Loss of control

During cruise at 9,000 ft, the aircraft encountered severe turbulence, and the electrical system failed. The pilot unintentionally lost control of the aircraft when he leaned forward on the control column yoke and used both hands to search in the dark for a torch on the cockpit floor.

After recovering the hand-held torch, the pilot was able to light the instrument panel and return the aircraft to the required heading and altitude. When the battery master switch was turned off, the electrical system returned to full operation on alternators.

Maintenance personnel found that an internal electrical short in one of the 12-volt batteries had contributed to the electrical failure. After replacement of the faulty battery and completion of satisfactory electrical system checks, the aircraft was returned to service.

The pilot of the aircraft now secures his torch to his shirt with a strap to enable him to use both hands to keep control of the aircraft should a similar situation arise.

The aircraft operator now secures torches in all its aircraft with the addition of a quick release strap on the torch container.

On 20 June 2007, at approximately 0615 Western Standard Time, a Cessna Aircraft Company C208 Caravan float plane, registered VH‑NRT, departed Broome Airport, WA on a Visual Flight Rules (VFR) charter flight to Talbot Bay. On board the aircraft were the pilot and 10 passengers.

About 35 to 40 minutes into the flight, the weather conditions deteriorated, and the pilot elected to discontinue the flight and return to Broome. During the return flight, the aircraft entered an area of reduced in-flight visibility that resulted in the loss of the visual horizon.

Whilst manoeuvring the aircraft to regain visual meteorological conditions (VMC), the pilot became disoriented. The pilot made a general radio broadcast requesting assistance, which was intercepted by the crew of another aircraft who then provided advice and reassurance to the pilot. The pilot was able to regain control of the aircraft and, shortly after, resume the remainder of the flight.

The approach to Broome required the non-instrument-rated pilot to descend through cloud before becoming visual and landing.

This incident highlighted the risks of inadvertent flight into Instrument Meteorological Conditions (IMC) and of the recovery from those conditions, particularly in respect of a pilot that does not hold an instrument rating.

Aviation Safety Recommendations

[ R2007014SR029 ] [ R2007014SR030 ]

Preliminary report released 8 May 2007

On 23 February 2007, at approximately 1710 Eastern Daylight-saving Time, a Van's Aircraft Inc. RV-4 aircraft, registered VH-ZGH, took off from Essendon Airport, Victoria, with the owner-pilot and one passenger on board. The flight was to the designated Moorabbin aerobatic area over Clyde North.

At approximately 1740, witnesses reported observing the aircraft descending in a spin after completing an aerobatic manoeuvre. The aircraft engine was heard to gain power during the spin and the aircraft speed rapidly increased. The aircraft was then seen to enter into, what appeared to be, an unstable spiral dive.

At approximately 1,500 ft above the ground, witnesses reported that the engine noise was very high-pitched and loud, and objects were seen to separate from the aircraft. The rapid spiral descent continued and the aircraft was observed to impact the ground almost vertically. The aircraft was destroyed by impact forces and a post-impact fire. The pilot and passenger were fatally injured.

On 3 November 2008, a SAAB Aircraft Company 340B-229 (SAAB), registered VH-ORX, was conducting a regular public transport flight from Orange, NSW to Sydney. The crew reported that, at about 0724 Eastern Daylight-saving Time, when tracking to join a 7 NM (13 km) final for runway 34 Right (34R), a passenger sustained minor injuries following a possible wake turbulence event that resulted in a momentary loss of control of the aircraft.

Examination of the available radar, meteorological and aircraft operational data identified that the momentary upset probably resulted from wake turbulence, which was generated by an Airbus Industrie A380-800 (A380) that was conducting a parallel approach to runway 34 Left (34L). There was a 35 kt left crosswind affecting both aircraft's approaches.

Airservices Australia (Airservices) reported to the SAAB operator that, as a result of this incident, they had introduced a number of interim minor changes to Sydney parallel runway operational procedures during high crosswind conditions. Those minor changes would have effect while Airservices carried out a review of A380 operations. In addition, the Civil Aviation Safety Authority has opened a regulatory change project to review and update wake turbulence separation information in the Manual of Standards Part 172.

At 1026 Eastern Standard Time on 18 June 2008, a Robinson Helicopter Company R44 Clipper II helicopter, registered VH-RYW, departed Cairns Airport, Qld, to film a residential development site that was located in the vicinity of False Cape, about 10 km east of the airport. On board the helicopter were the pilot and three passengers.

