[Peetwo]

Final Report AO-2024-046 - 

Attributed to Popinjay, via his media minions...
 

ATSB finalises Cairns hotel helicopter accident investigation

The ATSB has finalised its investigation into an accident involving a Robinson R44 helicopter which struck the roof of a Cairns hotel early in the morning of 12 August 2024.

“The investigation found that the pilot conducted an unauthorised and unnecessary flight at night, while affected by alcohol,” said ATSB Chief Commissioner Angus Mitchell.

“The pilot did not hold the appropriate endorsements to fly at night, did not have any experience flying the R44 at night, and they conducted the flight well below the 1,000 ft minimum height for flight over built up areas.” 

The ATSB finalised the investigation after determining it unlikely that broader safety issues or lessons would be uncovered.

“The ATSB primarily investigates to identify industry systemic safety issues, and to then influence the adoption of targeted actions to reduce future risk,” said Mr Mitchell.

“Our final report published today provides assurance to the Cairns community and the aviation industry that after gathering and analysing the available evidence, there are unlikely to be broader transport safety issues that require addressing to reduce future risk arising from this tragic accident.”

The report details that the pilot was an employee of the helicopter operator, and had gained access to their premises after entering a code into a security door keypad, and then to the hangar and the helicopter. The pilot held valid New Zealand and Australian commercial helicopter pilot licences, and had previously flown R44 helicopters. However, they were employed by the operator as a ground handler, and were not approved to, nor employed to fly the operator’s helicopters.

“Using a combination of CCTV footage, witness accounts, GPS data from the helicopter and air traffic control surveillance radar data, the ATSB was able to develop a detailed sequence of events of the accident flight,” Mr Mitchell said.

Prior to the flight, the pilot had been socialising with friends at various venues in Cairns, where they had been consuming alcohol, the report details. They had returned to their apartment around 11 pm, with CCTV footage showing them driving away from the apartment complex at 1:09 am. CCTV footage from the operator’s hangar showed the pilot moving the helicopter outside onto a helipad just after 1:30 am.

“We know from GPS and air traffic control radar data that the helicopter departed Cairns Airport shortly before 1:47 am, while CCTV footage showed that the helicopter’s strobe lights were turned off by the pilot,” Mr Mitchell said.

After taking off, the helicopter headed south towards the Cairns city centre, flying over the pilot’s apartment building and then tracking to the northern end of the Cairns wharf complex, where it completed an orbit before heading north towards the marina and continuing along the coastline.

After crossing the coastline and flying over the pilot’s apartment a second time, the helicopter circled back towards the foreshore, following it for about 1 km. 

Throughout the flight the helicopter’s altitude did not exceed 500 ft.

“Two security cameras recorded very brief portions of the final part of the flight and showed the helicopter pitching up, then almost immediately descending steeply before colliding into the roof of the hotel at about 1:51 am,” Mr Mitchell said.

“Wreckage distribution and impact marks indicate that the helicopter was inverted at impact.” 

Most of the helicopter came to rest on the hotel roof and was destroyed by impact forces and a fuel-fed post-impact fire. The pilot was fatally injured. 

Parts of the main rotor blade were found in the hotel rooms below the accident site, while the helicopter’s instrument panel, main rotor head and most of the main rotor blades were found within the hotel grounds. A portion of the same main rotor blade that struck the hotel windows was found in parkland across the road.

Fortunately there were no injuries to hotel guests and staff, nor passersby.

“From the available evidence there were no airworthiness factors with the helicopter that likely contributed to the accident,” Mr Mitchell said.

“The flight was a purposeful act, but there was no evidence available to explain the pilot’s intentions.”

Mr Mitchell concluded: “I would like to acknowledge that the nature of this accident is deeply distressing to the pilot’s family, and they have asked that I share with you their request for privacy at this time.”

Read the report: Collision with building involving Robinson R44 II, VH-ERH, at Cairns, Queensland, on 12 August 2024

Publication Date: 10/10/2024

MTF...P2 

[Peetwo]

Final Report AO-2024-046 - Part II 

Attributed to Popinjay, via his media minions...
 

ATSB finalises Cairns hotel helicopter accident investigation

The ATSB has finalised its investigation into an accident involving a Robinson R44 helicopter which struck the roof of a Cairns hotel early in the morning of 12 August 2024.

“The investigation found that the pilot conducted an unauthorised and unnecessary flight at night, while affected by alcohol,” said ATSB Chief Commissioner Angus Mitchell.

“The pilot did not hold the appropriate endorsements to fly at night, did not have any experience flying the R44 at night, and they conducted the flight well below the 1,000 ft minimum height for flight over built up areas.” 

The ATSB finalised the investigation after determining it unlikely that broader safety issues or lessons would be uncovered.

“The ATSB primarily investigates to identify industry systemic safety issues, and to then influence the adoption of targeted actions to reduce future risk,” said Mr Mitchell.

“Our final report published today provides assurance to the Cairns community and the aviation industry that after gathering and analysing the available evidence, there are unlikely to be broader transport safety issues that require addressing to reduce future risk arising from this tragic accident.”

The report details that the pilot was an employee of the helicopter operator, and had gained access to their premises after entering a code into a security door keypad, and then to the hangar and the helicopter. The pilot held valid New Zealand and Australian commercial helicopter pilot licences, and had previously flown R44 helicopters. However, they were employed by the operator as a ground handler, and were not approved to, nor employed to fly the operator’s helicopters.

“Using a combination of CCTV footage, witness accounts, GPS data from the helicopter and air traffic control surveillance radar data, the ATSB was able to develop a detailed sequence of events of the accident flight,” Mr Mitchell said.

Prior to the flight, the pilot had been socialising with friends at various venues in Cairns, where they had been consuming alcohol, the report details. They had returned to their apartment around 11 pm, with CCTV footage showing them driving away from the apartment complex at 1:09 am. CCTV footage from the operator’s hangar showed the pilot moving the helicopter outside onto a helipad just after 1:30 am.

“We know from GPS and air traffic control radar data that the helicopter departed Cairns Airport shortly before 1:47 am, while CCTV footage showed that the helicopter’s strobe lights were turned off by the pilot,” Mr Mitchell said.

