International

On 25 December 2012, a Bombardier DHC-8-202 aircraft, registered as P2-PXI, sustained an engine failure during approach to Pt. Moresby Airport, Papua New Guinea (PNG). The aircraft continued the approach and landed safely, with no injuries reported.

As the incident occurred in PNG, the PNG Accident Investigation Commission (AIC) was responsible for investigating this occurrence. To assist its investigation, the AIC requested assistance from the Australian Transport Safety Bureau (ATSB) in the download of data from the aircraft’s Flight Data Recorder (FDR) and Cockpit Voice Recorder (CVR).

To facilitate the work, and 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 PNG AIC and initiated an external aviation safety investigation under the Australian Transport Safety Investigation Act 2003.

Following receipt of the CVR and FDR units on 14 January 2013, both units were successfully downloaded in accordance with the relevant manufacturer’s instructions. The downloaded audio and flight data was examined and confirmed as containing detail from the occurrence flight, before being provided to AIC representatives on 16 January 2013, together with a selection of graphical and tabular presentations of the flight data.

Contact details for the PNG Accident Investigation Commission are available at: www.aic.gov.pg/contact.html

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

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.

At about 0444 on 26 September 2012, the 104.5 m LPG tanker MT Norgas Cathinka collided with the 96 m ferry Bahuga Jaya in Sundra Strait, Indonesia. The Bahuga Jaya sank as a result of the collision, with the reported loss of 8 lives.

The Indonesian National Transportation Safety Committee (NTSC) is responsible for investigating this occurrence. The NTSC requested assistance from the Australian Transport Safety Bureau (ATSB) in the replay, display and analysis of voyage data recorder (VDR) data from the MT Norgas Cathinka. To assist the NTSC and provide protection of the recorded data and analyses, the ATSB initiated an External Investigation under the provisions of the Transport Safety Investigation Act 2003.

For further information in relation to the investigation of this accident, please refer to the NTSC.

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: https://knkt.go.id/en

At approximately 1325 hours Eastern Standard Time on 26 September, 1970, a Piper PA23-250 Aztec aircraft, registered VH-SPM, collided with the precipitous face of a ravine, 490 feet below the main line of a ridge, on the eastern slopes of Mt. Scratchley in the Territory of Papua. The aircraft was engaged on a charter flight for the carriage of passengers and baggage from Kokoda to Port Moresby. The aircraft reported its departure from Kokoda but, when it did not arrive at Port Moresby, search and rescue procedures were initiated. The wreckage was sighted on 1 October, 1970 in dense rain forest, 10,100 feet above mean sea level. At first, the efforts of ground rescue parties to reach the wreckage were frustrated by extremely bad weather conditions, the high altitude and the precipitous terrain. Thirteen more days elapsed before a member of a mountain rescue party reached the accident site to find that the aircraft had been destroyed by impact forces and the pilot and the three passengers on board· had suffered fatal injuries.

On Saturday 9 June 2012 at around 0700 local time, an Impulse 180TDI amateur-built aircraft departed Tököl airfield, Hungary for a flight to Straubing, Germany. While en-route, the aircraft encountered adverse weather conditions, and following a Mayday radio call from the pilot, the aircraft impacted the ground, fatally injuring the pilot and passenger. 

The Bundesstelle für Flugunfalluntersuchung (BFU) of Germany is investigating this occurrence. In response to a request from BFU officers for technical assistance in the examination of a mobile phone and tablet device recovered from the accident aircraft, the Australian Transport Safety Bureau initiated an external aviation safety investigation in accordance with the provisions of the Transport Safety Investigation Act 2003.

The mobile phone and tablet device were subsequently received at the ATSB facilities in Canberra for analysis.  While the relevant logic circuitry of both devices was functional, security features enabled on both devices prevented a successful recovery of any navigational or location/tracking data that may have existed within the units. A report was issued to the BFU documenting the process and procedures undertaken and the devices were returned to the BFU.

For more information on this investigation, please contact the BFU: www.bfu-web.de/ 

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

What happened

On 13 September 2012, a Boeing 737 aircraft, registered VH-YIO (YIO), departed Bali International Airport (Denpasar), Indonesia on a scheduled passenger service to Brisbane, Queensland.

The aircraft became established in the cruise and the seat belt sign was turned off. Shortly after, the crew observed opposite direction traffic on the aircraft’s traffic alert and collision avoidance system (TCAS), about 1,000 ft above and slightly to the left. The crew observed the aircraft pass to the left. Airservices Australia surveillance data indicated the aircraft passed with about 0.9 NM lateral and 1,400 ft vertical separation.

