Collision with terrain

At about 0715 eastern daylight time on 23 July 2011, a Moyes Dragonfly airplane, registration N402HA, was substantially damaged when it impacted terrain at Ridgely Airpark, Ridgely, Maryland, US. The pilot was fatally injured. The aircraft was being operated on a glider-tow flight.

As the accident took place in the US, the National Transportation Safety Board (NTSB) was responsible for the investigation. As part of its investigation (reference ERA11FA413), the NTSB requested assistance from the Australian Transport Safety Bureau (ATSB) to gather information from the aircraft's manufacturer, who is based in Australia.

In accordance with clause 5.18 of Annex 13 to the Convention on International Civil Aviation (Annex 13), the ATSB appointed an  accredited representative to assist the NTSB and initiated an investigation under the Australian Transport Safety Investigation Act 2003. In addition to obtaining the aircraft information for the NTSB investigation from the Australian manufacturer, the ATSB facilitated the development of safety action by the aircraft manufacturer and provided comments on the NTSB’s draft investigation report in accordance with clause 6.3 of Annex 13 in November 2012.

The NTSB is finalising its report and, when complete, this report will be available on the NTSB website at www.ntsb.gov.

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

What happened

On the morning of 23 November 2012, the pilot of a Piper Cherokee Six, registered VH-TSZ, with two other owner-pilots on board, took off from runway 24L at Jandakot Airport, Western Australia. After turning onto the track to Beverley and at about 700 ft above ground level, the engine lost power. The pilot immediately turned the aircraft towards runway 30 and focussed on flying the aircraft while the owner-pilot in the copilot seat conducted some of the troubleshooting checks. The engine did not regain power.

With insufficient height and speed to reach the runway, the pilot force landed the aircraft into wooded bushland within the airport precinct, approximately 150 m short of a cleared area in the undershoot of runway 30. The aircraft was substantially damaged by impact with trees. The occupants exited the aircraft with only a minor injury to one passenger.

What the ATSB found

The ATSB found no mechanical defects or fuel supply anomalies that would have prevented normal engine operation. The evidence for carburettor icing was equivocal and therefore, could not be ruled out as a contributing factor. No other likely contributing factors were identified.

It was also found that the pilot did not ensure all of the available procedures for an engine power loss and power-off landing were followed, which resulted in reduced gliding performance and a higher-than-necessary landing speed.

The pilot had not completed a flight review in the 2 years prior to the occurrence, increasing the operational risks including the response to emergency situations.

Safety message

The conduct of emergency procedures relies on the application of established knowledge and skills, reinforced by the use of a pre-take-off emergency briefing, and conduct of flight reviews. By not complying with the periodic flight review requirements, the pilot missed an opportunity to maintain those critical skills.

On 7 November 2012, at about 1000 Eastern Standard Time a Cessna 172N registered VH-JGR (JGR) departed Archerfield Airport, Queensland on a training flight. The purpose of the flight was to conduct solo pre-test revision, prior to the pilot performing the Private Pilot Licence (PPL) flight test. The aircraft was booked for 2 hours. During the flight, the aircraft impacted terrain and was substantially damaged. The pilot was the only person on board and suffered severe injuries as a result of the accident and was airlifted to hospital.           

The aircraft activated air switch indicated that the aircraft was airborne for approximately 45 minutes prior to the accident, placing the time of the accident about 3 hours prior to the aircraft being located.     

This accident highlights the importance of lodging a Search and Rescue Time (SARTIME), Flight Plan or Flight Note with a responsible person, to eliminate any major delays in commencing a search. Failure to do this means that you are relying on being able to get an emergency call out, using your Emergency Locator Transmitter (ELT) to alert the Rescue Coordination Centre Australia (RCC) or relying on someone noticing that you have gone missing.       

Update 12 November 2012 - Preliminary factual report release

On 3 October 2012, the ATSB commenced an investigation into an accident involving a Robinson R22 Beta helicopter, registered VH-LLF, which collided with terrain 130 km west of Halls Creek, Western Australia.

