[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