After taking off, the helicopter headed south towards the Cairns city centre, flying over the pilot’s apartment building and then tracking to the northern end of the Cairns wharf complex, where it completed an orbit before heading north towards the marina and continuing along the coastline.

After crossing the coastline and flying over the pilot’s apartment a second time, the helicopter circled back towards the foreshore, following it for about 1 km. 

Throughout the flight the helicopter’s altitude did not exceed 500 ft.

“Two security cameras recorded very brief portions of the final part of the flight and showed the helicopter pitching up, then almost immediately descending steeply before colliding into the roof of the hotel at about 1:51 am,” Mr Mitchell said.

“Wreckage distribution and impact marks indicate that the helicopter was inverted at impact.” 

Most of the helicopter came to rest on the hotel roof and was destroyed by impact forces and a fuel-fed post-impact fire. The pilot was fatally injured. 

Parts of the main rotor blade were found in the hotel rooms below the accident site, while the helicopter’s instrument panel, main rotor head and most of the main rotor blades were found within the hotel grounds. A portion of the same main rotor blade that struck the hotel windows was found in parkland across the road.

Fortunately there were no injuries to hotel guests and staff, nor passersby.

“From the available evidence there were no airworthiness factors with the helicopter that likely contributed to the accident,” Mr Mitchell said.

“The flight was a purposeful act, but there was no evidence available to explain the pilot’s intentions.”

Mr Mitchell concluded: “I would like to acknowledge that the nature of this accident is deeply distressing to the pilot’s family, and they have asked that I share with you their request for privacy at this time.”

Read the report: Collision with building involving Robinson R44 II, VH-ERH, at Cairns, Queensland, on 12 August 2024

Publication Date: 10/10/2024

Courtesy the Oz:

Cairns chopper crash pilot affected by alcohol, ATSB report finds

An investigation into a Cairns helicopter crash that killed pilot Blake Wilson, has found he was drunk at the time he “purposefully” undertook the unauthorised flight.

The 23-year-old was working as a ground handler for Nautilus Aviation in Cairns, when he took the Robinson R44 and crashed it into the rooftop of the DoubleTree by Hilton hotel, early in the morning of August 12.

An Australian Transport Safety Bureau investigation revealed toxicology tests showed he had a “significant” blood alcohol content at the time, but was drug free.

Prior to the fateful flight, Mr Wilson had been out with friends to celebrate a new posting with Nautilus Aviation to Horn Island.

CCTV footage showed him drinking at various venues in Cairns, before returning to his apartment about 11pm.

Two hours later, for reasons no-one can fathom, Mr Wilson then got into his car and drove to Cairns Airport, where security cameras showed him moving a helicopter to a helipad.

He turned off the helicopter’s strobe lights before taking off at 1.47am, in an apparent attempt to conceal his departure from air traffic control and Cairns Airport staff.

The collision with the hotel roof occurred just four minutes later, at 1.51am.

ATSB chief commissioner Angus Mitchell said security cameras recorded brief portions of the final part of the flight, showing the helicopter pitching up, then almost immediately descending steeply before colliding into the roof of the hotel.

“Wreckage distribution and impact marks indicate that the helicopter was inverted at impact.” said Mr Mitchell.

Most of the helicopter came to rest on the hotel roof and was destroyed by the impact and a fuel-fed fire.

Although Mr Wilson held a helicopter pilot licence, he did not hold a night rating and there were no records of him flying a helicopter in Australia.

Mr Mitchell said the entire flight was conducted below an altitude of 500ft (152m) well below the 1000ft minimum height for flying over built up areas.

Parts of the main rotor blade were found in the hotel rooms below the crash site, while the helicopter’s instrument panel, main rotor head and most of the main rotor blades were scattered in the hotel grounds.

A portion of the same main rotor blade that struck the hotel windows was found in parkland across the road.

Mr Mitchell said it was fortunate there were no injuries to hotel guests and staff, nor passers-by.

“From the available evidence, there were no airworthiness factors with the helicopter that likely contributed to the accident,” Mr Mitchell said.

“The flight was a purposeful act, but there was no evidence available to explain the pilot’s intentions.”

He said Mr Wilson’s family were deeply distressed by the incident, and had requested privacy.

Plus, attributed to DTS Stewie Macleod today...

Bankstown forced landing likely after fuel starvation due to low quantity, unbalanced flight



A Cessna 210 was force landed on a Bankstown Airport taxiway, likely after a low amount of fuel combined with unbalanced flight to starve the engine, an Australian Transport Safety Bureau investigation has concluded.

On 26 May 2024, a Cessna T210M single piston-engine aeroplane was being ferried from Maitland to Bankstown, New South Wales, where it was to undergo maintenance. There was a pilot and a passenger on board.

During the approach to Bankstown, the engine stopped.

“The pilot identified a taxiway on the airport as a suitable place for a forced landing and elected to leave the flap retracted and the gear up in order to reduce drag and maximise glide range,” ATSB Director Transport Safety Stuart Macleod said.

Once the aircraft was over the airport, the gear was lowered, but it did not successfully lock in place due to the limited time available.

“The aircraft landed wheels-up, resulting in minor damage, but fortunately both occupants were uninjured,” Mr Macleod outlined.

An ATSB investigation determined the aircraft departed Maitland with sufficient fuel to complete the intended flight, but it was likely the amount of fuel reduced to a level that, in combination with unbalanced flight approaching Bankstown, resulted in the engine being starved of fuel.

“Fuel starvation occurrences can often be prevented by conducting thorough pre-flight fuel quantity checks combined with in-flight fuel management,” Mr Macleod explained.

“Pilots are reminded to check fuel quantities prior to departure using a known calibrated instrument such as a dipstick.”

“In addition, comparing the expected fuel burn with actual fuel remaining after a flight, will give a validated fuel burn for the aircraft and ensure the measuring equipment is accurate.”

The ATSB’s final report directs pilots to familiarise themselves with CASA’s Advisory Circular Guidelines for aircraft fuel requirements, which provides further guidance for in‑flight fuel management.

While it did not contribute to the occurrence, the ATSB also concluded the pilot’s decision to carry non-essential crew on a ferry flight for maintenance placed that additional occupant at unnecessary risk of injury.

