Collision with terrain

On the evening of 27 July 2011, the owner-pilot of a Robinson Helicopter Co. R22 helicopter, registered VH-YOL, was conducting a local flight from Big Rock Dam to Brooking Springs homestead near Fitzroy Crossing, Western Australia. The pilot was reported missing, and the wreckage of the helicopter was located the following day, 14 km north-west of Fitzroy Crossing township. The helicopter was seriously damaged, and the pilot sustained fatal injuries.

The pilot was attempting to fly visually at low level on a dark night in an area that did not contain any local ground lighting. About halfway into the flight, the pilot inadvertently allowed the helicopter to develop a high rate of descent, resulting in a collision with terrain.

The investigation found that the pilot was operating at night without the appropriate training or qualification in a helicopter that was not suitably equipped. An examination of the helicopter found no evidence of any pre-existent defects or anomalies.

No organisational or systemic issues were identified that might adversely affect the future safety of aviation operations. However, the accident highlighted the significant risk to non‑night-qualified pilots of spatial disorientation and subsequent collision with terrain when attempting visual operations at night.

On 24 June 2011, a Super Petrel amphibious aircraft, registered 24-7654, was being operated on a private flight with the pilot and one passenger on-board. While operating over Lake Jindabyne, New South Wales (NSW), witnesses observed the aircraft to depart from controlled flight and impact the lake surface. The aircraft was destroyed by the forces of the collision and the two occupants were fatally injured.

The NSW Police Service are investigating this occurrence. Following recovery of the aircraft wreckage, officers requested assistance from the Australian Transport Safety Bureau (ATSB) in the recovery of data from the aircraft's electronic flight instrumentation systems (EFIS). To protect the information supplied by the NSW Police Service to the ATSB and investigative work undertaken to assist the police service, the ATSB initiated an investigation under the Transport Safety Investigation Act 2003.

The EFIS was sent to the ATSB's technical facilities in Canberra for examination. The examination established the existence of relevant data on the EFIS and a download procedure was developed and tested successfully.

On 24 November 2011, a technical specialist from the ATSB attended the Cooma Police Station and provided assistance and guidance to the police in their download of the EFIS equipment. The data was successfully recovered and was retained by the police service.

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

On 14 January 2010, a Royal New Zealand Air Force (RNZAF) Red Checkers aerobatics team CT-4 Airtrainer aircraft collided with terrain while practicing for an upcoming aerobatics display. The pilot was fatally injured in the accident and the aircraft was destroyed by a post-impact fire.

An Appareo Systems GAU1000 data recorder was fitted to the aircraft to gather performance data as part of a fatigue monitoring programme. Although the recorder was severely fire damaged, it was recovered from the aircraft wreckage by RNZAF investigators, who subsequently requested assistance from the Australian Transport Safety Bureau (ATSB) in the recovery of any stored data on the recorder that may have survived the accident and fire.

Following preparatory research into the nature of the recorder's design and operation and the subsequent non-destructive examination to evaluate the physical condition of the damaged unit, a number of attempts were made to recover data from the removable secure digital/multimedia memory card (SD/MMC) - all of which were unsuccessful. Further examination of the recorder, however, located an on-board NAND flash memory device, which subsequently yielded a large quantity of valid recorded data after its removal from the primary circuitry and interrogation in a universal reader/programmer unit. The data was provided to the RNZAF on 12 August 2010.

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

At 0720 Western Standard Time on 15 June 2011, a Piper Aircraft PA-46-310P Malibu, registered VH-FAL, departed from Doolgunna Station, on a private flight to Meekatharra WA, with the pilot and one passenger on board.

While on finals to land at Meekatharra, the pilot initiated a go-around due to another aircraft occupying the runway.

On the downwind leg of the second approach, the engine lost power and the aircraft impacted terrain about 500 m short of the runway threshold. Both occupants sustained injuries.

The pilot stated that his usual actions were to set the aircraft fuel selector to the fullest fuel tank for take-off, then manage the fuel balance by appropriate tank selection during the flight. He stated that as this process was routine for him, he could not actually recall having made a change to the tank selection during the flight

To ensure the safe conduct of a flight, it is crucial that pilots establish a disciplined cockpit routine that covers all critical aspects of in-flight management.

On 14 April 2011, a Christen Eagle aircraft collided with terrain about 60 km north-east of Bangkok, Thailand. Both persons on board, one of whom was Australian and held a Recreational Aviation Australia pilot certificate, were fatally injured.

As the accident took place in Thailand, the Aircraft Accident Investigation Committee (AAIC) of Thailand is responsible for its investigation. As part of its investigation, the AAIC requested assistance from the Australian Transport Safety Bureau (ATSB) to gather details of the Australian pilot's qualifications and experience. In accordance with clause 5.23 of Annex 13 to the Convention on International Civil Aviation (Annex 13), the ATSB appointed an accredited representative to assist the AAIC and initiated an investigation under the Australian Transport Safety Investigation Act 2003. The ATSB provided details of the pilot's qualifications and experience to the AAIC.

In accordance with Annex 13, the AAIC of Thailand is responsible for releasing the final investigation report on this occurrence.

Contact details for the AAIC are:

Acting Chief, Aircraft Accident Investigation Group
(Member & Secretary, the Aircraft Accident Investigation Committee of Thailand)
Flight Standards Bureau
Department of Civil Aviation
71, Soi Ngarmduplee, Rama IV Road
Sathorn, Bangkok, 10120, Thailand
Tel: +66 2286 2933, Fax: +66 2286 2925

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

On 11 May 2011, the Indonesian National Transport Safety Committee (NTSC) requested technical assistance from the Australian Transport Safety Bureau (ATSB), in the recovery of information from the flight data recorder (FDR) and cockpit voice recorder (CVR) of a XAC MA60 aircraft that impacted the sea on approach to Kaimana Airport, Papua Barat, Indonesia on 7 May 2011. The 21 passengers and 4 crew on-board the aircraft were fatally injured in the accident.

