Aviation Short Investigation Bulletin, Third Quarter 2011, Issue 7
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Issue 7 Issue 2011 Quarter Third Bulletin: Investigation Short Aviation ATSB TRANSPORT SAFETY REPORT Aviation Short Investigations AB-2011-128 Final Aviation Short Investigation Bulletin: Third Quarter 2011 Issue 7 ATSB TRANSPORT SAFETY REPORT Aviation Short Investigations AB-2011-128 Final Aviation Short Investigation Bulletin Third Quarter 2011 Issue 7 Released in accordance with section 25 of the Transport Safety Investigation Act 2003 Published by: Australian Transport Safety Bureau Postal address: PO Box 967. Civic Square ACT 2608 Office location: 62 Northbourne Ave, Canberra City, 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 2011. In the interests of enhancing the value of the information contained in this publication you may download, print, reproduce and distribute this material acknowledging the Australian Transport Safety Bureau as the source. However, copyright in the 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. Report No. Publication date ISBN AB-2011-040 December 2011 978-1-74251-232-7 - ii - CONTENTS Jet aircraft AO-2011-010: VH-VQN and VH-UOP, Breakdown of runway separation ........................................ 1 AO-2011-049: VH-VNG / VH-FMP, Airspace separation event ........................................................ 5 AO-2011-054: VH-VOB, VH-VGZ, Loss of separation assurance ...................................................... 9 AO-2011-064: VH-OGR, Turbulence event ...................................................................................... 13 AO-2011-073: VH-VWX, Performance calculation event ................................................................. 17 AO-2011-079: VH-FNU, Flight crew incapacitation .......................................................................... 21 AO-2011-089: VH-VQA, Incorrect aircraft configuration ................................................................. 23 Piston aircraft AO-2011-018: VH-NRF, Engine failure ............................................................................................. 27 AO-2011-037: VH-WZI, Partial right engine failure .......................................................................... 33 AO-2011-042: VH-SMY, Collision with terrain ................................................................................. 37 AO-2011-048: VH-FTB, Collision with terrain .................................................................................. 41 AO-2011-052: VH-CKX, Runway undershoot ................................................................................... 45 AO-2011-072: VH-FAL, Total loss of power ..................................................................................... 49 AO-2011-095: VH-WYG/N171UA, Breakdown of separation .......................................................... 53 AO-2011-096: VH-FRI, Icing Event ................................................................................................... 57 AO-2011-097: VH-BZE/ VH-PVL, Runway incursion ......................................................................... 61 AO-2010-098: VH-DSA, Total Power Loss ........................................................................................ 65 AO-2011-122: VH-SHZ, Fuel starvation event .................................................................................. 69 Helicopter AO-2011-059: VH-BNG, Wirestrike ................................................................................................. 73 AO-2011-063: VH-XXW, Loss of control .......................................................................................... 77 AO-2011-067: VH-BHU, Wirestrike ................................................................................................. 81 AO-2011-069: VH-XAA, Loss of control ........................................................................................... 85 AO-2011-080: VH-HSW, Wirestrike ................................................................................................. 89 AO-2011-124: VH-RTB, Collision with terrain.................................................................................. 93 - iii - - iv - 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 Short 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 investigation completed between the period 1 July 2011 and 30 September 2011. - v - - vi - AO-2011-010: VH-VQN and VH-UOP, Breakdown of runway separation Date and time: 31 January 2011, 0756 CST Location: Darwin Airport, Northern Territory Occurrence category: Serious incident Occurrence type: Breakdown of separation Aircraft registration: VH-VQN and VH-UOP Aircraft manufacturer and model: VH-VQN: Airbus A320-232 VH-UOP: Cessna Aircraft Company 404 Type of operation: VH-VQN: Air transport – high capacity VH-UOP: Air transport – low capacity Persons on board: VH-VQN: Crew – Unknown Passengers – Unknown VH-UOP: Crew – 1 Passengers – 8 Injuries: Crew –Nil Passengers – Nil Damage to aircraft: Nil At 0747 Central Standard Time3, the crew of VQN FACTUAL INFORMATION were approved a pushback clearance from the SMC. On 31 January 2011, an Airbus A320-232 aircraft, registered VH-VQN (VQN), was being prepared for a At 0750, the pilot of a Cessna Aircraft Company scheduled passenger service from Darwin, 404 aircraft, registered VH-UOP (UOP), conducting a Northern Territory to Sydney, New South Wales. scheduled passenger service from Darwin to Snake Bay, Northern Territory requested a taxi clearance During pre-flight preparations, the crew of VQN from the SMC. The pilot received a clearance to taxi were assigned runway 29 (Figure 1) by Defence air to holding point ‘Victor Two’ (V2) for runway 11. traffic control (ATC)1 for their departure.