No blame Every ATSB investigation report includes the text: It is not a function of the ATSB to apportion Helicopter pilots blame or determine liability. At the same time, an investigation report must include warned of risk factual material or sufficient weight to Robinson R22 helicopter pilots are being urged to support the analysis and findings. regularly check and maintain their aircraft’s drive Simply put, we’re not in the business of system following a fatal accident in North-West blaming people for accidents or incidents— . but we are in the business of explaining what While mustering near Julia Creek on 9 May 2011, happened so we can minimise the chance of a Robinson R22 helicopter was flying close to the it happening again. This ‘no blame’ approach ground when it lost drive to the rotor system. This has major benefits for improving transport safety. It ensures that people are willing to resulted in a high rate of descent before the helicopter give us sensitive information without fear hit the ground. The pilot, the only occupant of the that it will be used against them. This helps helicopter, died in the accident. us understand dimensions of an accident or The ATSB found that two v-belts that transfer torque incident that might otherwise be unknown from the engine to the rotor system had failed. The to us. We use this information to identify damage to the forward v-belt indicated that it had safety issues, to promote safety action and to partially dislodged from the drive sheave, resulting educate. in significant damage to the belt. At some point, the It is sometimes the case, however, that the v-belt fragmented, compromising the redundancy of facts of an accident speak for themselves. the belt-drive system. Once the rear v-belt failed, all And we put those facts on the table so drive to the rotors was lost. everyone understands what happened and As a result of the drive failure the pilot needed to why we have arrived at our conclusions. make an autorotative landing from a low altitude and at As a result, I’ve seen more headlines than minimal speed. Autorotation is a descent with power I’d like that start with the words ‘ATSB off—the helicopter’s rotor system continues to rotate blames.’ We don’t. Our investigators take at about normal RPM as a result of the air flowing our no-blame mandate very seriously. It is a upwards through the main rotor system. There was foundation of their work and of ATSB culture. limited time for the pilot to recognise the condition Besides being a legislated requirement, the and respond accordingly, and for the autorotation no-blame philosophy extends to the way we to develop. This resulted in a high rate of descent at directly cooperate with anyone involved in an impact. occurrence. This accident highlights the need for R22 helicopter Our goal is to understand whether the system operators to pay careful attention to the installation, of safety itself needs to be changed to maintenance and inspection of drive belts and other improve safety. components of the helicopter’s drive system. The accident also highlights the importance of pilot proficiency in autorotations during emergency situations. When performing autorotations, there are a number of factors that must be considered in planning 24 Hours Martin Dolan and execution to achieve a successful outcome. The 1800 020 616 Chief Commissioner ATSB Research and Analysis Report into Helicopter Web www.atsb.gov.au Accidents 1969–88 includes useful information on the Twitter risks associated with autorotations.  @ATSBinfo Email The investigation report AO-2011-060 is available on [email protected] the ATSB website. Fatal aircraft accident at Canley Vale

On 15 June 2010, a about the operation Piper PA-31P-350 of the engines. Mojave, with a pilot The investigators and a flight nurse discovered that when on board, was flying the pilot reported to from Bankstown ATC that he was turning Airport, NSW to the aircraft around, in there had been surging Queensland. Twelve of an engine which was minutes after taking consistent with uneven off, the pilot reported fuel distribution to the to Air Traffic Control cylinders. that he was turning It was found that the aircraft around as following the shutdown he was having ‘a few of the right engine the problems.’ He shut aircraft’s airspeed and Wreckage of the Piper Mojave at Canley Vale, NSW one engine down rate of descent were due to an unspecified not optimised for flight ‘engine issue.’ with one inoperative engine. In addition, At about 0806 Eastern Standard Time, The fact that the pilot had not given the spectral analysis indicated it was the aircraft collided with a powerline much detail about the nature of the unlikely that the left engine was being support pole at Canley Vale. Both problems he was experiencing created operated at maximum continuous power occupants died in the accident and the a challenge for the investigation. as the aircraft descended. As a result, aircraft was destroyed by the impact Examination of the engines, propellers the aircraft descended to a low altitude forces and an intense post-impact fire. and governors and other aircraft over a suburban area and the pilot was components found no evidence of any The ATSB commenced an in-depth then unable to maintain level flight, pre-impact faults. In order to understand which led to the collision with terrain. investigation immediately. The the engine performance during the investigators constructed a detailed occurrence, the ATSB conducted The Civil Aviation Safety Authority chronology, using information from a spectral analysis of the pilot’s has since started a project to amend recordings of radio communication radio transmissions. The changes in advisory material relating to multi- between the pilot and ATC, recordings frequencies of signals from the aircraft’s engine aircraft training and operations of radar data, ATC documentation, propellers and alternators throughout the to include guidance information about meteorological data and post-accident transmissions gave valuable indications engine problems encountered during the witness interviews. climb and cruise phases of flight. This amended guidance material will include information about aircraft handling, Important safety messages for pilots when flying twin-engined aircraft with one engine shut down: engine management, and decision- making during these phases of flight.  • The optimal speed must be flown and the maximum continuous power selected on the operative engine to achieve the aircraft’s published one The investigation report, AO-2010-043, engine inoperative performance. is available on the ATSB website. • It is important to verify the aircraft’s performance before conducting a descent. • Pilots should use the appropriate PAN or MAYDAY phraseology when advising Air Traffic Control (ATC) of non-normal or emergency situations. Investigation briefs Broadcast and actively Prepare for the worst Wrong lever results in listen Investigation AO-2012-084 runway accident Investigation AO-2012-102 The ATSB is highlighting the importance Investigation AO-2012-110 of carrying personal communication Two aircraft proximity events at Ballarat The inadvertent retraction of an Aero equipment and taking extreme care Airport on the same day have reinforced Commander’s landing gear on the when refuelling aircraft. This comes how it is critical for pilots to broadcast runway shows the ease with which after an accident where a helicopter was and actively listen to the Common Traffic habitual piloting actions can result in an destroyed by fire and the two occupants Advisory Frequency (CTAF) and maintain error. were left without any survival gear or a vigilant lookout at all times to enhance communications equipment. traffic and situation awareness. This is The operation of the particularly important in a high-traffic- On 19 June 2012, the helicopter, a gear level and safe pin density environment. Eurocopter AS-350BA, was 15 minutes into a flight from Ceduna to Border at the same time had Both incidents on 4 August 2012 involved Village, South when the pilot two Cessna 172S aircraft on converging become an automatic and passenger smelt fumes in the headings arriving at the same time at cockpit. Shortly after smelling the fumes, action, reducing the the airport. Both incidents were seen by the pilot conducted an emergency observers on the ground. In both cases effectiveness of the safe landing in a remote area about 50 km one of the two pilots involved had been pin as a countermeasure. west of Ceduna. Once on the ground, unaware that the incident had occurred. the passenger exited the helicopter and The Aero Commander 500S departed noticed smoke and fire coming from the Charleville Airport, Queensland, bound Pilots should not hesitate rear cargo compartment. The pilot and for via Toowoomba on a passenger escaped without injury. to call and clarify another freight charter flight. About 300 meters aircraft’s position and The helicopter was fitted with an into the landing roll at Toowoomba Emergency Locator Transmitter which airport, the pilot inadvertently retracted intentions. could have transmitted their position to the landing gear while attempting to Search and Rescue. However, it did not retract the aircraft’s wing flaps. This In the first instance, the aircraft passed activate and was destroyed in the fire. resulted in the main gear collapsing and in close proximity with about .2 NM Neither the pilot nor the passenger was the aircraft sliding for a short distance lateral separation and 300 feet vertical carrying a satellite phone or a personal before coming to rest on the runway. The separation. In the second case, the emergency radio beacon (EPIRB). pilot, the only person on board was not distance reduced to 0.1 NM laterally and Fortunately, they were rescued several injured. 