The ATSB has released its preliminary factual report  into the collision. The information contained in the report is derived from the initial investigation of the occurrence. Readers are cautioned that new evidence will become available as the investigation progresses that may alter the circumstances as depicted in the preliminary report. As such, no analysis or findings are included in the report.

In the late afternoon on 3 October 2012, the pilot of a Robinson R22 Beta collided with terrain in a gorge on the Gliddon River (near the Margaret River).

The tail of the helicopter collided with an overhanging rock formation and a section of the tail boom separated from the fuselage. The helicopter rolled to the left and descended out of view of witnesses. The helicopter was found submerged on its right side with substantial damage. The pilot was deceased.

The ATSB attended the accident site, but was unable to closely examine the submerged wreckage. From the surface it was evident that the cabin roof was crushed in, both main rotor blades had severed a short distance from the main rotor hub, and one of the fuel tanks had detached from the aircraft structure.

The investigation is continuing and will include analysis of the available information to identify safety factors.

It is anticipated that the investigation will be completed by April 2013.

Read the

On 16 August 2012 at approximately 1245 Coordinated Universal Time (UTC), a Jabiru J230 aircraft, registered N365R, was substantially damaged when it ditched in Gull Lake, New York, USA, following a loss of power. The two occupants were not injured.

As the accident occurred in the USA, the US National Transportation Safety Board (NTSB) is responsible for investigating this occurrence. As part of its investigation, the NTSB requested assistance from the Australian Transport Safety Bureau (ATSB) as the State of Manufacture of the aircraft and engine. In accordance with clause 5.18 of Annex 13 to the Convention on International Civil Aviation, the ATSB appointed an accredited representative to assist the NTSB and initiated an investigation under the Australian Transport Safety Investigation Act 2003.

The NTSB investigation is now approaching completion. A final investigation report into the circumstances of the power loss will be published and available from the NTSB’s website.

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

On 19 August 2012 at about 1520 Eastern Standard Time, a Kawasaki Heavy Industries 369HS helicopter, registered VH-JWJ, was approaching a landing site at Konwack, Victoria. As the helicopter approached the intended landing site the ‘engine out’ caution light illuminated, accompanied by the low rotor revolutions per minute (RPM) horn and a loss of power.

The pilot immediately lowered the collective to enter autorotation, but then increased the position of the collective lever to clear a line of trees directly in his path. Clearing the trees, the pilot was able to maintain speed by keeping the nose of the helicopter down while descending. The right skid contacted the ground and was torn off, taking the tail boom with it. The aircraft skidded for about 80 m before coming to rest. The pilot was uninjured while the passenger sustained a minor head wound.

The cause of the reported power loss could not be determined. The accident highlights the value of restraints and helicopter safety helmets for both pilots and passengers.

Aviation Short Investigation Bulletin – Issue 14

On 6 July 2012, a Bell Helicopter B206L1/C30P, registered P2-HCY, impacted terrain about 130 km south-south-east of Mount Hagen, Papua New Guinea (PNG). The pilot and two passengers on board the aircraft were fatally injured.

The PNG Accident Investigation Commission (AIC) is investigating this accident in accordance with its obligations under Annex 13 to the Convention on International Civil Aviation (Annex 13).

On 20 July 2012, the AIC requested Australian Transport Safety Bureau (ATSB) assistance in terms of investigator support and technical advice. In accordance with paragraphs 5.23 and 5.24 of Annex 13 (Aircraft Accident and Incident Investigation) to the Convention on International Civil Aviation, the ATSB appointed an Accredited Representative and an Advisor to the Accredited Representative (ATSB investigators). These investigators assisted the AIC with engineering expertise for the airframe and engine examination as part of an External Investigation under the provisions of the Australian Transport Safety Investigation Act 2003.

The wreckage was transported to Port Moresby by the AIC for examination by the team of two ATSB investigators, along with AIC investigators and representatives from the airframe and engine manufacturers. After examination of the wreckage, several instruments and the engine and its associated components were sent to Australia for a detailed examination under the control of the ATSB. Support and information was provided to the AIC during the course of the investigation and the ATSB's Engineering Group Report was provided to the AIC in July 2013.

