Collision with terrain

Preliminary report released 27 April 2008

This preliminary report details factual information established in the investigation’s early evidence collection phase and has been prepared to provide timely information to the industry and public. Preliminary reports contain no analysis or findings, which will be detailed in the investigation’s final report. The information contained in this preliminary report is released in accordance with section 25 of the Transport Safety Investigation Act 2003.

On 17 November 2007, the owner-pilot of a Cessna Aircraft Company C337G (Skymaster), registered VH-CHU, was conducting a private flight in accordance with the visual flight rules from Moorabbin Airport, Vic. to Merimbula, NSW. The pilot, who was accompanied by three passengers, had indicated that he would be tracking along the coast. The aircraft did not arrive at Merimbula and on 19 November 2007 aircraft wreckage and three of the deceased occupants were found on a beach between Venus Bay and Cape Liptrap, Vic. Some wreckage was later found in the sea, off the beach. There were no survivors.

On the evening of 13 October 2007, an Embraer-Empresa Brasilia EMB-120 ER, registered VH-EEB, was taxiing at Sydney Kingsford Smith Airport, NSW, to take off on a freight charter flight to Melbourne, Vic. The aircraft was lined up with the left edge of the runway. Shortly after the take-off roll commenced, the crew reported feeling two or three bumps on the runway, after which time the crew's attention was drawn to an electrical burning smell in the cockpit, followed by a high-speed warning. The smell dispersed and the flight continued as normal to Melbourne.

Pre-flight checks for the return flight to Sydney revealed damage to the aircraft, which was subsequently found to have been caused by impact with the runway edge lighting on the left side of Sydney runway 16R, where the aircraft had started its take-off run. The aircraft was grounded at Melbourne for repair.

On 26 May 2007 at about 1644 Western Standard Time, a Piper Aircraft Corp PA-28RT-201 aircraft, registered VH-FTT, departed Jandakot Airport for Esperance, WA. On board the private, visual flight rules (VFR) flight were the non-instrument-rated owner-pilot, and two passenger friends.

The flight arrived at Esperance about 1 hour and 40 minutes after last light, and in marginal weather conditions. The aircraft impacted the ground on what appeared to be a right base for runway 11. There were no survivors.

There was no evidence of any technical defect or other failure of the aeroplane, or of its associated systems, prior to the impact with terrain. That, and the normal operation of the approach and landing aids, and apparent activation of the aerodrome lighting, suggested that the most likely factors that contributed to the development of the occurrence related to the operation of the aircraft.

The investigation was unable to conclusively establish the reason for the impact with terrain. The investigation could not exclude the possibility of a sudden incapacitation of the pilot due to a cardiac condition. However, the weather conditions enroute to, and in the vicinity of Esperance were such that the pilot's decision to attempt the flight indicated a low appreciation, or an acceptance, of the associated risks. The attempted approach and landing under those conditions represented a significant level of risk for any flight attempted under the night VFR.

On the afternoon of 1 February 2007, a Piper PA-28R Cherokee Arrow, with the pilot, a flight instructor and a passenger was approaching to land on Runway 22 at Leongatha aerodrome, Vic. At the same time the pilot of a Cessna 188B Agwagon was taking off on Runway 18 at Leongatha.

Both aircraft were operating under the visual flight rules (VFR). When the Arrow was on base leg, the pilot of the Agwagon broadcast on the Leongatha common traffic advisory frequency (CTAF) that he intended to conduct aerial spraying operations on a property 2 NM to the north of the aerodrome and that he would depart from Runway 18. The instructor and the pilot of the Arrow heard that transmission but did not visually check the position of the Agwagon on the ground. After turning onto final, the pilot of the Arrow broadcast his intention to make a full stop landing on Runway 22, but that transmission was not heard by the pilot of the Agwagon. The pilot of the Agwagon reported that he visually checked the approach to Runway 22 before commencing his takeoff, but did not see the Arrow.

When the Arrow was on the landing roll on Runway 22 and the Agwagon had just become airborne on Runway 18, the two aircraft collided at the intersection of the runways. Both aircraft were substantially damaged but none of the occupants were injured.

The investigation found that the lookout by the pilots of both aircraft was not adequate to ensure that there was no conflicting traffic for their respective operations. Neither aircraft displayed landing lights that may have improved the chance of the pilots seeing each other. Sun glare may have increased the difficulty for the pilots of the Arrow seeing the Agwagon.

On 2 April 2009, a flight instructor and student pilot in a Robinson Helicopter Company R22, registered VH-YDA, were conducting normal circuit and autorotation training at Proserpine/Whitsunday Coast Airport, Qld. At 1400 Eastern Standard Time, the helicopter collided with terrain on the grass at the side of the departure end of runway 11. The helicopter was seriously damaged, and the instructor was seriously injured.

After the accident, neither pilot could recall any of the flight sequence immediately before the impact. There were no witnesses to the accident and no relevant recorded data. An examination of the helicopter wreckage indicated that there were no pre-impact defects. Due to a lack of information, the investigation was unable to determine why the helicopter collided with terrain.