“While the passenger was reportedly present to assist with navigation and radio communication, the ferry flight was conducted under a CASA special flight permit, requiring only essential operating crew be carried,” Mr Macleod said.

“These conditions are in place to minimise the consequences if an incident occurs during such a flight.”

Finally, the report notes, the pilot failed to complete the engine failure during flight checklist which, if followed, would have increased the likelihood of the engine being restarted in flight.

“Practising forced landings from different altitudes under safe conditions can help pilots prepare for an emergency situation,” Mr Macleod explained.

“Being familiar with emergency checklists and your aircraft’s systems will assist in an emergency when identifying and managing an engine failure.”

Read the report: Fuel starvation involving Cessna T210M, VH-MYW, 4 km north-west of Bankstown Airport, New South Wales, on 26 May 2024

Publication Date: 11/10/2024

MTF...P2 

[Peetwo]

Yet another fatal midair collision?? -

Via SkyNews Oz:

Three men confirmed dead after mid-air collision between two light planes in Sydney's south-west
Police have confirmed three men have died after a mid-air crash between two planes in Sydney's south-west.

Adriana Mageros and Bryant Hevesi
October 26, 2024 - 4:04PM

Three men have been confirmed dead after a mid-air crash between two light aircraft in Sydney’s south-west.

The horror crash occurred in the vicinity of Belimbla Park, near Oakdale, about 11.50am on Saturday.

Just before 3.30pm, police confirmed three men had been found deceased following the incident which involved a Jabiru aircraft and a Cessna 182.

Two crime scenes have been established in the area, which is located in the Macarthur region of New South Wales.


Emergency services have raced to the scene of a fatal mid-air crash between two aircraft in Sydney’s south-west. Picture: 7NEWS

Aerial footage captured by 7NEWS showed smoke rising from thick mountainous terrain in the Belimbla Park area.

Multiple emergency crews, including police, ambulance and firefighters, could be seen on the ground on Saturday afternoon.

Members of the public have been urged to avoid the area as investigations continue.

The Oaks Rural Fire Brigade confirmed numerous crews have been deployed to the scene of the aircraft collision.


Smoke seen billowing from thick terrain after the crash. Picture: 7NEWS

"Multiple crews are currently converging to Wanawong Rd Belimbla Park for a reported aircraft incident," it wrote on Facebook.

"Please stay clear of the area and use caution around emergency vehicles."

The cause of the crash is set to be probed by the Australian Transport Safety Bureau (ATSB).

"A team of transport safety investigators from the ATSB's Canberra office, with experience in aircraft operations and maintenance, is preparing to deploy to the accident sites of both aircraft to begin evidence-collecting activities," an ATSB statement said.

"Over coming days, investigators will undertake site mapping, examine the wreckage of both aircraft, and recover any relevant components for further examination at the ATSB’s technical facilities in Canberra.

"Investigators will also seek to interview any witnesses and involved parties, and collect relevant recorded information including any air traffic control and flight tracking data, as well as pilot and aircraft maintenance records, and weather information."

Plus the ATSB media link: https://www.atsb.gov.au/media/2024/mid-a...est-sydney

MTF...P2

[Peetwo]

Popinjay and Iron Bar to the rescue!! -

Via the ABC:

And from the PJ minions..

Engine failure or malfunction involving Boeing 737, VH-VYH, at Sydney Airport, New South Wales, on 8 November 2024

Summary

The ATSB is investigating an engine failure or malfunction involving a Boeing 737, VH-VYH, at Sydney Airport, New South Wales, on 8 November 2024. The aircraft was operating as Qantas flight QF520, scheduled from Sydney to Brisbane, Queensland. 

During take-off from runway 34R at Sydney Airport at about 1240, the aircraft's right engine sustained a failure or malfunction. The flight crew declared an emergency to air traffic control and returned to Sydney, landing on runway 34L. After being visually inspected and cleared by the Aviation Rescue Fire Fighting Service (ARFFS), the aircraft was taxied back to the gate and the passengers and crew disembarked normally. It was reported that some engine debris had exited the engine through the tailpipe and started a grass fire which was extinguished by the ARFFS. No other aircraft damage was evident. 

As part of the evidence collection phase of the investigation, ATSB investigators will obtain and examine maintenance records, recorded data such as flight data and radio recordings, and interview the flight crew. The engine and components will be examined at an appropriate facility. 

A final report will be released at the conclusion of the investigation. Should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify relevant parties, so that appropriate safety action can be taken.

Hmm...note how quickly Popinjay and the Commissioners can generate an AO (aviation occurrence) number, when motivated by a high profile investigation involving the Red Rat (only listed as a 'Short' ATM)...

Next, the Coulson 737 air tanker accident final report is released, via PJ's media minions (again attributed to Popinjay  ):

737 air tanker accident highlights importance of standardised operating procedures, including minimum drop heights


Minimum safe drop heights are in development for large firefighting aircraft in Australia, to address safety issues identified by an ATSB investigation into a 737 air tanker accident in south-west WA.

‘Bomber 139’, a Boeing 737 aircraft converted as a large air tanker, impacted a ridgeline after completing a drop while extending a fire retardant containment line during a bushfire-fighting task in the Fitzgerald River National Park on 6 February 2023.

After striking the ridgeline, the aircraft cleared a small line of foliage before impacting the ground a second time and then sliding to rest. The two pilots on board were able to evacuate through a cockpit window before the aircraft was consumed by a post-impact fire.

“The ATSB’s investigation found that the aircraft was conducting a drop at a low height and airspeed over descending terrain, which required the use of the idle thrust engine power setting and a high rate of descent,” ATSB Chief Commissioner Angus Mitchell said. 

“Towards the end of the drop, the aircraft’s height and airspeed decayed as it approached rising terrain that had not been detected, and was not expected, by the aircraft captain.”

While the aircraft’s thrust levers had been advanced mid-way through the drop, there was insufficient time for engine power to increase to allow the aircraft to climb away and safely clear the ridgeline crossing the aircraft’s exit path.

The report notes the ridgeline had likely not been detected as the captain, who was the pilot flying, had declined a ‘Show Me’ run from the Birddog aircraft, had conducted right hand circuits (restricting their visibility of the target area as they were seated in the left seat on the flightdeck), likely had no visibility of the ridgeline during the go-around from the first drop, and was led by the Birddog to the target through smoke on the second drop.