100 feet vertically. hours later. A manual ‘safe’ pin had been The pilots reported making CTAF calls The investigation could not determine incorporated as a design feature to but some differences between the the cause of the fire but an earlier prevent inadvertent retraction of the pilots’ and observers’ recollections of spillage during refuelling may have landing gear. However, the pilot’s events could not be reconciled. Any provided an initial fuel source for the operation of the gear level and safe pin at radio broadcasts made by the pilots fire. The operator has since ensured the same time had become an automatic could not be verified, as transmissions at that all operations will have access to action, reducing the effectiveness of the Ballarat are not recorded. the appropriate equipment, and has safe pin as a countermeasure. experienced a reasonable amount of amended the survival procedures for airport activity on that day. As a result of this accident, the operator carrying large containers of fuel. has taken a number of safety actions, ATSB reminds pilots that in accordance This accident also highlights the including modifying the landing gear with Civil Aviation Advisory Publication importance of making decisions to control, and implementing random flight 166-1 ‘…radio broadcasts should be reduce the level of risk to the safety checks by check and training captains. In made as necessary to avoid the risk of of the aircraft and its occupants in addition, the ATSB is encouraging pilots a collision or an airprox. event. A pilot emergency or abnormal situations. to take the time to identify any control should not hesitate to call and clarify the lever positively before they action it.  other aircraft’s position and intentions if In this case the pilot elected early to there is any uncertainty.’  conduct a precautionary landing and investigated the source of the fumes. 

First defence against Inspect and maintain Depressurisation errors and omissions fuel cap seals warnings Investigation briefs Investigation AO-2012-112 Investigation AO-2012-125 Investigation AO-2012-127 The ATSB is cautioning pilots to be On 22 September 2012, a Piper PA- The ATSB urges pilots to acquaint diligent in the performance of checklist 32 was being operated on a private themselves with the warning signs of items during all stages of flight. This scenic flight near Yea, Victoria. About a pressurisation systems failure, and reminder comes following an incident in five minutes after departing, at about to maintain a high level of vigilance, which a Piper Seneca experienced fuel 1,000 feet above ground level, the pilot following a depressurisation event starvation while cruising at 9,000 feet changed the fuel selection from the left involving a Metro 3 in September 2012. above mean sea level (AMSL). main tank to the right tip tank. About The depressurisation occurred during three minutes later, at about 800 feet The aircraft had departed Hobart a scheduled passenger flight from the engine failed. The pilot changed the Airport for Bankstown on a private Narrabri to Sydney. On board were seven fuel selector back to the left main tank flight. When the aircraft was about passengers and two flight crew. During and placed the fuel mixture and throttle 19 km south of Nowra, the pilot (who the climb, the Captain noted that he was control full forward but the engine did not was the only person on board) heard a not feeling well and that he was not as respond. As a result, the pilot elected to bang and the left engine stopped with accurate as usual; the First Officer (FO) conduct a forced landing. the right engine stopping shortly after. reported that he felt fine at that time. The pilot immediately feathered the The deterioration of The Captain noted that the FO was propellers, declared a PAN and started taking longer than usual to reply to his looking for a suitable area to land. He fuel cap seals can allow request for a check of the cabin altitude, proceeded through the memory items the ingress of water when the cabin altitude warning light on the emergency checklist. While illuminated. There was no audible performing the emergency checklist, into fuel tanks. pressurisation alert fitted to the aircraft the pilot discovered that the right fuel nor was there required to be. The crew selector was in the cross-feed position The pilot moved the throttle to the idle donned oxygen masks and descended and the left fuel tank had run out of fuel. position and prepared for landing. During the aircraft to 10,000 ft. They elected He repositioned the fuel selectors and the landing the pilot noted that the to continue to Sydney with the cabin restarted both engines. engine power had been restored. The unpressurised. aircraft subsequently hit two fences and At the time of the engine restart, the sustained substantial damage. The cabin altitude warning switch was aircraft had descended to 4,000 feet later found to be out of tolerance and AMSL. The pilot advised air traffic control Subsequent inspections found water was replaced. At the time of the incident, that both engines were now running and contamination in the fuel tanks. Before there was no routine maintenance that he would continue to Bankstown as the flight, the aircraft had been sitting regime for the cabin altitude warning planned. idle for several months, fully fuelled, system. The operator, Brindabella in a hangar. The pilot reported that he On landing, the aircraft had a significant Airlines, has amended their cabin had washed the aircraft several months lateral