The NTSC is responsible for investigating this occurrence. In accordance with clause 5.23 of Annex 13 to the Convention on International Civil Aviation, the ATSB appointed an accredited representative to assist the NTSC and initiated an investigation under the Australian Transport Safety Investigation Act 2003.

Download and analysis of the FDR and CVR was successful and both were found to contain good quality data including the entire accident flight. Support and information was provided to the NTSC during the course of the investigation and the ATSB's Technical Analysis Report was provided to the NTSC.

A final investigation report regarding this occurrence will be released by the NTSC.

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.

At about 1410 EST, on 30 April 2011, the crew of an Aerospatiale AS350FX2 helicopter registered VH-RTV (RTV) was replenishing gas well-head inhibitor tanks using sling load operations from Ballera Airport, Queensland. During one such operation to a well-head that was surrounded by water, the tail rotor blades struck two pipes that extended above the other pipework. 

At the time, the pilot was descending the helicopter prior to releasing the sling. Both he and the crewman were focusing on maintaining clearance from other parts of the well-head and neither saw the two pipes that the tail rotor struck.

Immediately following the occurrence, the operator introduced procedures which specifically addressed inhibitor tank replenishment to supplement the external and sling load procedures which were already in place.

On 18 April 2011 at about 1320 Eastern Standard Time, the pilot of Eagle Aircraft DW-1 bi-plane aircraft, registered VH-FTB (FTB), departed the Ingham authorised landing area (ALA) to conduct aerial agricultural work about 28 km to the south.

During the second application run, FTB impacted a tree with the right lower wing leading edge. The tree was void of foliage and stood to the foreground of other leaved trees, making it difficult to see from ground level.

The pilot was able to control FTB and fly the aircraft to an adjacent field where it landed in an upright position. On contact with the ground, FTB cart- wheeled before coming to rest. The pilot sustained serious injuries to the head, back and right leg. The aircraft was seriously damaged.

The accident highlights the inherent risks associated with operating at low-level, the need for quick decision making and the importance of adequate safety equipment.

On 25 March 2011, a Cessna 172 aircraft, registered VH-SMY, departed Geraldton on a charter passenger flight to East Wallabi Island (in the Abrolhos Islands group), Western Australia.

While on final approach to the Island, the nose of the aircraft was positioned at a 45° angle to the runway to remain aligned with the centreline due to gusty winds. The wind conditions appeared to be from an east to south-easterly direction. When at about 500 ft the pilot elected to overfly the runway.

A second approach was commenced, but the wind was again too strong for a landing with a go-around conducted. Despite full power being applied the engine did not perform as expected during the climb for another circuit.

During downwind, the pilot noted that the windsock was moving considerably. On final, the aircraft was again at a 45° angle and experiencing wind buffet.

During the landing flare, the aircraft floated, before touching down about halfway along the runway. Determining the aircraft could not be stopped by the runway end, the pilot elected to go-around. He moved the throttle full forward, but the engine did not deliver full power. The aircraft momentarily became airborne before contacting a sand dune and coming to rest upright in the water.

The pilot reported that, due to the recent commencement of his employment with the operator, he wanted to complete the flight.

This accident highlights the need for pilots to be aware that self-imposed undue pressure, can come about for a variety of reasons (time or task-oriented). It is important to understand one's personal limitations, especially when flying in or around adverse weather conditions.

What happened

At 0445 Eastern Standard Time on 24 February 2011, the pilot of an Aero Commander 500S, registered VH-WZU, commenced a freight charter flight from Cairns to Horn Island, Queensland under the instrument flight rules. The aircraft arrived in the Horn Island area at about 0720 and the pilot advised air traffic control that he intended holding east of the island due to low cloud and rain. At about 0750 he advised pilots in the area that he was north of Horn Island and was intending to commence a visual approach. When the aircraft did not arrive, a search was commenced but the pilot and aircraft were not found. On about 10 October 2011, the wreckage was located on the seabed about 26 km north-north-west of Horn Island.

What the ATSB found

The ATSB found that the aircraft had not broken up in flight and that it impacted the water at a relatively low speed and a near wings-level attitude, consistent with it being under control at impact. It is likely that the pilot encountered rain and reduced visibility when manoeuvring to commence a visual approach. However, there was insufficient evidence available to determine why the aircraft impacted the water.

Several aspects of the flight increased risk. The pilot had less than 4 hours sleep during the night before the flight and the operator did not have any procedures or guidance in place to minimise the fatigue risk associated with early starts. In addition, the pilot, who was also the operator’s chief pilot, had either not met the recency requirements or did not have an endorsement to conduct the types of instrument approaches available at Horn Island and several other locations frequently used by the operator.

What has been done as a result

Following the accident, the operator ceased operations and did not have the opportunity to enhance its processes.

Separately, and although not undertaken as a result of the accident, in May 2012 the Civil Aviation Safety Authority (CASA) issued a notice of proposed rulemaking relating to flight crew fatigue management. In the case of single pilot public transport operations, this included a proposal to restrict the duration of a flight duty period and the number of late-night duty periods in certain circumstances. In addition, in July 2012 CASA issued draft requirements for the installation of additional equipment in small aircraft involved in passenger transport operations, such as a terrain awareness and warning system and weather radar equipment.

Safety message

Although no firm conclusions could be drawn regarding why the aircraft impacted the water, the ATSB highlights the need for pilots to ensure they have had sufficient sleep prior to conducting a flight, and that operators have processes in place to manage the potential fatigue risks, including those associated with early starts.