“Not detecting the rising terrain likely contributed to the captain allowing the aircraft to enter a low energy state during the drop.”

Further, the co-pilot did not identify nor announce any deviations during the retardant drop, which could have alerted the aircraft captain to the low-energy state of the aircraft.

“Notably, the operator and tasking agency had not published a minimum drop height for large air tankers,” Mr Mitchell said.

“This resulted in the co-pilot, who did not believe there was a minimum drop height, not making any announcements about the aircraft’s low energy state prior to the collision.”

The accident occurred when the aircraft was conducting a second drop after releasing three-quarters of its retardant load on the prior run.

“The operator’s practice of the pilots recalculating, and lowering, their target drop speed after a partial load drop also contributed to the aircraft’s low energy state.” 

The investigation found that neither the operator nor the relevant Western Australian Government Departments had published a drop height for large air tankers (whereas the US Forest Service has a minimum large air tanker drop height of 150 ft). 

This meant that aircraft captains could exercise their own judgement for drop heights to improve accuracy.
Bomber 139 was operating in Australia under a contract with the National Aerial Firefighting Centre, which did not impose a minimum drop height, but required the operator to comply with the standard operating procedures (SOPs) of the member state for the aircraft’s nominated operational base, in this case Western Australia.

In turn the Western Australia large air tanker SOPs did not impose a minimum drop height limit. 
 
Since the accident Coulson Aviation implemented a minimum drop height of 200 ft for its airtankers, while the Western Australian Department of Fire and Emergency Services and the Department of Biodiversity, Conservation and Attractions are amending procedures to incorporate drop heights, including a large airtanker drop height of 200 ft.

Meanwhile, at a national level, the Australasian Fire and Emergency Services Authorities Council, the parent organisation for the National Aerial Firefighting Centre, has undertaken to develop national large air tanker SOPs.
Separately, the ATSB has issued a safety recommendation to Coulson Aviation to address crew resource management procedures for retardant drops to reduce the risk of the aircraft entering an unrecoverable state before the pilot monitoring alerts the pilot flying.

“This accident highlights that standard operating procedures and crew resource management should be implemented with the intent to prevent an unsafe situation from developing,” said Mr Mitchell.

“Safety standards should not be solely dependent on the performance of the pilot flying and recovery call-outs.”

Read the report: Controlled flight into terrain involving Boeing 737-3H4 Fireliner, N619SW, Fitzgerald River National Park, Western Australia on 6 February 2023

Publication Date:
06/11/2024

 

MTF...P2

PS: See - HERE - the UP thread for the discussion on the B737 airtanker FR.

[Peetwo]

AO-2024-008 (Short) & AO-2023-020 (Defined) Final Reports completed?? - 

Courtesy of PJ's media minions and attributed to DTS Stewie Macleod:

Fuel management, unsecured cap risk highlighted in Aero Commander forced landing



[b]The pilot of an Aero Commander had to land the aircraft in a field after fuel siphoned overboard due to an incorrectly installed fuel cap, an ATSB investigation has concluded.[/b]

On 8 March 2024, the twin-engine Aero Commander 500-S was conducting a return freight flight from Bankstown to Parkes, with multiple stops each way.

Upon landing after the first sector of the day, the pilot found the aircraft’s fuel cap was off and secured only by a retention chain.

The pilot re-secured the cap, but found the cap off again after the second sector, after landing in Parkes.“For the two sectors from Bankstown to Parkes, the fuel cap had been incorrectly installed with the retention chain lodged in the fuel tank’s anti-siphon valve, resulting in the cap dislodging in flight, and fuel being siphoned overboard,” ATSB Director Transport Safety Stuart Macleod explained.

An inspection and rectification conducted at Parkes by a maintenance engineer fixed the issue.

“However, the pilot identified an unexplained discrepancy between expected fuel remaining and gauge quantity indication, but did not refuel to a known quantity, or amend the flight log,” Mr Macleod noted.

“This meant the aircraft left Parkes without enough fuel to complete the remaining sectors on its return trip back to Bankstown.

”After departing Parkes, the pilot likely did not monitor the fuel gauge, continued fuel calculations based on an incorrect fuel quantity, and did not refuel the aircraft to a known quantity when they landed at their final interim location, Bathurst.

Subsequently, shortly after take-off for the final sector to Bankstown, both engines lost power due to fuel exhaustion, and the pilot conducted a forced landing in a field. Fortunately, the aircraft was undamaged, and the pilot uninjured.

“A missing or unsecured fuel cap should be treated as an emergency, and if detected pilots should immediately divert to the nearest suitable aerodrome,” Mr Macleod said.

Since the incident, the operator, GAM Air, published a notice to pilots reinforcing fuel management procedures. It also commenced periodic auditing of pilot fuel calculations.

Additionally, in response to an ATSB finding that its Quick Turn Around – Pre-Start checklist did not include a fuel quantity check before start, the operator has announced the intention to discontinue using this specific checklist.

“Pre-flight fuel quantity checks should use at least two different verification methods to determine the amount of fuel on board,” Mr Macleod said.

“When using computed fuel on board and comparing against gauge readings, it is important that calculations are accurate. If any discrepancy is detected between the two methods, another method such as filling to a known quantity is required.”

Read the final report: Fuel exhaustion involving Aero Commander 500-S, VH-MEH, 6 km east of Bathurst Airport, New South Wales, on 8 March 2024 

Publication Date: 19/11/2024

Plus attributed to DTS Dr Godlike:

Saab 340 fire and smoke event highlights importance of aircraft configuration knowledge



An in-flight fire and smoke incident involving a Saab 340 freight aircraft over New South Wales last year highlights the importance of operators ensuring flight crews are aware of differences in aircraft configurations.

On 23 April 2023, the Saab 340A was being used for a non-revenue positioning flight from Wagga Wagga, New South Wales, to Charleville, Queensland with a captain and first officer on board. The aircraft was owned by Pel-Air and was being operated by flight crew from Pel-Air's sister company Regional Express (Rex).

While in cruise, the flight crew received a cargo smoke indication on the central warning panel, and fitted their oxygen masks and smoke goggles as a precaution.

