Collision with terrain

What happened

On the morning of 1 April 2013, the pilot of a Cessna 210 was one of a group intending to fly various light aircraft under the visual flight rules from Bullo River homestead to Emkaytee, a private airstrip near Darwin, Northern Territory. Low cloud delayed all of the departures from Bullo River and the aviation forecasts and weather radar images accessed by the group via the internet indicated isolated thunderstorms, low cloud, and rain in the intended area of operation. Some improvement was forecast after 1130 local time.

By lunchtime the weather had lifted at Bullo River and the pilots observed that the weather radar images were indicating an improvement en route. All of the pilots departed between 1300 and 1500, some electing to track via the coast and the rest tracking as required more or less on the direct track. The pilot of the Cessna 210 departed at about 1415 with three passengers to track via the coast.

The pilots in the group were communicating by radio on a discrete frequency and the Cessna 210 pilot was heard to report at about 1510 that he was approaching Cape Ford and the weather ahead was gloomy, or words to that effect. That was the last radio transmission from the pilot.

When the aircraft did not arrive at Emkaytee a search was initiated. Bodies and a small amount of wreckage were found on the southern shoreline of Anson Bay, about 10 km south-east of Cape Ford. There were no survivors.

What the ATSB found

During the flight from Bullo River to Emkaytee, the pilot continued to track along the planned coastal route towards a thunderstorm, probably encountering conditions such as low cloud, reduced visibility and turbulence, and as a result of one or more of those factors the aircraft descended and collided with water.

Safety message

Tracking visually via a coastal route in marginal weather conditions can be advantageous in terms of ease of navigation and absence of elevated terrain, but can also increase the risk of spatial disorientation in the context of drastically reduced visibility exacerbated by a lack of surface definition when over water.

In situations where significant weather is forecast or otherwise expected, pilots are encouraged to access the Bureau of Meteorology detailed weather briefings (via the phone number on the area forecast) to assist with understanding the conditions at the time as well as the immediate trend.

On 9 September 2011, a Cessna 208B ‘Grand Caravan’ aircraft, registered PK-VVE, collided with terrain and was destroyed on a cargo flight from Wamena to Kenyam in the Pasema District of West Papua, Republic of Indonesia. The pilot and copilot, the only persons on board were fatally injured. 

As the accident took place in Indonesia, the Indonesian National Transportation Safety Committee (NTSC) is responsible for investigating this occurrence, consistent with Indonesia’s obligations as State of Occurrence under Annex 13 to the Convention on International Civil Aviation Aircraft Accident and Incident Investigation (Annex 13).

The pilot of the aircraft was an Australian citizen and, in accordance with the ‘special interest’ provisions of paragraph 5.27 of Annex 13, the Australian Transport Safety Bureau (ATSB) appointed an expert to the NTSC investigation. This allowed the ATSB to receive relevant factual information that was approved by the NTSC for public release and a copy of the NTSC’s final investigation report. 

The NTSC subsequently requested ATSB support in the analysis of the available recorded data from the flight and with finalising the draft investigation report. To facilitate this support, the ATSB appointed an accredited representative in accordance with paragraph 5.23 of Annex 13 and, in order to protect the information supplied by the NTSC, commenced an external investigation under the Transport Safety Investigation Act 2003. The ATSB completed its work as accredited representative in March 2013.

The National Transport Safety Committee of Indonesia is responsible for releasing the investigation report.

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

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

Website: http://knkt.dephub.go.id/knkt/ntsc_home/ntsc.htm

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

Response to Inquest Findings

The Coroner’s Court of Queensland, without holding an inquest, recently made findings into a 2013 fatal accident involving a Cessna T210N aircraft near Roma Airport.

The ATSB summary explains that on 25 March 2013, the pilot of a Cessna T210N aircraft and a passenger took off from Roma airport to the north about 30 minutes before dawn. The aircraft crashed descending in a left turn about 2 km north-west of the airport. There was no indication of any mechanical defects in the aircraft, however the pilot was not qualified to fly at night.

The Coroner adopted the Sequence of Events as set out in the Australian Transport Safety Bureau final report in relation to how the accident occurred and incorporated into his findings those of the ATSB regarding the likelihood of pilot spatial disorientation.