fuel imbalance, as the left wing procedures and maintenance system, earlier and speculated that water may tank was empty and the right wing tank and is exploring alterations to their have entered the tank through the fuel was almost full. As a result, the aircraft simulator training. cap. departed the runway during the landing People on board an aircraft that roll. The pilot regained control and the The deterioration of fuel cap seals can experiences a loss of pressure when aircraft taxied to the parking area without allow the ingress of water into fuel flying above 10,000 ft will experience the further incident. The aircraft was not tanks. CASA Airworthiness Bulletin effects of hypoxia—a condition where damaged and the pilot was not injured. (AWB 28-008) Water contamination of the body is starved of enough oxygen to fuel because of failure of fuel filler cap The pilot had been accustomed to function normally and, if left unchecked, contains information on inspecting fuel being assisted on flights by his wife, can ultimately lead to death. Symptoms filler and caps and conducting pre-flight who would hold the checklist and read can include those experienced by the inspections of fuel filler/caps and fuel out the items. On this flight, however, Captain. An earlier ATSB study has samples.  she was not with him. Checklists are shown that there is a high chance of the most readily available means of surviving a pressurisation system failure, risk management against errors and provided that the failure is recognised omissions.  and the corresponding emergency procedures are carried out expeditiously. The investigation report AO-2012-127 contains useful resources for those wishing to learn more about hypoxia, and how to protect themselves from it.  Thunderstorms add stress The fatal in-flight breakup of a Cessna 210 highlights the danger that thunderstorms can pose to aircraft, and the importance of leaving information about your plans with a responsible person. The accident occurred on 7 December 2011 during a private flight from Roma to Dysart in Queensland conducted under visual flight rules. Before departing, the pilot (the only person on board) logged onto the National Aeronautical Information Processing System to access weather information. Although he entered basic flight details to obtain route-specific information, he did not nominate a SARTIME (time at which, if no contact had been made, Search and Rescue should be Wreckage of the Cessna 210, 100 km NNW Roma, Queensland activated) or leave a Flight Note with a responsible person. (There was no tail separated. The aircraft had been aircraft structure. Thunderstorms can formal requirement to lodge a SARTIME structurally sound before the separation bring with them a number of hazards or a Flight Note, but pilots are regularly and no aircraft system defects were to aviation, including severe turbulence urged to do so.) identified. The investigation found that and wind gusts. thunderstorms had been recorded The aircraft did not arrive at Dysart as Airspeed is a critical factor in the stress in the area, and cruise power setting sustained by an aircraft. Pilots need to expected, and the Rescue Coordination had been maintained until an onboard Centre was advised at 0750 the next be aware of the manoeuvring speed for engine monitoring system ceased the aircraft weight, and to control the morning. Wreckage was not found until recording. more than 24 hours after the pilot had airspeed so as not to exceed that value departed. The pilot died in the accident. Although the precise circumstances when full control deflection is required leading to the accident were not known, or severe turbulence or wind gust are From interrupted engine data recording, a combination of aircraft airspeed encountered.  the ATSB established that about with the effects of turbulence and/ 30 minutes into the flight, the outer The investigation report AO -2011-160 or control inputs generated stresses is available on the ATSB website. sections of the wings and part of the that exceeded the design limits of the

Keeping an eye on safety SafetyWatch AVIATION | MARINE | RAIL www.atsb.gov.au/safetywatch

atsb.gov.au/safetywatch REPCON BRIEFS

and put into a work pack for the aircraft when it is next due for heavy maintenance to reduce Australia’s voluntary confidential aviation reporting scheme the number of MEL items. REPCON allows any person who has an aviation safety concern to report it to the ATSB Operator response: confidentially. All personal information regarding any individual (either the reporter or any The operator’s Maintenance Control person referred to in the report) remains strictly confidential, unless permission is given by department has recently made a series of the subject of the information. changes to its management system including MEL management to ensure the quantity of The goals of the scheme are to increase awareness of safety issues and to encourage MELs and defects is reduced and sustained safety action by those best placed to respond to safety concerns. at acceptable levels and to avoid any MEL overruns. Overweight operators using an Australian standard weight has These changes include: been a practical and efficient way for pilots to The reporter expressed a safety concern accurately access their aircrafts payload. If the 1. The introduction of a Daily Compliance regarding the disregard for safety within the ATSB/CASA requires so, we would have no Review Meeting to monitor defects and operator’s management. The reporter stated opposition to individually weighing our 650+ MELs, ensuring appropriate management that a culture of overloading the aircraft has field workers to establish a company standard action is taken with identified problems. been encouraged by management. weight. 