A short time later, the cockpit filled with smoke.

“Commencing a diversion to Cobar, the first officer made a PAN-PAN call, and thick smoke filled the flight deck, preventing the crew from effectively seeing external visual references, or the aircraft’s flight instruments,” ATSB Director Transport Safety Dr Stuart Godley said.

While the crew was completing emergency checklists, there were warnings for avionics smoke, the cabin depressurised, and there was a right engine fire detection fail indication.

Fortunately, the crew was able to land at Cobar and evacuate the aircraft on the runway, uninjured.

Fire and Rescue personnel located a heat source at the air conditioning pack, and doused the area with water. An internal inspection later found fire damage in the area around the right recirculating fan.

An investigation by the ATSB determined the in-flight fire likely stemmed from the failure of the recirculating fan’s electronic box sub-assembly.

The investigation’s final report notes the aircraft had been operated by Rex as a passenger aircraft, before being modified to cargo configuration in 2009, for operation by Pel-Air.

“The Rex pilots usually operated passenger aircraft and were not familiar with the cargo-configuration of this aircraft, and Rex did not ensure its flight crews received training in the differences between passenger and freight-configured Saab 340 aircraft,” Dr Godley explained.

Further, it was identified both Pel-Air and Rex’s flight crew operating manuals did not include reference to the location and operation of the cross-valve handle, and the pilots were unable to locate it during the emergency checklist procedures, due to smoke.

Closing of the cross-valve was part of the checklist to address a cargo compartment smoke event, and the pilots were therefore unable to properly action this checklist, despite searching for more than a minute for the cross-valve handle.

The investigation also found the smoke curtain (to isolate the cargo area) was not in place for the flight, as is required for the cargo configuration of the Saab 340, and Saab’s pre-flight documentation for the cargo-configured 340 did not require crews to confirm that a smoke curtain was fitted.

The absence of a curtain, and the flight deck door being open, allowed smoke from the fire to enter the flight deck.
“The depressurisation occurred when the fire weakened the fuselage structure,” Dr Godley explained. 

“Fortunately, this depressurisation aided in the removal of enough smoke from the flight deck, to allow an unhindered approach into Cobar.”

Since the occurrence, Rex has amended its flight crew operating manual to require flight crews to verify the position of the cross-valve handle during pre-flight checks.

The operator has also updated training information delivered in their ground school to cover the cross-valve system for cargo-configured Saab 340 aircraft.

Pel-Air has also revised its flight crew operating manual, with a caution that the smoke barrier curtain must be installed whenever combustible material is carried.

Finally, Saab has revised its preparatory and walk-around pre-flight checklists to include the fitting of the smoke barrier curtain when carrying cargo in cargo-configured 340s.

“As this occurrence demonstrates, it is essential operators ensure flight crews are conversant with differences in aircraft configurations when required,” Dr Godley summarised.“Similarly, flight crew operating manuals must be relevant for the aircraft configuration, and manufacturer pre-flight checklists must cover the modifications fitted, so operators can write the appropriate documentation for flight crews.”

Read the final report: In-flight fire and cabin smoke involving Saab 340A, VH-KDK, 114 km east-north-east of Cobar, New South Wales, on 23 April 2023

Publication Date:
20/11/2024

MTF...P2

[Peetwo]

AO-2025-001 - Collision with water involving Cessna 208, VH-WTY, near Rottnest Island, Western Australia, on 7 January 2025

Via ATSB:

Rottnest Island Cessna 208 accident

Date: 08/01/2025

Media Contact: media@atsb.gov.au

The Australian Transport Safety Bureau (ATSB) has commenced a transport safety investigation into a collision with water accident involving a Cessna 208 floatplane during take-off near Rottnest Island, off Perth, on Tuesday afternoon.

As reported to the ATSB, during take-off the floatplane collided with the water, before coming to rest partially submerged.

The ATSB will deploy a team of transport safety investigators from its Perth, Brisbane and Canberra offices, specialising in human performance, and aircraft operations and maintenance.

Investigators will conduct a range of evidence-gathering activities, including site and wreckage examination, and recovery of any aircraft components for further examination at the ATSB’s technical facilities in Canberra.

Investigators will also seek to interview those on board, and any other witnesses and involved parties, and collect relevant recorded information including available flight tracking data, as well as pilot and aircraft maintenance records, and weather information.

The ATSB asks anyone who may have witnessed or has photos or video footage of the aircraft at any phase of the flight, or in the immediate aftermath of the accident, to make contact via the witness form on our website at their earliest opportunity.

---

Summary

The ATSB is investigating a collision with water involving a Cessna 208 Caravan Amphibian, registered VH-WTY, near Rottnest Island, Western Australia, on 7 January 2025. On board was one pilot, and 6 passengers.

During the water take-off, the aircraft was observed to become airborne then impact the water. The pilot and 2 passengers were fatally injured, and 3 passengers sustained serious injuries.

The ATSB deployed a team of transport safety investigators to the accident site with experience in aircraft operations, maintenance, and human factors. As part of the on-site and evidence collection phase of the investigation, ATSB investigators will examine the aircraft wreckage and other information from the accident site. They will also examine recovered components, interview witnesses and any involved parties, examine maintenance records and operator procedures, retrieve and review recorded data, and collect other relevant information.

The ATSB calls for any witnesses who may have seen the accident, or any pilots operating in the area who may have heard radio calls from the accident aircraft, to make contact with us via the witness form on our website.

The ATSB will release a preliminary report detailing factual information established in the investigation’s evidence-gathering phase in about two months. A final report will be released at the conclusion of the investigation and will detail analysis and findings.

However, if at any time during the investigation we discover a critical safety issue, the ATSB will work closely with the relevant stakeholders so action can be taken to address that issue.

Finally Popinjay to the rescue...

MTF...P2 

[Kharon]

Rottenest Seaplane.

Preliminary ATSB report – HERE – pretty much confirming most of what was observed/ known.  Being completely unfamiliar with the C 208 and even less familiar with 'water' operations; I read through ATSB report – and the UP commentary, more for a general knowledge increase rather than an a commentary standpoint. However, (always one) two item puzzled me and any light cast would be much appreciated; to wit:-

Wreckage examination (from Fig.8) onward.