The Coroner stated:

Unfortunately for reasons that are currently unknown [the pilot] decided to take-off in darkness only 30 minutes from first light. The ATSB considers he suffered from the well-known phenomenon of spatial disorientation and the plane crashed into the ground causing his death and that of his passenger.

Safety message

This accident reinforces the need for day visual flight rules pilots to consider the minimum visual conditions for flight, including the relevant weather information and usable daylight. In this case, if the pilot had delayed the departure by 30 minutes, the flight would most likely have progressed safely in daylight conditions.

There are numerous airports in Australia, including Roma, that have an abundance of ground lighting in one take-off direction but not another. This accident highlights the potential benefits of night visual flight rules and instrument-rated pilots considering the location of ground lighting when planning night operations.

Finally, the benefit of crash-activated emergency locator transmitters that include global positioning system-based location information, thereby providing for a timely emergency response in the event of an accident, is emphasised.

Inquests are separate to ATSB investigations

The Coroner formulated his findings and recommendations independently of the ATSB. The ATSB cannot speak for the Coroners findings. However, the ATSB supports the coronial process and in the interests of ensuring that safety information is made available to the broadest audience the ATSB is making this publication.

The Coroner's report is expected to be made available from the Coroner's Court of Queensland. Contact details are available at: www.courts.qld.gov.au/courts. Queries regarding the Coroner's findings should be directed to the Coroner's Court at Brisbane.

On 15 March 2013, a student pilot was conducting solo circuit training at Jandakot Airport, Western Australia, in a Grob G‑115C, registered VH-ZTM (ZTM). 

At 1135 Western Standard Time, on the student’s third solo circuit to runway 06R, ZTM began to drift to the left of the runway centreline. The student elected to go-around and applied full power. Following the application of power, the nose pitched up abruptly and the aircraft then rolled to the left before pitching nose down. The left-wing tip contacted the ground, and the nose gear and right main gear collapsed before the aircraft came to a stop. The student pilot was able to exit the aircraft without injury, however the aircraft sustained substantial damage.

As a result of this occurrence, the flight training school has advised the ATSB that they are taking the following safety actions:

• Increased emphasis on Stabilised Approach Criteria to be made during pre-flight briefings.
• Instructor training and standardisation to include more emphasis on the essential use of rudder.
• Inclusion on the training syllabus of an upper air exercise prior to first solo, to check student use of rudder and go-around procedures.
• A more detailed brief on landing technique, for the G115C, to be included in the standard operating procedures.

A go-around is an aborted landing of an aircraft that is on final approach. The Aircraft Owners and Pilots Association (AOPA) has identified that for the ten-year period, between 1994 and 2003, accidents that occurred during a go-around accounted for approximately 6 % of the total accident rate for general aviation. During a go-around the aircraft is trimmed for landing, not for going around and the pilot will need to be positive with attitude changes as power is applied.

Aviation Short Investigation Bulletin Issue 20

On 9 March 2013, two glider clubs were conducting gliding operations at Tocumwal aerodrome, New South Wales. A Grob G103 Twin Astir glider, registered VH‑UIZ (UIZ), was towed airborne, however, after a number of orbits looking for rising air, the pilot of UIZ tracked to return to the circuit and land. A few minutes later, a Cessna 150 registered VH‑ROZ (ROZ), became airborne towing a glider. ROZ and this glider were from one gliding club, UIZ from the other. Following the release, the pilot of ROZ turned left and tracked for a left downwind for runway 36L.

Witnesses on the ground reported hearing both pilots making all necessary CTAF broadcasts.

Just as ROZ touched down on runway 36L, the pilot felt a heavy jolt on the top of the cockpit and simultaneously heard a loud noise. Immediately, he saw the windscreen fill with the underside of a glider. He observed the glider continue down the runway at about 5 to 10 ft above ground level. The pilot was uninjured and, on exiting the aircraft, observed a wheel contact print on the top of the aircraft. The pilot of UIZ was uninjured and landed the glider well down the runway. On exiting the glider, the pilot observed damage on the left wing and fuselage.

