Collision with terrain

ATSB response to the Coroner

The ATSB notes that NSW Deputy State Coroner, Sharon Freund has recently released a finding into a fatal accident involving aircraft registered VH-EKS.  The ATSB was not required to give evidence, however the report of the ATSB was utilized by the Coroner for the purpose of her findings.  The Coroner’s findings were substantially in accordance with the ATSB investigation.

Circumstances of the accident

At about 1452 Eastern Daylight-saving Time on 24 December 2008, a Cessna Aircraft Company 172L aircraft, registered VH-EKS, with a pilot and one passenger, departed Mudgee on a private visual flight rules (VFR) flight to a property near Glen Innes, New South Wales. About 15 minutes after departure, the pilot encountered increasing cloud and, after climbing to assess the weather ahead, decided to descend visually through the cloud in order to maintain visual meteorological conditions.

The pilot descended the aircraft into a valley that was enshrouded in cloud. After flying up the valley for a short time, the pilot decided to turn back. During the turn-back manoeuvre, the aircraft entered cloud. The pilot became disorientated and the aircraft collided with terrain.

The pilot and passenger were seriously injured and the aircraft was seriously damaged. Shortly after, the passenger succumbed to his injuries.

ATSB Findings

The ATSB made the following findings:

Contributing safety factors

• The pilot chose not to obtain the relevant aviation weather forecasts for the flight.
• The pilot chose not to turn back or divert, after climbing to 7,500ft and identifying deteriorating weather ahead.
• The weather conditions were such that there was an increased risk of the pilot being unable to continue the flight in visual meteorological conditions.
• The pilot flew into instrument meteorological conditions, in which he was not qualified to operate.
• The pilot became disoriented, reducing the likelihood of a successful turn back and precipitating the collision with terrain.

Other safety factors

• The pilot did not fully plan the flight in accordance with the flight planning requirements, specifically with respect to fuel planning.
• The current advice in Civil Aviation Advisory Publication 5.81-1(0) Flight Crew Licensing Flight Reviews in relation to the assessment of navigation skills, represents a missed opportunity to identify a pilot’s capacity to make safe and appropriate decisions during cross-country flying. [Minor safety issue]
• The flight planning requirements at page 88 of the Visual Flight Guide included a transcription error that inadvertently limited the application of the requirements of Civil Aviation Regulation 239. [Minor safety issue]

Other key findings

• The pilot's decisions not to submit any form of flight notification and not to replace the aircraft's emergency locator transmitter contributed to the delay and confusion in mounting an expeditious search and rescue.

Safety action

In respect of CAAP 5.81-1(0) and page 88 of the Visual Flight Guide, the Civil Aviation Safety Authority (CASA) took action to amend the CAAP and withdrew the Visual Flight Guide for amendment.

CASA’s response to the safety issues may be found at Safety Issues

ATSB investigations and coronial investigations

Coronial investigations are separate to ATSB investigations. In this matter the respective authorities are largely in accord as to the factors that contributed to the development of the accident involving VH-POJ.

The ATSB's report can be downloaded by clicking on the link: 

The Coroner's report can be obtained from the Coroner's Court of NSW Contact details are available at: www.coroners.justice.nsw.gov.au. Queries regarding the Coroner's findings should be directed to the Coroner's Court of NSW.

On 7 November 2008, a Piper Aircraft Corp. PA-31-350 Chieftain, registered VH-OPC, was being operated on a private flight under the instrument flight rules from Moorabbin Airport, Vic. to Port Macquarie via Bathurst, NSW. On board the aircraft were the owner-pilot and three passengers.

The flight from Moorabbin to Bathurst was conducted in accordance with the pilot's flight plan and a review of recorded air traffic control data and communications did not reveal any problems during that flight. After refuelling at Bathurst Airport, the pilot departed from runway 35 for Port Macquarie in dark-night conditions with light rain in the area. At about 2024, some 2½ minutes after reporting airborne, residents of Forest Grove to the north of Bathurst Airport, heard a sudden loud noise from an aircraft at low altitude. Shortly after, there was the sound of an explosion and the glow of a fire. The aircraft was found to have impacted terrain resulting in serious damage to the aircraft. The four occupants were fatally injured.

The aircraft had impacted the ground upright, slightly right wing low, at a descent angle greater than 20°. The wreckage trail, oriented on a ground track of 165° M, extended for about 300 m. Almost all of the major aircraft parts were seriously impact and fire damaged. The propellers indicated high rotational energy. The landing gear and wing flaps were retracted.