2. Benchmarking with industry to ensure The reporter states that this can be shown We have a 10 kg per person baggage MELs are reduced to best practice levels during regular flights from the company’s allowance which every employee is made and the establishment of performance home base to mining operations. The aware of throughout the company inductions targets based on IATA data. operator uses standard passenger weights process. The pilot of a company aircraft 3. The introducing of a process whereby and baggage weights for flight planning reserves the right to turn away any baggage all MELs have to be authorised by these flights. These passengers are normally that exceeds the 10 kg limit. Maintenance Watch and therefore members of mining drill crews and would on are tracked in the Engineering and average weigh approximately 100 kgs and Company freight is processed by our stores area and is marked with its weight, Maintenance IT platform. This enables they generally take baggage well in excess of operational oversight by Engineering the nominated 10 kgs. description of goods, the manager who approved it to be transported, the contact management. Named party response: number and name of the person who is to 4. Changing operational policy to ensure The opening statement of this report states; receive it at its destination. aircraft do not get released to service each “overloading the aircraft has been encouraged These simple methods of establishing payload morning until all overnight documentation by management” of our aircraft have been developed over the is received and reviewed by Planning, greatly enhancing operational oversight by As discussed, recently an employee (pilot) past 7½ years of operation. They are simple, management. was caught knowingly overloading a company easy to apply and help eliminate human error aircraft and was issued a written warning. that may be associated with the calculation of CASA response: an aircraft’s weight limitations. Following this, we received a letter from the CASA notes the operator’s response to the employee’s lawyer demanding the written Should the ATSB/CASA have any input on reported concerns. CASA has conducted warning be withdrawn. As a consequence how our current process could be improved operational surveillance at the operator’s of this, the employee, by way of his failure any feedback would be appreciated. Maintenance Control office to observe to acknowledge any wrongdoing and outcomes of their recent restructure of the demonstrating his inability to learn from his CASA response: section and in light of the operator’s response mistakes, has had his employment with our CASA has undertaken surveillance of the contained within this Repcon. company terminated. operator. Three ramp checks have been conducted and any matters of concern have CASA is of the view that the newly created This single occurrence alone demonstrates positions, daily compliance meeting, and that our management does not tolerate, nor been addressed. CASA will continue to monitor operations. benchmarking with industry will support the encourage the operation of the company’s organisation’s Minimum Equipment List being aircraft outside of their design limits. All reduced to best practice levels.  allegations suggesting otherwise are totally Maintenance refuted. documentation In response to the second statement; on commencement of our aviation operations, The reporter expressed safety concerns about with guidance from Civil Aviation Advisory maintenance documentation, particularly Publication 235-1 Standard Baggage and as it relates to a Minimum Equipment List Passenger Weights, we adopted 86kg per (MEL). The reporter is concerned that a pilot How can I report to REPCON? passenger as a standard weight as our aircraft may miss an expiry date for a MEL due to the fall into the range of 10–14 passengers. This large number of items that they have to sort Online: has worked well and is a good representation through on board and in consequence, may www.atsb.gov.au/voluntary.aspx of the average weight of our employees and inadvertently fly an aircraft which does not Telephone: 1800 020 505 due to the nature of our operation where comply with the approved MEL. Email: [email protected] we are moving upwards of 250 employees Mail: Freepost 600 The reporter suggests that items that are to a week into and out of remote worksites, PO Box 600, Civic Square ACT 2608 be fixed should be removed from the tech log