As a result of this occurrence, the GFA has advised the ATSB that they will raise awareness of collision risk at non-towered aerodromes with its members through the Gliding Magazine and through its biennial Safety Seminars.

As a result of this occurrence, the operator of the glider tug has advised the ATSB that they are sourcing quotes for the fitment of FLARM collision warning system to their gliders and glider tug aircraft.

When operating outside controlled airspace, it is the pilot’s responsibility to maintain separation with other aircraft. For this, it is important that pilots utilise both alerted and unalerted see-and-avoid principles. Pilots should never assume that an absence of traffic broadcasts means an absence of traffic.

Aviation Short Investigation Bulletin - Issue 19

On 9 February 2013, a Cessna 150F, registered VH-ICE (ICE), landed on the 11^th fairway of the Mt Broughton Golf Club, New South Wales after the initial leg of a return flight from Robertson. The pilot was the only person on-board and had been authorised and pre-arranged with the Golf Club to use the fairway as a landing area.

After landing to the south, the pilot backtracked along the landing area to conduct a short field take-off in the same direction.

The pilot reported that the aircraft accelerated as normal, however during the take-off run he realised the aircraft would not clear the trees at the end of the landing area and elected to reject the take-off. The left wing impacted a tree; the aircraft turned over and came to rest inverted. The pilot was uninjured, and the aircraft sustained substantial damage.

An insurance assessor attended the accident site and reviewed the landing area. The assessor determined that the effective available take-off length of the landing area was 1,180 ft. Based on performance charts in the approved Cessna 150F owner’s manual, the take-off distance required by the unmodified Cessna 150 F was 1,583 ft. There was no available performance data that took into account the installation of the 160 hp engine.

This accident highlights the importance of following the published performance data for your aircraft and knowing the performance requirements, physical characteristics and dimensions of the landing area that you are intending to take-off and land on. Other factors, such as environmental conditions, may affect the usable landing area length needed for a safe take off, landing or rejected take-off.

Aviation Short Investigation Bulletin Issue 19

On 7 February 2013 at about 1655 Eastern Daylight-saving Time a Eurocopter AS350 B2 helicopter, registered VH-EWM (EWM) was conducting water-bombing operations near Hobart, Tasmania, when it collided with terrain. The pilot, the sole person on board, suffered minor injuries and the helicopter sustained substantial damage.

The spot fire EWM was working on was not particularly large but was on a downhill slope and in a gully. The pilot reported that the overall wind was north-north-westerly, but the fire created a localised westerly in-draft, within the gully. The pilot slowed EWM in preparation of making a water drop. Approaching the hover at about 80 ft above ground level, and immediately following the loss of translational lift (TL), the helicopter suddenly commenced an uncommanded left yaw and descent. Without any warnings or alarms, the helicopter rotated rapidly 2-3 times to the left. The pilot raised the collective to decrease the rate of descent and countered the yaw with anti-torque pedal input; however, the rate of yaw increased. The pilot reported that “in a very short period of time” the helicopter was in the trees. The pilot received minor injuries, and the helicopter was substantially damaged.

As the ATSB did not attend the accident site, or examine the helicopter, the reason for the accident could not be conclusively established.  The described behaviour of the helicopter by the pilot was consistent with Loss of tail rotor Effectiveness (LTE). In this condition of flight, the tail rotor loses aerodynamic efficiency. Factors which contribute are:

• Low airspeed
• High power
• An adverse relative wind

Water-bombing helicopters operate at very low altitudes, in very challenging and often rapidly changing conditions. Any sudden onset of an abnormal condition of flight presents negligible time for recovery.

Eurocopter circulated Service Letter No 1673-67-04 in 2005 regarding the yaw axis control features for all helicopters under certain flight conditions.

Aviation Short Investigation Bulletin Issue 20

On 25 December 2012, a Fokker 100 aircraft, registered XY-AGC, collided with terrain on approach to Heho Airport, Myanmar, fatally injuring one of the aircraft’s occupants and a motorist on the ground.