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

Mr David Inau
Chief Executive Officer
Papua New Guinea Accident Investigation Commission
Telephone: +675 311 2406

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

At 0840 Eastern Standard Time on 6 July 2012, during mustering operations near Miranda Downs aeroplane landing area, Queensland, the right skid of a Robinson R22 Beta, registered VH-STK (STK), struck a tree and the helicopter collided with terrain. The pilot, the only occupant, was seriously injured and the helicopter sustained substantial damage.

The operator conducted an investigation into the accident and, using Global Positioning System (GPS) data, determined that STK had climbed to about 2,500 ft above sea level before commencing a left spiral descent. Bureau of Meteorology data, obtained by the operator, indicated that the temperature was 14.7° C and the dew point 1.3° C. The operator determined that the combination of temperature and dew point would indicate a moderate carburettor icing risk at cruise power and a serious icing risk at descent power.

As a result of this occurrence, the aircraft operator has advised the ATSB that they have reminded their pilots of documentation in relation to carburettor icing and auto-rotations.

Pilots are reminded to maintain awareness of the weather conditions that are conducive to carburettor ice formation and closely monitor aircraft performance during times when the risk exists.

Aviation Short Investigation Bulletin - Issue 13

On 10 June 2012, a Robinson Helicopter Company R44 Raven 1, registered VH-HOU, was seriously damaged following a reported loss of power and collision with terrain near Maryvale Northern Territory. On board the helicopter were a pilot and three passengers. One passenger was seriously injured as a result of the accident.

The helicopter was to provide support and aerial filming of a competitor participating in the annual Finke Desert race. A definitive reason for the reported loss of engine power could not be determined. However, a review of the carburettor icing chart reveals that the temperature / dew point spread, put the accident flight in the “Serious Icing – Descent Power” operating realm.

The helicopter manufacturer has previously issued a Safety Notice in regard to the use of the carburettor heat assistance system, warning that if used it will reduce carburettor heat on lift off and may require adjustment in flight.

Aviation Short Investigation Bulletin - Issue 12

What happened

At about 0930 Eastern Standard Time on 28 May 2012, the pilot of a Cessna Aircraft Company 172 aircraft, registered VH-WLF, departed Wentworth Airport, New South Wales for a private flight under the visual flight rules. No details of the flight were submitted to Air Traffic Services nor left with any other person and there was no requirement to do so. A property owner at the airport witnessed the aircraft depart and, following the failure of the aircraft to return to Wentworth, notified the police on the afternoon of 29 May 2012. As a result of that notification, a search was initiated.

Following an extensive visual search involving multiple aircraft, the crew of a search helicopter sighted the aircraft wreckage on the evening of 30 May 2012 near the Murray River, about 10 km west of Wentworth Airport. Upon landing, the helicopter crew established that the pilot had received fatal injuries.

What the ATSB found

The ATSB found that shortly after departure from Wentworth Airport the aircraft collided steeply with terrain at high speed and that the accident was not survivable. There was no evidence of any in-flight failure of the airframe structure or flight control system and the engine appeared to have been producing significant power at impact.

Based on advice from the aircraft manufacturer following their consideration of on-site evidence, and in the absence of an identified problem with the aircraft, the ATSB concluded that continual pilot input was probably applied to the flight controls immediately before the impact with terrain. However, the possibility that the pilot may have applied that input as a result of incapacitation could not be discounted.

Safety message

Although there was no requirement for details of the flight to be provided to Air Traffic Services or other agencies, the lack of such information hampered the search and rescue (SAR) response to this accident. If information on the intended flight route had been available, a more focussed search effort would have been possible and probably have resulted in the rapid location of the aircraft. In addition, although the carriage of a portable emergency locator transmitter (ELT) complied with the relevant regulations, a crash-activated ELT installation, normally associated with a permanent aircraft installation, would have expedited the provision to SAR agencies of more timely advice of an accident. Although earlier location of the aircraft would not have reduced the severity of the outcome in this instance, the availability of accurate flight information generally provides for a more timely emergency response.