ATSB release final R44 forced landing report

The Australian Transport Safety Bureau (ATSB) has published its final report into the safe forced landing of Robinson R44 VH-SJK, which was swallowed up by thick scrub at Sydney’s Royal National Park at Bundeena 16km south of Sydney Airport on December 17 last year.

Having departed Sydney Airport for a private flight with a family of four on board, the R44 was flying at 500ft over water to Cape Banks on the north shore of Botany Bay before turning south to fly a coastal route over the water outside of controlled airspace.

When the helicopter was about 200-300m off the coast and climbing through 650ft, the pilot, Peter Butler, heard the low rotor RPM warning horn activate and immediately turned right towards the shore line. During the turn and when over land, the rotor RPM tachometer indicated a decay in RPM when he raised the collective.

Having identified a landing site, Butler lowered the collective to enter an autorotation from about 300ft above the ground at 70kt and landed the R44 with about 7-8kt forward speed using a standard autorotation flare and cushion technique with no injuries to his passengers or himself.

Landing upright in very dense scrub with the engine and rotor still turning, Butler shut down the helicopter and used a mobile phone to call rescue services.

All four were winched out by the Westpac Life Saver Rescue Helicopter Service.

A post-recovery maintenance inspection was conducted, which included a visual inspection and ground run of the helicopter. No fault was found with the engine, drive system or flight controls.

The ATSB’s report concluded “the low rotor RPM was probably the result of a reduction in power input to the rotor from the engine, but the fault could not be reproduced during post-recovery tests.”

In its safety message section of the report, the ATSB said the lesson learned from this emergency was the importance of training and professional development.

“Although [the pilot] only used their helicopter for private flights, [he] trained for a commercial helicopter licence to improve their knowledge and skill in handling their helicopter,” said the ATSB report.

“[He] did not believe [he] could have flown a successful emergency landing without [his] previous recurrent proficiency training in practice autorotations.”

On the day of the incident, Butler told the ABC that the training required to obtain his pilot’s licence became vital when he realised there was an emergency.

“You train and train for these things before CASA will give you a licence and I’m glad they make us do it,” said Butler.

”This is the first time in a long time that I’ve had any problems and I was very glad I had the training to know what to do. You don’t get much warning.”

The full report is available on the ATSB’s website.


Source : Australian Aviation

ATSB releases study on aviation fatalities over past 10 years

The ATSB says 28 aircraft were involved in fatal accidents in 2015 and a further 28 in an accident resulting in serious injuries. (ATSB)

A graph showing the accident rate for VH- aircraft in flying training. (ATSB)

There were 31 aviation-related fatalities in Australia in 2015, with the bulk of those deaths occurring in the general and recreational aviation sectors, new figures show.

The statistics are outlined in a report from the Australian Transport Safety Bureau (ATSB) published on Wednesday covering aviation occurrence statistics between 2006 and 2015.

Recreational aviation recorded 18 fatalities from 76 incidents in 2015, while general aviation had 12 fatalities from 130 incidents, the report said.

Meanwhile, there was one death in commercial air transport from nine incidents.

“In 2015, Australia had 31 fatalities and 32 serious injuries – 28 aircraft were involved in fatal accidents and a further 28 in an accident resulting in serious injuries,” the ATSB report said.

“There was a total of 227 aircraft involved in accidents, and 185 involved in serious incidents (indicating an accident nearly occurred).”

ATSB chief commissioner Greg Hood said commercial air transport had the lowest number of accidents in the 10-year study period in 2015.

However, Hood expressed concern that in 2014, which was most recent year flying hours data was available, the flying training accident rate per million hours flown was more than double that of any year in the previous eight.

“The increase in accident rates involving flying training is an emerging safety concern – we’ll continue to keep a close eye on this sector to get a better understanding of the safety issues involved,” Hood said in a statement.

Looking at the longer term figures, the ATSB report found that 17 of the 19 fatalities in commercial air transport in the 2006-2015 time period involved aircraft conducting charter operations.

Further, the ATSB said: “Growth in recreational (non-VH) flying and improving awareness of reporting requirements, led to more than a tenfold increase in the number of recreational safety incidents reported to the ATSB between 2006-2015.”

The ATSB report noted the number of accidents and incidents involving remotely piloted aircraft (RPAs), commonly known as drones, was on the rise, with 12 accidents, four serious incidents and four incidents involving RPAs recorded in 2015.

“This is a significant increase compared to any other year in the previous 10 years and reflects the increasing prevalence of these aircraft,” the ATSB report said. The figures do not include incidents where pilots of conventional aircraft have reported encountering an unidentified RPA/model aircraft.

The report said most of the incidents involving RPAs involved collision with terrain, often caused by mechanical/electrical failure or radio interference.