- Dot point - “The flap selector was in the ‘full’ position and the flap position indicator was showing an intermediate position of about 15°. The wing flaps were in the retracted position.”

Take any help I can get on that??? Can the Pilot 'see' if the flap selected is actually in that position? How much flap is routinely used for a 'choppy' water take off?  Puzzled.

- Dot point - The instrument panel and combing appeared undamaged. All circuit breakers were pushed in except those corresponding to the strobe light and stall warning.

Again; is it routine to isolate the stall warning? I can see where it may become a 'nuisance' when the aircraft is 'bouncing about'?

Just asking, the curiosity curse lives....

Toot – toot.

[Peetwo]

Rottnest Seaplane.

Preliminary ATSB report – HERE – pretty much confirming most of what was observed/ known.  Being completely unfamiliar with the C 208 and even less familiar with 'water' operations; I read through ATSB report – and the UP commentary, more for a general knowledge increase rather than an a commentary standpoint. However, (always one) two item puzzled me and any light cast would be much appreciated; to wit:-

Wreckage examination (from Fig.8) onward.

- Dot point - “The flap selector was in the ‘full’ position and the flap position indicator was showing an intermediate position of about 15°. The wing flaps were in the retracted position.”

Take any help I can get on that??? Can the Pilot 'see' if the flap selected is actually in that position? How much flap is routinely used for a 'choppy' water take off?  Puzzled.

- Dot point - The instrument panel and combing appeared undamaged. All circuit breakers were pushed in except those corresponding to the strobe light and stall warning.

Again; is it routine to isolate the stall warning? I can see where it may become a 'nuisance' when the aircraft is 'bouncing about'?

Just asking, the curiosity curse lives....

Toot – toot.


P2 Addendum: 'Popinjay to the rescue!!'

Pilot assessment of sea and weather conditions, operator risk controls, and assessment and approval for floatplane operations are among a range of factors the ATSB will consider as it continues its investigation of a fatal floatplane accident off Rottnest Island, Western Australia. 

The ATSB’s preliminary report from its ongoing investigation details that on the morning of 7 January 2025, the Cessna Caravan with a pilot and 10 passengers on board operated on a passenger flight from South Perth to Rottnest Island, landing on the water at Thomson Bay.

Later that day, the pilot and six of the passengers returned to the aircraft for the return flight to South Perth. 

The take-off commenced at about 4pm, on an easterly track towards Phillip Rock, a rocky outcrop at the southern end of Thomson Bay. About 32 seconds later and 600 m from the start of the take-off run, the aircraft became airborne with a high nose attitude, before it rolled rapidly to the left and impacted the water.

Immediately after the collision, the aircraft remained partially afloat, and four surviving passengers moved into a small pocket of air in the rear of the cabin. One passenger opened the top part of the rear right door, through which they and one other passenger escaped. 

Another passenger was rescued by a witness, who broke the rear left cabin window and pulled the passenger out of the aircraft, while the fourth passenger also escaped through the window. 

The pilot and remaining two passengers were fatally injured.

“This preliminary report has been released to provide timely factual information as to the nature of the accident and updates on where the investigation is likely to focus,” ATSB Chief Commissioner Angus Mitchell emphasised.

“As the investigation continues investigators will continue to gather, review and examine evidence, in order to develop our analysis to identify those factors that contributed to the accident, as well as any factors that increased safety risk.” 

The preliminary report describes events on Rottnest Island prior to the accident flight, including that the pilot exchanged texts with the chief pilot of the operator, Swan River Seaplanes, about sea and wind conditions.

“This included a forecast noting strong and gusting winds, and consideration of an early return to South Perth,” Mr Mitchell noted.

“The pilot then boarded a small boat to assess conditions in Thomson Bay, and subsequently elected for a take-off in a different direction to take-offs conducted on prior trips.”

The ATSB’s subsequent examination of the aircraft wreckage did not identify any damage consistent with the aircraft having struck an underwater landmass or object, while a specialist borescope examination of the engine did not identify evidence of pre-accident damage. 

“The engine will be subject to a tear down by the manufacturer Pratt & Whitney Canada, the results of which will be provided to the investigation, and we will also continue our analysis of the aircraft’s recorded flight data” Mr Mitchell said.

“The investigation will include analysis of flight data from previous flights, and will seek to understand the handling of the aircraft, particularly in the context of the conditions in Thomson Bay on the afternoon of the accident.”

Bureau of Meteorology data, as well as video captured by witnesses and others, showed that conditions on the afternoon were windy with some waves in Thomson Bay. 

“The investigation will consider the information the pilot had access to for assessing these conditions, and the procedures and other risk controls used by the operator for assessing and planning take-offs from Thomson Bay,” Mr Mitchell said.

“We will also consider the system used by the operator to identify and analyse the risks associated with operating from this location, and the approvals for floatplane operations”.

The investigation will also give further consideration to recent maintenance history of the aircraft, which had entered service with the operator on 2 January (having been in storage since March 2024), and to the assessment and approval processes for floatplane operations at Rottnest Island.

“The investigation will seek to uncover and identify systemic safety risk factors. Should any critical risks be identified, we will immediately notify relevant parties so they can take safety action,” Mr Mitchell concluded.

Read the preliminary report: Collision with water involving Cessna 208 Caravan, VH-WTY, Thomson Bay, Rottnest Island, Western Australia, on 7 January 2025

Publication Date
27/02/2025

PS: This prelim was actually 21 days overdue according to the ICAO Annex 13 requirement for a prelim report to be published within 30 days of the accident occurring

[Kharon]

One day; it will all make sense.

Or, at least be something I can understand. Not being the brightest bulb on the Christmas tree don't help with the head scratching- however, I wish I could be shed of this nagging irritation about the Rottenest C 208 water operation event: I really do. The 'answer' is certainly simple enough; but it eludes and puzzles me; although I don't know why it should. However, that said – homework time.

It seems that there have been some 'mods' and 'tweeks' made over time to the 208 Flap operation 'system'. Nothing major – basic system – wise and certainly nothing that could (in normal, routine operations) create any sort of 'problem'. Seems simple enough. Your 'Basic' may be found – HERE – at Section 7:24. One page, self explanatory read. Changes and 'tweeks' may be found – HERE-; albeit not an 'official' guide it serves it's purpose. Non of this explains the curious statement from the ATSB related to the Flap system – Nada, zip, nuttin.

