed the pilot’s concerns about the prospect of infringing controlled airspace, and negated the need to consider a precautionary landing. With respect to precautionary landings, pilots are encouraged to initiate an early go-around given any doubt regarding the prospects of a safe landing.

Aviation Short Investigations Bulletin - Issue 39

During the initial climb after take-off, the pilot of the Cessna 402 observed that the nose landing gear had failed to retract. While orbiting clear of the airfield, the pilot commenced troubleshooting and found that the hydraulic system circuit breaker had tripped. After resetting the circuit breaker, several further retraction attempts failed to resolve the problem. The pilot then attempted to lower the landing gear using the emergency function. These attempts were also unsuccessful. After briefing the passengers on emergency procedures and with RFFS in position, the pilot commenced the landing with an unlocked nose gear. During the approach, the pilot shut down both engines and turned off the fuel. He then realised that the aircraft would land short of the runway.

The aircraft came to rest 10 metres outside of the airport boundary fence. The pilot and passengers were uninjured. Engineering inspection of the aircraft revealed a wire in the electrical loom to the left main landing gear which had shorted to structure. When a selection was made with the landing gear selector lever, power applied to move the electro-hydraulic shuttle valve from the idle position to either up port or down port would pop the circuit breaker. This prevented the nose gear from completing the cycle to the fully down position and also prevented the return of all the gears to the up and locked position. The emergency blow down bottle was removed and examined. It was found to require a force well in excess of the maintenance manual requirement to operate the mechanism. These two defects prevented the landing gear from being locked down.

While conducting spraying operations, the aircraft hit a single wire earth return (SWER) power line. The power line contacted the propeller and proceeded to wrap about the propeller hub. The power line was pulled taut by the aircraft, the pilot lost control, and the aircraft impacted the ground 1,000 metres beyond the point of wire contact. The lateness of the day combined with low overcast is believed to have contributed to the pilot's inability to detect the wire in his flightpath.

During the impact sequence, the underfloor framework with the attachment points for the seat and seat belt appear to have distorted altering their geometry. This in turn may have allowed sufficient movement of the pilot against the loosened restraints for his head to contact with the instrument panel. As he was wearing a helmet at the time, the sequence resulted in severe concussion and not a more serious head trauma.

The wind at the time was reported to be from the south-east at 15 to 20 kt with gusts to 25 kts. The pilot had flown away from a mob of cattle at 50 kts in a south-westerly direction across the wind, to check on some other animals. He then reduced speed and turned left into wind at a height of about 15 ft above ground level. As he was rolling out of the turn, the helicopter sank to the ground. The helicopter cartwheeled forward and came to rest inverted. The aircraft was within weight and balance limits for the flight and was reported to have been operating normally before the accident. The pilot reported having flown 6.4 hours that day.

The flight was part of a private holiday tour with four adults and two children in the aircraft. The pilot was conducting an approach to land at a property airstrip. There was a headwind of about 20 kts on final approach and he was maintaining an airspeed of 80 kts. When the aircraft descended below the tree line just before landing it entered an area of windshear. The pilot noted an increase in speed at this time and said that the aircraft bounced a number of times after the initial touchdown.

He then elected to go around, applied full engine power, and retracted the flaps from 30 to 20 degrees. He then became concerned about clearing trees to the left of the strip as the aircraft had veered left during the go-around. The aircraft subsequently collided with the trees and impacted the ground heavily. The pilot and one passenger sustained minor injuries. There was no reported problem with the engine or the aircraft during the go-around. Post-accident examination of the aircraft indicated that, at impact, the flaps were in the process of retracting, and the landing gear was down.