Examples of RPA incidents detailed in the report included a 3kg DJI S900 falling out of the sky and landing on a parked car, while an Aeronavics SkyJib 8, which has a maximum takeoff weight of 16kg, at the Melbourne Cricket Ground for the 2015 Cricket World Cup final fell to the ground after the the crew operating the RPA lost control of the aircraft.

The ATSB report said the number of occurrences involving RPAs had increased from 14 occurrences in the eight-year period between 2006 and 2013 to 37 over the two years covering 2014 and 2015.

“Given the significant growth in the use of remotely piloted aircraft, it is likely that the number of incidents and accidents will continue to increase in the short term,” Hood said.


Australian Aviation

Australian Transport Safety Bureau seeks to be more data driven

Australian Transport Safety Bureau (ATSB) chief commissioner Greg Hood says the greater use of data to identify trends will be a big focus in the period ahead.

While the ATSB will continue to investigate major accidents and incidents, there will also be an emphasis on uncovering potential safety issues as part of efforts to be a more predictive organisation.

“To ensure we remain relevant and effective, we will start to refocus our efforts that deliver significant safety benefits to Australia,” Hood told delegates at the Australian Airports Association (AAA) national conference in Canberra on Wednesday.

“We will also seek to improve our efficiency by becoming more data driven. The ATSB has one of the richest national information datasets of all safety-related occurrences in aviation.”

“My goal is to utilise data to such an extent that we continue evolving from being a reactive organisation, to a proactive organisation and ultimately to being a predictive organisation.”

One area of study currently underway that reflected the ATSB’s push to, in Hood’s words “interrogate the data more aggressively”, concerned weather forecasts and observations.

The ATSB study was looking at how the reliability of weather forecasts affected the ability of flight crews to conduct a safe landing.

There have been a number of “unforecast weather episodes” relating to flights into major Australian ports that have led to unforeseen diversions, holding and “in some cases landing below the published minima” in recent times, Hood said.

“By understanding the relationships between weather reliability and aircraft operations, we will be able to essentially predict higher risk time periods and locations and drive down the probability of an accident occurring,” Hood said.

“Our research is seeking to understand how the reliability of weather forecast affects the ability of the flight crew to conduct a safe landing.

“Compared to Europe and North America, weather in Australia is pretty good and the likelihood of an accident happening because of weather conditions unsuitable for landing is much lower but in making it even lower, the probability of a major accident happening reduces considerably.”

Hood reaffirmed the ATSB’s commitment to continue to investigate the majority of accidents and serious incidents involving the travelling public.

“That is in my statement of expectations with the government and this is where there is the greatest risk of loss of life and the greatest likelihood of finding significant safety issues that lead to important safety actions,” Hood said.

Also, Hood said the ATSB would seek to direct investigation, research and education resources towards areas where there was the largest risks to transport safety.

“In doing so we will be more able to selectively allocate our limited resources to investigating those accidents and incidents that have the greatest potential for improving transport safety,” Hood said.

“If there is no obvious public safety benefit to investigating an accident the ATSB is less likely to conduct a complex, resource-intensive investigation.

“There are diminished safety benefits to investigating occurrences where there are obvious contributing factors such unauthorised low-level flying, wire strikes or flying visually into poor weather conditions.

“Instead, educating pilots on the dangers of high-risk activities is where we focus most of our efforts with an emphasis on using social media as a key communications tool.”


Australian Aviation


Govt open to extending search for MH370 as Canberra hosts three-day summit on missing jet

A supplied image of ATSB investigators looking at a wing flap believed to be from MH370. (ATSB)

Federal Minister for Infrastructure and Transport Darren Chester says he is open to extending the search for missing Malaysia Airlines flight MH370 based on any relevant new information as a new report suggests the aircraft entered into a steep descent before crashing into the Indian Ocean.

The Australian Transport Safety Bureau’s (ATSB) latest report on the search, published on Wednesday, has detailed analysis of wing debris that investigators hope may provide more clues on the missing Boeing 777-200ER’s flightpath before it crashed in the Indian Ocean.

The report said the flap from the aircraft’s right wing was “most likely in the retracted position at the time it separated from the wing”.

Further, the ATSB said the right flaperon was “probably at, or close to, the neutral position at the time it separated from the wing”.

The findings, alongside additional analysis of the satellite communications data was “consistent with the aircraft being in a high and increasing rate of descent at that time”, the ATSB said.

“Additionally, the wing flap debris analysis reduced the likelihood of end-of-flight scenarios involving flap deployment,” the report said.

The findings suggest it was unlikely the aircraft crashed into the ocean following a controlled rate of descent.