Wreckage examination (from Fig.8) onward. ATSB - Dot point - “The flap selector was in the ‘full’ position and the flap position indicator was showing an intermediate position of about 15°. The wing flaps were in the retracted position.”

Being ignorant of float operations; I assume that 'flap' would be used for take off; makes sense. Fine; would the routine (first 'slot' position) 10° be used; or, would the selector be moved to the intermediate 15° (not slotted) position? No idea if it actually matters or is even relevant. Well not until you read the next line from the ATSB.

ATSB - “The wing flaps were in the retracted position.”

This is direct contrast to – ATSB “The wing flaps were selected etc...” This discovery – after retrieval of the air-frame. It was also noted – ATSB - “ The flap selector was in the ‘full’ position.

This aircraft 'collided, at speed with water. This aircraft was 'probably' (guess) configured with flap @ 10 or even 15° of flap for the take-off. The cockpit indicator reflects that selection; Flap selector on retrieval shows a 'Full' down selection (last 'slotted' position) but the Flaps themselves were found 'retracted'.

Please explain – someone. I cannot deduce any sensible reason from the systems notes which can even begin to explain this curiosity. Nor do I have the operational knowledge to dive any deeper. BUT there is no-way known that this is not a factor  in this drama. ATSB seem to have skipped around this data. However; this is an electrical system; what the pointer shows is what you selected. Somewhere between zero flap afterwards and flap 15° (Assumed) set for the take off – how is it that on recovery Flap was 'retracted'?

P2: "This prelim was actually 21 days overdue according to the ICAO Annex 13 requirement for a prelim report to be published within 30 days of the accident occurring."

Aye; it beats me – perhaps this is why ATSB dragged their collective 'Learning's (Grrr) out for 50 odd days; do they not know why either? T'is no matter; as stated – not within my area of expertise; but it surely does fall square into the 'curiosity' area – big time.  - Handing over::-::

Toot – toot.

[Peetwo]

Popinjay to the rescue??

Via PJ and his minions...  

Flapping cowling door likely distracted pilot prior to Jandakot Chipmunk accident


The pilot of a Chipmunk light aeroplane was likely distracted by an unsecured engine cowling before an aerodynamic stall and collision with terrain shortly after take-off from Jandakot Airport, in Perth’s south.

On 26 April 2024 a DHC-1 MK 22 Chipmunk single piston-engine aircraft took off from Jandakot Airport.

Shortly after take-off, the aircraft conducted a left turn, likely an attempt to return to land. The pilot declared a MAYDAY, and as the angle of bank increased, the aircraft descended and collided with terrain.

The pilot, who was the sole occupant of the aircraft, was transported to hospital, but later succumbed to their injuries.

An Australian Transport Safety Bureau investigation found the pilot did not detect the engine cowl latches on the left side were left unfastened prior to flight.

“Footage showed and witness reports indicate the cowling began to flap open and closed after take-off,” ATSB Chief Commissioner Angus Mitchell said.

A review of past occurrences involving other Chipmunk aircraft did not indicate a flapping cowling would necessarily result in controllability issues.
“Rather, the flapping of the cowling likely distracted the pilot, resulting in a high cognitive workload,” Mr Mitchell explained, “at which point the aircraft commenced a low level, high angle of bank turn, and aerodynamically stalled.”

Mr Mitchell said the accident illustrated the importance of pre-flight preparation to reduce the likelihood of an abnormal occurrence.

“It should also remind pilots of the hazards that can lead to loss of control events, such as high angles of bank, particularly at low height,” he added.
During its investigation, the ATSB also identified that all 12 rivets attaching the upper structure between the front and rear cockpits sheared during the accident sequence.

Metallurgical analysis showed all 12 of the rivets were of a non-conforming type, and half of them were about one-third of the specification strength.

While this compromised the crashworthiness of the aircraft, its impact on survivability in this accident could not be determined.

Nonetheless, the ATSB issued a Safety Advisory Notice on 11 September 2024, advising Chipmunk maintainers and owners of the importance of ensuring modifications are carried out to the required specification.

“The use of non-conforming rivets significantly compromised the accident aircraft’s crashworthiness,” Mr Mitchell summarised.

“Maintainers and owners of all aircraft are reminded that when modifications are made, they must conform to the required specifications, or be returned to these specifications during maintenance.”

Read the final report: Collision with terrain involving Oficinas Gerais de Material Aeronautico DHC-1 MK 22 Chipmunk, VH-POR, at Jandakot Airport, Western Australia, on 26 April 2024

Publication Date - 25/03/2025

  
MTF...P2 

[Kharon]

Oh! Look Mum; - “there's an aircraft in my ashtray.”

Not really; but close enough on a few occasions – it happens {mostly) Outside Controlled Airspace (OCTA). The factors are well known.  Aircraft are difficult to spot, even when you know where to 'look' – remembering the closing 'speed' equation. 120 Knots = 224 Kph.  150 Knots = 277.8 Kph. 180 Knots= 333.36 Kph. The climb and descent speeds of the two aircraft at Mangalore Beechcraft (Travelair) (AEM) and the PA 44 (Seminole) (JQF) provide a rough idea of the 'closure rate' between the pair (no wind data) [irrelevant} the rate of closure in a time scale matters here. Lets say JQF was climbing at about 100 Knots ~185 Kph. Lets say AEM was descending at 160 Knots ~296 Kph. = +/- 480 Kph. Ten nautical miles is about 18.5 Kilometers. Closing speed 259 knots. Ten miles at 259 knots = 2.3 minutes.  Time not really a factor – not with prior knowledge, a plan, or a sighting; provided you know there's an aircraft climbing on your descent path.

ATSB claim (quite rightly) that there were two experienced pilots on board; fair enough – however. One was conducting a check flight the other a training flight. Lets consider that for a moment. Technically and operationally two of the most 'critical' parts of operating under the IFR are the approach and landing phase and the take – off departure phase. When training or examining a candidate pilot; where do you imagine the attention of 'training/check pilot' will be mostly focused? Lots to do, much to watch, it is a 'busy' period where the potential for a serious error 'can' occur. Focus on task is not only demanded; but absolutely essential. 

