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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— Queensland. 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, Archerfield Airport 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 Australia 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 Brisbane airport 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.

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