The ATSB report also looked at drift analysis of the more than 20 pieces of debris that have been found since the Malaysia Airlines jet 9M-MRO carrying 239 passengers and crew lost contact with air traffic controllers en route from Kuala Lumpur to Beijing more than two years ago.

“Preliminary results of a drift analysis by Australia’s top scientific organisation, the CSIRO, also indicated it was unlikely that debris originated from the south of the current search area,” the ATSB report said.

“The northernmost simulated regions were also found to be less likely. Drift analysis work is ongoing and is expected to refine these results.”

The most recent ATSB operational update, published on October 26, said the entire 120,000 square kilometre search area was due to be completed by February 2017.

Canberra is hosting a First Principles Review Summit of the search, which will run from Wednesday to Friday and bring together Australian and international experts.

Chester, who opened the summit, said the gathering would review all the available data and analysis associated with the search so far, including the 20 odd items of debris that have been found off the coast of Africa since the aircraft disappeared in March 2014.

“The experts will also inform the remainder of the search effort, and develop guidance for any future search operations,” Chester said in a statement on Wednesday.

“A report detailing the findings of the review will be released after the meeting.

“Australia, Malaysia, and China continue to work together to find MH370. My thoughts, and the thoughts of all those involved in the summit, remain with the families and friends of the 239 passengers and crew.”

ATSB chief commissioner Greg Hood said recently the search for MH370 was following up on some sonar “underwater contacts” with an autonomous underwater vehicle.

“We’ve got almost 50 of those underwater contacts where the deep tow sonar has said there’s something there, it looks man made but we don’t know what it is,” Hood told delegates at the Regional Aviation Association of Australia (RAAA) national convention on October 21.

“Potentially we may have found the aircraft, but also potentially that underwater contact, they could be containers for example that have fallen off ships.”


Australian Aviation

ATSB releases final report into S-76 engine failure

Esso Australia’s Sikorsky S-76C, VH-EXU. (ATSB)

Elevated helideck profile showing a representation of the operator’s Category B departure with all engines operating (in black) and an estimation of the departure profile for the occurrence flight (in red). (ATSB)


The Australian Transport Safety Bureau (ATSB) has released its final report into the engine failure of an Esso Australia Sikorsky S-76C on the morning of July 11 2013 while the helicopter was departing from an offshore platform.

The failure of the right-hand engine in VH-EXU occurred as the helicopter was climbing out on departure from the Snapper platform in Bass Strait, 74km east of Longford, south-east of Sale in Victoria’s Gippsland region.

After setting the nose-down attitude for the departure, the crew reported a loud bang accompanied by significant airframe vibration.

The helicopter descended rapidly, however the pilot and co-pilot recovered the descent to within 30ft of the sea surface and established a positive rate of climb.

The crew also discharged fire extinguisher agent into the right engine during the recovery in response to an engine fire warning.

The S-76C, with two crew and 10 passengers on board, made a single-engine landing back to Longford under escort by other company helicopters.

The ATSB report said the engine failure was attributed to the fracture of a second-stage, high-pressure turbine blade.

The liberated blade impacted and damaged adjacent blades with the resulting loss of power and associated increased vibration.

The engine and failed blade structure were inspected by the engine manufacturer which concluded that the failure was due to a combination of metal fatigue, blade creep and oxidation deposits.

While a definitive cause for the blade fracture has yet to be determined, blade material, dimensional and quality assurance checks have ruled out any deficiencies.

“In the absence of a conclusive cause of the blade fracture and remedial information, the operator imposed a service life limitation on their helicopters’ engine turbine assemblies that were fitted with the same blades,” said the ATSB report.

“In addition, the engine manufacturer issued notifications to operators and introduced specific inspection requirements relevant to potentially affected turbine assemblies.”

The ATSB also said this event highlighted how a situation can quickly change from normal operations to one where the flight crew have to deal with an in-flight emergency.

Their report said effective crew interaction, thorough pre-briefing and anticipation of what can go wrong has been shown to increase the likelihood of a successful outcome and the recovery from the engine failure and the safe return to Longford reaffirmed the benefits of those preparatory actions.

At the time of writing, the engine manufacturer was continuing its investigation into the cause of the blade fracture.

The full report can be read on the ATSB website.


Australian Aviation

ATSB report says Virgin changed procedures after 2013 on-the-ground collision

A screenshot of the Virgin and Jetstar aircraft before the collision. (ATSB/Melbourne Airport)

Virgin Australia changed its operating procedures for aircraft pushing back from selected gates at Melbourne Tullamarine after an on-the-ground collision with a nearby Jetstar Airbus A320 in 2013, the Australian Transport Safety Bureau (ATSB) says.