Due to fire and impact damage, and limited information about the sequence of events after take-off, the evidence available to the investigation was limited. There were no indicators of aircraft malfunction or pilot impairment prior to the accident. After extensive examination, the investigation found there was no evidence of any aircraft unserviceability, and that airworthiness was not likely to have been a contributing factor in the accident. The investigation was unable to establish why the aircraft collided with terrain; however, pilot spatial disorientation or pilot incapacitation could not be discounted.

On the morning of 16 October 2008, a Gippsland Aeronautics GA-8 Airvan, registered VH-WRT, was being operated on a freight charter flight from Elcho Island and return, Northern Territory. At about 1230, it was realised that the aircraft was missing. A witness reported seeing the aircraft during the early stages of the flight and, shortly afterwards, a column of dark black smoke rising from the eastern side of the Napier Peninsula. On 17 October 2008, items of wreckage from the aircraft were found in the south-western part of Buckingham Bay. The pilot, who was the sole occupant of the aircraft, and the main wreckage of the aircraft have not been found. After consideration of the available evidence, the investigation was unable to identify any factor that contributed to the accident.

Although the investigation did not identify any issues that had the potential to adversely affect the safety of future operations, the operator took proactive safety action in response to the accident. That action included changed procedures in the areas of cargo restraint and the carriage of dangerous goods, the supervision and oversight of flights, and to the operator's flight following requirements. In addition, the operator has acted to reduce pilot workload.

On 24 September 2008, at about 1606 Eastern Standard Time, a Liberty Aerospace Inc. XL2 aircraft, registered VH-CZX, descended through trees and collided with terrain 2 km south of Luddenham, New South Wales. The sole occupant, a student pilot, was fatally injured and the aircraft sustained serious damage.

Air traffic control radar data recordings indicated that the aircraft departed straight and level flight from about 3,000 ft above ground level and descended very steeply at a high rate of descent to below the radar's minimum detection height. Witness observations, aircraft damage and wreckage distribution were consistent with a steep, low-speed collision with terrain.

The investigation was unable to determine the reasons for the departure from straight and level flight or establish the aircraft's movements in the period of time between the loss of radar information and the witnesses' visual observations.

No evidence of any mechanical fault that could have contributed to the accident was found. The weather was benign. A post-mortem examination of the pilot did not identify any pre-existing medical conditions that may have contributed to the accident.

Traces of a cannabis metabolite were present in the pilot's blood, indicating previous use of, or exposure to cannabis. There was no evidence that the pilot was impaired by cannabis at the time of the accident; however, there is extensive evidence that the use of cannabis increases the risk of the impairment of pilot performance.

The investigation did not identify any organisational or systemic issues that might adversely affect the future safety of aviation operations. However, following the accident, the flying school proactively modified its training syllabus to include additional instructional flights on the aircraft type prior to authorising extended solo flights.

On 14 September 2008, a Robinson Helicopter Company R44 Raven helicopter, registered VH-RIO, was being operated on a series of scenic flights in the Bungle Bungle ranges area of the Purnululu National Park, which was about 250 km south of Kununurra, Western Australia. At about 1230 Western Standard Time, the helicopter departed the Purnululu Aircraft Landing Area for an 18- minute scenic flight with the pilot and three passengers. When the helicopter did not return by the nominated time, a search was initiated. Shortly after, the burnt wreckage of the helicopter was located. The four occupants were fatally injured.

The pilot had deviated from the regular scenic flight track, speed and profile to operate out of ground effect (OGE) in close proximity to the terrain at a low airspeed or at the hover. The helicopter's estimated OGE hover performance was marginal. It is likely that the high level of engine power required to sustain a hover in the local conditions was not available, or not fully utilised by the pilot, resulting in; an uncommanded descent, overpitching of the main rotor as a result of the pilot's attempts to arrest that descent, and a main rotor RPM decay that significantly increased the rate of descent.

As a result of the investigation into this occurrence, two minor safety issues were identified:

• There was no Australian requirement for endorsement and recurrent training conducted on Robinson Helicopter Company R22/R44 helicopters to specifically address the preconditions for, recognition of, or recovery from, low main rotor RPM.
• There was a lack of assurance that informal operator supervisory and experience-based policy, procedures and practices minimised the risk of pilots operating outside the individual pilot's level of competence.