The occupants of the helicopter reported that while conducting the second period of filming, there was a sudden and violent movement of the nose of the helicopter to the right, which continued into a rapid rotation of the helicopter. The pilot's reported attempt to reduce the rate of right yaw was unsuccessful, and he entered autorotation and attempted to reach a clear area. The helicopter subsequently collided with trees before impacting the ground, seriously injuring the pilot and front seat passenger.

This accident highlighted the risk of loss of tail rotor effectiveness associated with the conduct of aerial filming/photography and other similar flights involving high power, low forward airspeed and the action of adverse airflow on a helicopter.

The investigation also identified that the lack of the nomination of a search and rescue or scheduled reporting time for the flight, decreased the likelihood of a timely response in the case of an emergency.

In response to this accident, the helicopter manufacturer advised that it was considering a revision to the aerial survey and photography flights safety notice that was contained in the R44 Pilot's Operating Handbook. That revision would, if adopted, include a discussion of the risk of unanticipated right yaw associated with the conduct of those flights.

Interim factual report released 25 July 2008

On 9 April 2008, a Fairchild Industries Metro III aircraft departing Sydney, NSW was observed on radar to be turning contrary to air traffic control instructions. The pilot reported that he had a '...slight technical fault...'. Recorded radar data showed the aircraft then completed a turn to the left before turning back to the right and disappearing from radar at an altitude of 3,900 ft. Searchers later discovered a small amount of aircraft wreckage floating in the ocean, south of the last recorded radar position. The pilot was fatally injured, and the aircraft was destroyed.

On 29 November 2006, an Australian Army Black Hawk helicopter, A25-221, crashed during a training flight. The helicopter was attempting to land on HMAS Kanimbla located in international waters off Fiji. Onboard the helicopter were 10 army personnel - four aircrew and six soldiers. Of those onboard, eight survived and two were fatally injured.

The helicopter sank in deep water and the flight data recorder (FDR) was recovered in March 2007 after a salvage operation. The Australian Department of Defence was responsible for investigating this accident and appointed a Board of Inquiry. The Department of Defence requested ATSB assistance in the recovery of data from the FDR. The Executive Director of the ATSB approved the request. To protect the information supplied by the ATSB to Defence and investigation work undertaken to assist Defence, the ATSB initiated an investigation under the Transport Safety Investigation Act 2003.

The solid-state memory was successfully downloaded and a copy of the data file was provided to a representative from the Directorate of Defence Aviation and Air Force Safety.

Information publicly released by the Board of Inquiry is available on the Department of Defence website: http://www.defence.gov.au

During an approach into Cairns Airport, Qld in overcast conditions late on the morning of 2 December 2006, the pilot of a Piper Navajo aircraft, registered VH-BTD, lost control of the aircraft and entered an uncontrolled descent. Control of the aircraft was regained shortly before the pilot became visual below the cloud base, and the pilot continued to Cairns.

The loss of control was the result of the pilot's inexperience with respect to the effects of spatial disorientation and with flight in instrument meteorological conditions (IMC).

This occurrence reaffirms the potential for spatial disorientation, if not recognised and recovered from appropriately, to result in the loss of aircraft control.

On 2 November 2006, the pilot of a Bell Helicopter Company 206A helicopter, registered VH-AAL, departed Coffs Harbour, NSW, on a private flight to a property located at Palmers Island, near Yamba, NSW. On board the 206A were the pilot and one passenger in the front left seat.

On arrival in the vicinity of Palmers Island, the pilot commenced a downwind turn into a strong quartering tailwind and the helicopter began an uncommanded right yaw. The pilot attempted to regain control, but the helicopter continued to yaw and to descend until it impacted the ground. The pilot and passenger sustained serious injuries and the helicopter was destroyed.

There was no evidence found of any mechanical or systems failures that may have contributed to the accident. The reported local conditions and nature of the loss of control were consistent with a loss of tail rotor effectiveness (generally referred to as LTE).

While a serviceable emergency locator transmitter was fitted to the helicopter, it had not been 'armed' prior to the flight and did not activate as a result of the impact.

Preliminary report released 31 October 2006

On 31 October 2006 at 1955 Eastern Standard Time, PA31-350 aircraft, registered VH-ZGZ, was on descent to Gladstone Airport, Qld when its radar track disappeared from the air situation display in the Brisbane Air Traffic Control Centre. Subsequently, the aircraft was found to have impacted terrain approximately 9 km south-east of Raglan, Qld. The pilot and two passengers were fatally injured. The aircraft was destroyed by impact forces and post-impact fire.