The incident, which occurred on August 10 2013, happened when the left wingtip of a Virgin Boeing 737-800 VH-YID pushing back for departure hit the tail cone of a Jetstar A320 VH-VGR that had just arrived from Sydney and was holding short of its gate.

The ATSB’s final report on the incident, published on Thursday, said the ground controller had issued pushback approval to the Virgin 737 located at gate E1 that required the Jetstar A320 to be on gate D2 before pushback could commence.

The Jetstar Airbus ended up stopping short of gate D2 after the automatic nose-in guidance system (NIGS) displayed a “STOP-WAIT” message.

The crew then transmitted to the controller that they were holding short of the gate because of the NIGS, the ATSB report said, then repeated the message about 40 seconds later because the first message had been “over-transmitted by another aircraft”.

“The message was acknowledged by the controller, who requested to be advised when the aircraft was at the gate,” the report said.

As a result, the Jetstar aircraft was not in position before the Virgin aircraft commenced its pushback.

The location of the two aircraft involved in the incident. (ATSB)

However, the ATSB report said the dispatcher of the Virgin 737 looked under the aircraft and saw that the Jetstar A320 had stopped, then waited for 15-20 seconds “to confirm the aircraft remained stationary”.

“While VGR was actually holding short of the gate, the dispatcher formed the opinion that the aircraft was on the gate based on the observation that it had been stationary for a period of time,” the ATSB said.

“This was consistent with their experience and as a result, they did not move to a position from where they could accurately assess VGR’s location.

“The pushback of the B737 was commenced with insufficient clearance from the A320, which was not identified prior to the collision as the dispatcher’s position to the right-front of the B737 prevented observation of its left wing.”

The left wingtip of the Virgin 737 contacted the tail cone of the Jetstar A320 immediately aft of the operating auxiliary power unit. The tail cone fell to the ground.

The damaged left wingtip of the Virgin 737. (ATSB)

The damage to the tail cone of the Jetstar A320 aft of auxiliary power unit. (ATSB)

While the ATSB report noted that from dispatcher’s perspective, the Virgin 737 obscured most of the Jetstar A320, it was normal practice for Virgin not to use a wing walker during pushback from gate E1.

“Following this occurrence, Virgin Australia Airlines Pty Ltd provided a local instruction to Melbourne Airport ground staff that stipulated the gates that required the presence of a wing walker prior to push back,” the ATSB said.

“Gate E1 was included in that list of gates.”

In terms of the radio communications between the flight crew of the Jetstar A320 and the ground controller, the ATSB said it was “not reasonable to expect that the transmission from VGR could have alerted the crew of YID to the collision risk”.

“In addition, in the lead up to the collision, the crew of VGR were communicating with their company to resolve the issue with the nose-in guidance system at the gate. This limited their ability to identify and therefore react to the collision risk.”

There were no injuries resulting from the incident.


Australian Aviation

ATSB investigating loss of separation between Jetstar A320 and Malaysia AirAsia X A330 near Gold Coast Airport

ATSB logo. (ATSB)

The Australian Transport Safety Bureau (ATSB) has confirmed it is investigating the circumstances where a Jetstar Airbus A320 and Malaysia AirAsia X A330 managed to fly too close to each other near Gold Coast Airport.

The incident, which took place about six kilometres north of Gold Coast Airport on July 21, involved an inbound Jetstar A320, VH-VFO, from Melbourne (Avalon) and an AirAsia X A330-300, 9M-XXS, departing for Auckland.

The ATSB said in a short message on its website said the flightpaths of the two aircraft led to a loss of separation, and both aircraft received a traffic collision avoidance system (TCAS) alert. As a result, the Jetstar A320 conducted a climb to increase separation.

“While these aircraft came closer than normal separation standards there was no risk of collision as the systems and the aircraft crews manoeuvred to avoid any further conflict,” the ATSB statement said.

“At this stage the details of the occurrence are yet to be verified and are limited to the notifications provided by Airservices Australia, Jetstar and Air Asia X.

“As part of this investigation, the ATSB will obtain air traffic control radar and audio information, interview the involved air traffic controllers and flight crews, and gather additional information.”

The ATSB said it would publish an update on the matter within the next few weeks, while the investigation was expected to be completed by June 2017.

Jetstar said in a statement on its website the pilots of flight JQ630 from Melbourne (Avalon) to the Gold Coast had taken “corrective action to restore the safe distance between the two aircraft”, adding that the flight landed without further incident.

“Our crew did a fantastic job and responded to the situation as they are trained to do. At all times they followed the instructions of air traffic control,” Jetstar said.

The Jetstar A320 was configured with 180 seats, while Malaysia AirAsia X’s A330s have 377 seats.


Australian Aviation