The Myanmar Accident Investigation Bureau (MAIB) is responsible for investigating this occurrence. As part of its investigation, the MAIB requested assistance from the Australian Transport Safety Bureau (ATSB) in the recovery and download of data from the aircraft’s Flight Data Recorder (FDR) and Cockpit Voice Recorder (CVR) units. 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 MAIB and initiated an investigation under the Australian Transport Safety Investigation Act 2003.

Following receipt of the CVR and FDR units on 21 January 2013, both units were successfully downloaded in accordance with the relevant manufacturer’s instructions. The download and data recovery operations were overseen by representatives of the MAIB and an Accredited Representative from the Dutch Safety Board (DSB). During preparations for the download process, ATSB specialists found that the crash survivable memory units (CSMU’s) from the both recorders had suffered damage from fire exposure. The CSMU is the module which carries the solid state chips that contain the recorded information.  The CVR CSMU was dismantled and the data recovered using data retrieval techniques appropriate for an accident-damaged flight recorder. However, the FDR CSMU had sustained a significantly greater degree of thermal damage and required specialised data recovery techniques involving recovery and downloading of individual chips. The data recovered from the discrete chips was later compiled into a single coherent data file using a specialised utility provided by the recorder manufacturer.

The downloaded audio and flight data was examined and confirmed as containing detail from the accident flight. The recovered information, together with a selection of graphical and tabular presentations of the flight data was provided to MAIB representatives on 25 January 2013.

Fire-damaged flight data recorder as-received

Thermally-damaged flight data recorder crash-survivable memory unit

The MAIB investigation has now been finalised and in accordance with the provisions of ICAO Annex 13, a copy of the final investigation report was provided to the ATSB on 28 January 2014.

A copy of the final report may be requested through the contact details below:

Myanmar Accident Investigation Bureau
First Floor, DCA HQ Building (B)
Yangon 11021, Myanmar
Tel: 951 533162
Fax: 951 533016
Email: ddmaib@dca.gov.mm

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

On 15 November 2012, an amateur-built SeaRey amphibious aircraft, registered VH-RRZ, was being operated on a private flight with only the pilot on-board. When the aircraft failed to arrive at its destination, search and rescue authorities were notified, and the aircraft was subsequently located on 16 November, having collided with terrain approximately 76 nautical miles north of Weipa, Qld. The aircraft was destroyed by impact forces and the pilot had sustained fatal injuries.

The QLD Police Service (Northern Coronial Office) is investigating this occurrence. Following examination of the aircraft wreckage, QPS officers requested assistance from the Australian Transport Safety Bureau (ATSB) in the recovery of data from a GPS unit found at the accident site. To protect the information supplied by the QLD Police Service and any data recovered from the examined device, the ATSB initiated an external investigation under the provisions of the Transport Safety Investigation Act 2003.

The examination found that the GPS memory chip which contains the flight data was damaged and the data was therefore not able to be recovered. The GPS was returned to the QLD police.

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

On 15 December 2012, four DH-82A (Tiger Moth) aircraft departed runway 12 at Luskintyre airport, NSW, for a practice formation flight. The pilot flying VH-DDA (DDA), the formation lead aircraft, applied full power for take-off. Passing through about 50 ft above ground level, the pilot flying noted that the aircraft was not climbing as expected and, realising that full power was not selected, applied full power by moving the throttle fully forward and lowered the nose of the aircraft slightly to gain speed.

As there was insufficient distance remaining to land on the runway, and it had become evident that a forced landing was imminent, the instructing pilot input a slight left bank so that the left wing of DDA took the main force of the impact. The aircraft landed and struck a tree before coming to rest. Both pilots were able to undo their four-point harnesses and exit the aircraft without assistance, although the pilot flying received serious facial injuries.

While both pilots reported that they had not reduced engine power after take-off, the accident was a result of decreasing airspeed and the aircraft being unable to recover following the reapplication of full power. The ATSB could not resolve this ambiguity.

The positive aspects of wearing full restraint harnesses, evacuating the aircraft quickly and extinguishing the fire ensured neither pilot experienced further injuries.

Comprehensive pre-flight briefings are important for all flights to ensure each crew member is aware of their respective roles as well as normal and non-normal operations.

Aviation Short Investigation Bulletin – Issue 17