AB-2012-065 Aviation Short Investigation Bulletin Issue 10
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InsertAviation document Short Investigation title Bulletin LocationIssue | Date10 ATSB Transport Safety Report Investigation [InsertAviation Mode] Short Occurrence Investigations Investigation XX-YYYY-####AB-2012-065 Final ATSB TRANSPORT SAFETY REPORT Aviation Level 5 Investigations AB-2012-065 Final Aviation Short Investigation Bulletin Issue 10 Released in accordance with section 25 of the Transport Safety Investigation Act 2003 Report No. AB-2012-065 Publication date 25 June 2012 ISBN 978-1-74251-270-9 Released in accordance with section 25 of the Transport Safety Investigation Act 2003 Publishing information Published by: Australian Transport Safety Bureau Postal address: PO Box 967, Civic Square ACT 2608 Office: 62 Northbourne Avenue Canberra, Australian Capital Territory 2601 Telephone: 1800 020 616, from overseas +61 2 6257 4150 Accident and incident notification: 1800 011 034 (24 hours) Facsimile: 02 6247 3117, from overseas +61 2 6247 3117 Email: [email protected] Internet: www.atsb.gov.au © Commonwealth of Australia 2012 Ownership of intellectual property rights in this publication Unless otherwise noted, copyright (and any other intellectual property rights, if any) in this publication is owned by the Commonwealth of Australia (referred to below as the Commonwealth). Creative Commons licence With the exception of the Coat of Arms, ATSB logo, and all photos and graphics, this publication is licensed under a Creative Commons Attribution 3.0 Australia licence. Creative Commons Attribution 3.0 Australia Licence is a standard form license agreement that allows you to copy, distribute, transmit and adapt this publication provided that you attribute the work. A summary of the licence terms is available from http://creativecommons.org/licenses/by/3.0/au/deed.en. The full licence terms are available fromhttp://creativecommons.org/licenses/by/3.0/au/legalcode. The ATSB’s preference is that you attribute this publication (and any material sourced from it) using the following wording: Source: Australian Transport Safety Bureau Copyright in material obtained from other agencies, private individuals or organisations, belongs to those agencies, individuals or organisations. Where you want to use their material you will need to contact them directly. - ii - CONTENTS Jet aircraft AO-2012-008: VH-VUJ / VH-VZS, Loss of separation assurance .................................................... 2 Turboprop aircraft AO-2011-162: VH-VSV / VH-TQG, Breakdown of separation ........................................................ 8 AO-2012-018: VH-ZZI and VH-MWO, Breakdown of Separation................................................... 11 AO-2012-043: VH-ZLH / VH-PGX, Runway incursion .................................................................... 15 Piston aircraft AO-2012-002: VH-MMG, Runway Undershoot ............................................................................ 20 AO-2012-003: VH-ZAP, Collision with terrain ............................................................................... 23 AO-2012-014: VH-HYC and VH-TAK, Aircraft proximity event ...................................................... 25 Helicopters AO-2012-016: VH-FUJ, Partial Power Loss ................................................................................... 30 - iii - INTRODUCTION About the ATSB The Australian Transport Safety Bureau (ATSB) is an independent Commonwealth Government statutory agency. The Bureau is governed by a Commission and is entirely separate from transport regulators, policy makers and service providers. The ATSB's function is to improve safety and public confidence in the aviation, marine and rail modes of transport through excellence in: independent investigation of transport accidents and other safety occurrences; safety data recording, analysis and research; and fostering safety awareness, knowledge and action. The ATSB is responsible for investigating accidents and other transport safety matters involving civil aviation, marine and rail operations in Australia that fall within Commonwealth jurisdiction, as well as participating in overseas investigations involving Australian registered aircraft and ships. A primary concern is the safety of commercial transport, with particular regard to fare-paying passenger operations. The ATSB performs its functions in accordance with the provisions of the Transport Safety Investigation Act 2003 and Regulations and, where applicable, relevant international agreements. The object of a safety investigation is to identify and reduce safety-related risk. ATSB investigations determine and communicate the safety factors related to the transport safety matter being investigated. It is not a function of the ATSB to