Soon after, the First Officer reported that they felt ‘cobblestone’ like turbulence. The aircraft then experienced a wake induced roll, initially to the right to a maximum angle of 6.5° and then left to 40.4°, with a 40 ft loss in altitude. As the roll to the left commenced, the crew immediately responded by applying full right aileron deflection. 

Surveillance data indicated that there was about 2.1 NM lateral, and 1,400 ft vertical separation and the correct air traffic control separation standards were being applied at the time. Nil injuries were received.

This incident demonstrated the value of periodic recurrent training, allowing the crew to react to the wake turbulence encounter intuitively and promptly. Furthermore, it is a timely reminder of the benefits of having the seat belt fastened, even when the seat belt sign is turned off, so that injuries during a turbulence encounter can be minimised.

Aviation Short Investigation Bulletin – Issue 17

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.

Safety summary

What happened

On 16 July 2012 at about 0830 New Zealand Standard Time, an Airbus A320-232 aircraft, registered VH-VQA and operated by Jetstar Airways, was conducting an Area Navigation (Required Navigation Performance) approach to runway 05 at Queenstown, New Zealand. During the approach the aircraft descended below two segment minimum safe altitudes. Upon recognising the descent profile error, the crew climbed the aircraft to intercept the correct profile and continued the approach to land.

What the ATSB found

The ATSB found that, contrary to their intentions, the crew continued descent with the auto-flight system in open descent mode, which did not provide protection against infringing the instrument approach procedure’s segment minimum safe altitudes. The ATSB also found that the crew were not strictly adhering to the operator’s sterile flight deck procedures, which probably allowed the crew to become distracted.

The ATSB found that the operator’s procedures did not specifically draw the crew’s attention to unchanged auto-flight system modes during descent or prompt crew reconsideration of the most suitable descent mode at any point during descent. Additionally, the operator’s procedures allowed the crew to select the altitude to which they were cleared by air traffic control on the Flight Control Unit altitude selector, irrespective of intervening altitude constraints. This combination of procedures provided limited protection against descent through segment minimum safe altitudes.

What's been done as a result

Following this occurrence, the operator included additional guidance material in its Flight Crew Training Manual regarding mode awareness. It also included a warning on its Queenstown approach charts to state that managed descent was required beyond the initial approach fix.

Safety message

The ATSB reminds operators and flight crew of the importance of continuous attention to active and armed auto-flight system modes. Equally, the ATSB stresses the importance of continually monitoring descent profiles and an aircraft’s proximity to segment minimum safe altitudes, irrespective of any expectation that descent is being appropriately managed by the auto-flight system. For flight crew, this occurrence illustrates once again the fallibility of prospective memory and the potentially serious effects of pilot distraction. For operators, it highlights the importance to safe operations of robust management procedures for auto-flight systems.

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.

The Air Accident Investigation Bureau (AAIB) of Mongolia is investigating a runway excursion that occurred at Oyut Domestic Airport, Mongolia on 30 March 2012 and involved a Fokker 50 aircraft, operating as Aero Mongolia Airlines flight Ju 8257. The aircraft exited to the right of the runway and its nosewheel and propeller struck a frangible, stake-mounted runway edge light as the pilot manoeuvred the aircraft back onto the runway. The aircraft was substantially damaged and there were no injuries to passengers or crew.

The investigation is being carried out in accordance Mongolia's obligations as the State of Occurrence under Annex 13 to the Convention on International Civil Aviation. On 11 May 2012, the AAIB requested Australian Transport Safety Bureau (ATSB) assistance by providing investigator support to obtain relevant technical information and verify the correct lighting installation. In accordance with paragraph 5.23 of Annex 13, the ATSB appointed an Accredited Representative to assist the AAIB. To facilitate this support, the ATSB commenced an investigation under the Transport Safety Investigation Act 2003. The ATSB coordinated with the Australian aerodrome lighting manufacturer for technical information and diagrams, which were provided to the AAIB.

The AAIB of Mongolia is responsible for releasing the final investigation report on this occurrence. Any enquiries in respect of the AAIB investigation and report should, in the first instance, be directed to the:

Air Accident Investigation Bureau

Ministry of Road, Transportation, Construction and Urban Development of Mongolia
Chinggis Khaan International Airport
Ulaanbaatar 34 Mongolia

Telephone: +976 9595 3339
E-mail: aaib@aaib.gov.mn

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