ATSB - “As such, the ATSB concluded that the pilots either failed to identify that a collision risk existed or identified the potential risk but incorrectly assessed that the aircraft were sufficiently separated. In either case, the primary defence of established self separation required in non controlled airspace was absent.”

I beg to differ M'Lud. Start  - HERE – with a good analysis by 'Blackburn' over on the UP. It is worthy of consideration – even if just for the questions it raises.
 
For example – Was the CTAF frequency 'busy'? Normally, on approach, comms are tuned to the CTAF and the area frequency (ATC). On approach/descent a 'silent' cockpit is the general rule; particularly during training to avoid distraction; unless something is turning Pear shaped. But here we have one taxi for departure coming South; one for approach heading North; one to climb, one to descend. It is a reasonable assumption that at least one of the instructing pilots would be waiting and listening for a radio call to 'sort out' the potential conflict.  It was, for a long while only a 'potential' conflict. Simple enough - “we'll maintain 5000' until over the aid” the response from the opposition Roger; will maintain 4000' until clear. CTAF busy – OK: call Center and sort it out there. But 'Sort it' the tooter the sweeter. So much for the crew efforts. Blackburn raises the specter of 'No Known Traffic' – twice. At 1120:28 the inbound pilot acknowledges the Center Controller advice of 'traffic'.

UP post - “The report also says that traffic was provided, however when AEM came on the local controller’s frequency, the crew of AEM were told on two occasions, 2 minutes apart (11.17.42 and 11.19.35) that there was NO IFR TRAFFIC. Up till then (2 minutes prior to the collision) JQF had not been provided any traffic info on the opposite direction descending traffic.

Can you spot the holes in the cheese? This report begs more questions than it answers; but, its hard to gainsay the ATSB summary:-

“Analysis conducted for the ATSB by an air traffic services subject matter expert identified a number of potential reasons why updated traffic information would not have been provided. Specifically, the controller: could reasonably expect the occupants of the aircraft were talking to each other and taking action to avoid each other may over-transmit the pilots while they are trying to talk to each other not being fully aware of any coordination between the occupants of the two aircraft, could give advice that created a hazardous situation.

Flatulent, slightly fluffy reasoning; ATC 'could' have made sure that the conflict message was delivered; and received confirmation earlier (much) from both crew. This is a part of this event which will always raise conjecture. Yet sometimes – rarely the planets align and events happen. This should have been preventable; one radio call from any party involved could have avoided it all. IFR particularly in IMC, especially in a known 'high volume' traffic area when the weather, cloud, traffic, comms and terrain is 'suspect'. The area is particularly busy; until there is dedicated ATC service (one consul) the risk remains high; more service or less aircraft seems to be the only 'bullet proof' solution; but even then, at the end of the shift there's only one fellah responsible for the flight. That's why they are paid  'the big bucks'..........

Toot toot..

[Kharon]

Mangalore (final)..

Over it; however - Somehow, the event at MNG keeps creeping into thoughts; stray notions pop up when the thinking gear is at idle (or playing Darts). The event has officially been put aside with the 'bases' neatly covered and the cracks papered over; but, something keeps nagging away. I try putting myself in each pilot seat; (even tried the ATCO stool).

“I have often tried to imagine how I might have acted differently. Always I end up in the same place.”

That place being in the right hand seat of the inbound aircraft.

Blackburn - “A review conducted by Airservices following the accident concluded that both aircraft were provided with, and acknowledged receipt of, mutual traffic that contained all relevant information.”

If we put that aside; we are left with a 13 second 'transmission' from the ATCO:-

“Between 1120:15 1120:28 Controller again called the pilots of AEM. Pilot responded and traffic information about JQF shortly to depart Mangalore was passed and acknowledged.”

So, lets start the clock about 11:22:19. 

“Between 11:22:19 1123:00 JQF Departure report to controller. Information was provided that the aircraft was passing 2,700 ft on climb to 7,000 ft and tracking to LACEY.”

“Controller advised the pilots that AEM was inbound to Mangalore in JQF's 12 o’clock position, for air-work, passing 5,000 ft on descent to not above 4,000 ft. AEM was apparently 10-11 NM from YMNG”.

By about this time, both fellah's in the right seats should have been paying a lot of attention. 10 miles ≈ 2.3 minutes (±) - a potential 'conflict' to deal with. Just a 'bread and butter' event operating OCTA. How many times during a day do IFR flights 'self separate? 'Lots of' is the ball park answer. So how long would you allow the flying pilot to establish contact with the opposite direction traffic and arrange separation? Not too long I should say.  Q - “Got that traffic mate”  A – “Yes advised them that we will maintain 5000 until clear”. Choc frog answer #1.

In the opposition aircraft; a similar scenario should be developing: “Comms established maintaining 4000' until clear”. Choc frog answer #2.

In the right hand seat, all should be quiet and content with this information provided. If it was not; then its time for the grown ups to step in and settle the quarrel;; the doomsday clock was ticking and -  Murphy was lurking.

The gods alone know what the ATSB 'simulation' of cockpit 'vision' cost; it is totally irrelevant to IFR operations (may be useful to junior VFR maybe) but IFR is a mental picture game- in IMC, OCTA all you have is the 'mind-map' of where you are and where the opposition is; this is a dynamic, fast moving, fluid situation. Communication is paramount in this routine, almost everyday occurrence, when the weather is liquid and lousy.

Oh! I don't know; but I feel the ATSB could have done a better job on this one. It reaches deep into fundamental operating practice across the spectrum; ATC, training, pilot attitudes, communication systems etc, etc. I particularity dislike this push toward more dependence on ADSB separation becoming the norm. Sure it is a great tool; but no more than that; it cannot replace an active, plugged in, situation aware mind on the flight deck. When it matters; really matters, it is that mind, not a machine which will save the day. One may only require that facility once or twice in a lifetime of flying – but when needed, it must be fully operational, when the clock is ticking.

Sorry to bang on; but the more I think about the Mangalore event; the more aligned 'holes' in the Reason cheese I find. But; as the prophets say:-

“Once is happenstance. Twice is coincidence. Three times is enemy action.

Toot – (and - back in my box) – toot.......