In response, the aircraft operator has since formalised the operating parameters applicable to pilots conducting scenic flights. In addition, the Civil Aviation Safety Authority will be reviewing the training requirements affecting R22/44 helicopters. The Australian Transport Safety Bureau has issued a Safety Advisory Notice to encourage operators to address the risk of their pilots operating outside the individual pilot's level of competence.

Response to Bungle Bungle inquest findings

A Western Australian Coroner recently released findings into a 2008 fatal Robinson R44 Raven helicopter accident near Purnululu in the Bungle Bungle Ranges in Western Australia.  The findings highlight a number of safety concerns that require review by the aviation industry in relation the safety issues raised by the ATSB in its report released on 7 July 2010.

These issues cover:

• Recovery from Low Main Rotor RPM;
• Formalisation of Operator, Policies, Procedures and Practices

Circumstances of the accident

On 14 September 2008 a Robinson R44 Raven Helicopter, VH-RIO, crashed near Purnululu in the Bungle Bungle Ranges in Western Australia.  All four occupants were fatally injured.  The ATSB investigation advised that it was likely that due to the local conditions the helicopter was in a situation where the necessary engine power was either unavailable, or not fully utilised by the pilot, to sustain a hover.   The crash site indicated there had been significant main rotor RPM decay and a high rate of descent.

Safety Issues

The ATSB found the following safety issues as part of the investigation:

1. Recovery from Low Main Rotor RPM

There was no Australian requirement for endorsement and recurrent training conducted on Robinson Helicopter R22/R44 helicopters to specifically address preconditions for, recognition of, or recovery from, low main rotor RPM.

At the time of the release of the ATSB report, CASA had advised that it was reviewing the requirements for initial pilot training and endorsement and recurrent training on all helicopters, including a review of the Helicopter's Flight Instructor's Manual.

While noting that CASA was undertaking this review, the Coroner made a recommendation for CASA to address the safety issue raised by the ATSB.

In response to the safety issue CASA has advised the ATSB as follows:

"CASA is intending to produce an Instructor Pack for Awareness Training (AT) on the key hazards as specified in FAA SFAR 73.  This AT would be generic in nature, but would address specific discussion points on matters relevant to specific types, including but not limited to R22/R44."

2. Operator policy, procedures and practices

During the course of the investigation the ATSB also considered it necessary to draw the attention of all operators in the industry to the potential lack of assurance that informal operator supervisory and experienced-based policy, procedures and practices minimise the risk of their pilots operating outside the individual pilot's level of competence.

Operators were encouraged to take action where considered appropriate.

The ATSB continues to advocate that all operators in the industry should consider their procedures for appropriately tasking pilots.  Backing this, the Coroner noted the specific risks associated with low flight, including conducting aerial photography.

ATSB investigations and Coronial Inquiries

Inquests are separate to ATSB investigations.  In this matter the respective authorities largely agree on what the safety issues are that the industry needs to take account of.

The ATSB's report can be downloaded by clicking on the link: AO-2008-062.  Feedback can be provided via the website.

The Coroner's report can be obtained from the Coroner's Court of Western Australia.  Contact details are available at: http://www.coronerscourt.wa.gov.au.  Queries regarding the Coroner's findings should be directed to the Coroner's Court of Western Australia.

At about 0650 Eastern Standard Time on 15 May 2008, the pilot and sole occupant of a Cessna Aircraft Company C210L aircraft, registered VH-IDM, departed Karumba Airport, Qld, to conduct a low-level geophysical survey flight, under the visual flight rules. The aircraft was due back at Karumba at 1115. At approximately 1000, Australian Search and Rescue (AusSAR) detected an Emergency Locator Transmitter transmission and initiated a search. At approximately 1300, the wreckage of the Cessna 210 was located, and the pilot was found to be fatally injured.

Recorded data showed the pilot conducted a series of planned east-west survey lines at an altitude of 260 ft above ground level. As planned, the pilot initiated a left turn to track to the north. During the left turn, the aircraft lost altitude, and increased bank angle and speed. The on-site information indicated that the aircraft's initial impact was in a steep left-wing-down attitude, consistent with a loss of control.

The investigation found the loss of control was probably due to pilot loss of consciousness as a result of an irregularity of heart rhythm associated with either focal scarring or chronic inflammation of the heart muscle.