apportion blame or determine liability. At the same time, an investigation report must include factual material of sufficient weight to support the analysis and findings. At all times the ATSB endeavours to balance the use of material that could imply adverse comment with the need to properly explain what happened, and why, in a fair and unbiased manner. About this Bulletin The ATSB receives around 15,000 notifications of aviation occurrences each year; 8,000 of which are accidents, serious incidents and incidents. It is from the information provided in these notifications that the ATSB makes a decision on whether or not to investigate. While further information is sought in some cases to assist in making those decisions, resource constraints dictate that a significant amount of professional judgement needs to be exercised. There are times when more detailed information about the circumstances of the occurrence would have allowed the ATSB to make a more informed decision both about whether to investigate at all and, if so, what necessary resources were required (investigation level). In addition, further publicly available information on accidents and serious incidents would increase safety awareness in the industry and enable improved research activities and analysis of safety trends, leading to more targeted safety education. To enable this, the Chief Commissioner has established a small team to manage and process these factual investigations, the Level 5 Investigation Team. The primary objective of the team is to undertake limited-scope, fact-gathering investigations, which result in a short summary report. The summary report is a compilation of the information the ATSB has gathered, sourced from individuals or organisations involved in the occurrences, on the circumstances surrounding the occurrence and what safety action may have been taken or identified as a result of the occurrence. In addition, the ATSB may include an ATSB Comment that is a safety message directed to the broader aviation community. The summary reports detailed herein were compiled from information provided to the ATSB by individuals or organisations involved in an accident or serious incident. - iv - JET AIRCRAFT - 1 - AO-2012-008: VH-VUJ / VH-VZS, Loss of separation assurance Date and time: 8 January 2012, 2140 ESuT Location: 47 NM (87 km) S of Tamworth Airport, New South Wales Occurrence category: Incident Occurrence type: Loss of separation assurance Aircraft registration: VH-VUJ and VH-VZS Aircraft manufacturer and model: VH-VUJ: Boeing Company 737-8FE VH-VZS: Boeing Company 737-838 Type of operation: Air transport –high capacity Persons on board: VH-VUJ: Crew –6 Passengers –169 VH-VZS: Crew - 6 Passengers - 117 Injuries: Crew – Nil Passengers – Nil Damage to aircraft: Nil operating at conforming levels prescribed in the FACTUAL INFORMATION Tables of Cruising Levels3 in the Australian Aeronautical Information Publication (AIP). VZS was On 8 January 2012, at 2140:54 Eastern Daylight- one of those aircraft. saving time1, a loss of separation assurance (LOSA)2 occurred between a Boeing Company B737- In accordance with AIP, air traffic control (ATC) could 8FE, registered VH-VUJ (VUJ) and a Boeing Company only assign cruising levels not conforming to the B737-838, registered VH-VZS (VZS), near Tamworth tables when traffic or other operational Airport, New South Wales (NSW). There was no circumstances required. Pilots were also only able to infringement of separation standards. request non-conforming levels when the pilot in command determined it to be essential to the safety Both aircraft were conducting scheduled passenger of the flight, and its occupants. Adverse weather services, with VUJ operating from Sydney, NSW to and the deviations necessary to avoid it could be Brisbane, Queensland and VZS operating from considered to meet those requirements. Brisbane to Sydney. At 2124:24, the controller instructed the northern At 2110:17, the occurrence controller (controller) sector controller to take VZS out of the holding assumed responsibility for 2 control sectors. At that pattern at FL 330 and continue tracking the aircraft time, radar surveillance data indicated that VZS was on its flight planned route for Sydney. At that time, in a holding pattern at flight level (FL) 330 in VUJ was about 37 NM (68.5 km) to the north-west of another controller’s sector to the north. Holding was Sydney, passing 18,400 ft on climb. due to traffic management requirements resulting from adverse weather enroute to, and in the vicinity At 2129:35, the controller received coordination of Sydney. from a southern sector controller on VUJ. That aircraft wasthen about 58 NM (107.4 km) north- Due to extensive weather diversions during that west of Sydney, on a heading of 350º to divert afternoon and evening, many aircraft