The investigation found that the use of safety helmets would reduce the risk of pilot injury during door(s)-off operations.

The investigation also found that the helicopter was about 11 kg overweight on take-off for the flight.

The ATSB has completed its technical analysis report of the flight recorder data from a British Aerospace BAe146-300 aircraft, registered PK-BRD, on behalf of the Indonesian National Transportation Safety Committee (NTSC). The aircraft was operating a cargo transport flight from Jayapura to Wamena, West Papua, Indonesia when it collided with terrain following a rejected landing approach (go-around) at Wamena on 9 April 2009. All six people on board were fatally injured.

The National Transportation Safety Committee (NTSC) of Indonesia is responsible for investigating this occurrence. The NTSC requested assistance from the Australian Transport Safety Bureau (ATSB) in the recovery and analysis of information from the aircraft's flight data recorder and cockpit voice recorder. 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.

To protect the information supplied by the NTSC to the ATSB and investigative work undertaken to assist the NTSC, the ATSB initiated an investigation under the Transport Safety Investigation Act 2003.

The ATSB provided information to the NTSC during the course of the investigation and the ATSB's Technical Analysis Report has now been provided to the NTSC.

The NTSC is responsible for releasing a final investigation report on this occurrence.

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.

On 24 February 2009, at 1417 Eastern Standard Time, a Piper Aircraft PA28-180 Cherokee aircraft, registered VH-DAC, departed Normanton Airport, Qld on a visual flight rules private flight to Mount Isa with the pilot as the sole occupant. The aircraft did not arrive at Mount Isa as expected and was later found to have impacted terrain at a location adjacent to the planned track. The aircraft was seriously damaged, and the pilot was fatally injured. Examination of the wreckage did not indicate any pre-existing technical fault that may have contributed to the accident. The pilot was not qualified to fly in instrument meteorological conditions (IMC). He may have inadvertently entered IMC while attempting to avoid rain and cloud associated with a weather system that was moving over the intended route at the time.

On 11 February 2009 at about 1922 Eastern Standard Time, a Bombardier Inc DHC‑8‑315 commenced the take-off roll on runway 01 at Townsville Aerodrome for Cairns, Queensland. During the take-off, the pilot in command realised that the aircraft was aligned with the left runway edge. The aircraft was manoeuvred to the centre of the runway and the take-off rejected. It was later determined that the aircraft's left mainwheel had damaged a runway edge light. There were no injuries to the 34 passengers or five crew members and no damage to the aircraft.

The investigation found a number of factors that may have led to the pilot in command not aligning the aircraft on the runway centreline for the take-off. Those factors included misinterpreting the normal runway cues, time pressure to depart, the weather conditions at Townsville Aerodrome and the associated delays during the aircraft's arrival, landing and departure.

Following this occurrence, the operator amended their operational procedures to ensure aircraft were aligned on the centreline of the assigned runway. In addition, the Australian Transport Safety Bureau (ATSB) has released an Aviation Research and Analysis Report (AR-2009-033) that examined a number of domestic and international occurrences in which pilots commenced the take-off while aligned with the runway edge lighting. In that examination, eight common factors were identified that increased the risk of a misaligned takeoff or landing occurrence, including: the distraction or divided attention of the flight crew; a confusing runway layout; the presence of a displaced threshold or the conduct of an intersection departure; poor visibility or weather; air traffic control clearance(s) issued during runway entry; no runway centreline lighting; flight crew fatigue; and recessed runway edge lighting.

The ATSB has developed a Pilot Information Card that will alert pilots of the increased risk of a misaligned takeoff as a result of those factors, which will be distributed to relevant parts of the industry and will be available from the ATSB on request.

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.

The pilot's decision not to obtain the relevant Bureau of Meteorology forecasts prevented a full understanding of the weather likely to affect the flight and what impact this might have on his flight planning, including alternate routes and fuel requirements. Similarly, the pilot's decision not to submit any form of formal flight notification, and to not replace the normally carried portable Emergency Locator Transmitter, adversely affected the prompt commencement of a search and rescue following the accident.

While not contributory to the accident, the investigation identified an error in the flight planning requirements in the Visual Flight Guide (VFG) for VFR flights away from a departure aerodrome. The Civil Aviation Safety Authority (CASA) has advised that the VFG has been withdrawn for amendment.

The investigation also identified that the optional nature of the navigational component of the Aeroplane Flight Review (AFR) meant that a pilot's navigation skills could remain un-assessed for an extended period. While this did not contribute to the accident, CASA has advised that the optional nature of the navigational component will be amended to being a recommended element of the AFR, and that guidance will be provided on its conduct.

Preliminary report released 19 January 2009

At about 2026 Eastern Daylight-saving Time on 7 November 2008, a Piper Aircraft Corp PA-31-350 Chieftain, registered VH-OPC, collided with terrain. The aircraft was seriously damaged, and the four occupants were fatally injured.