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Latest unnecessary, bollocks Popinjay Media Releases -   

The chalk, via PJ HQ:

Cessna 172 go-around accident emphasises importance of appropriately actioning checklists



A Cessna 172 that collided with terrain during a forced landing at Murwillumbah was likely not configured correctly during an attempted go-around, an Australian Transport Safety Bureau investigation has concluded.

The aircraft was on final approach at Murwillumbah during a private flight from Gold Coast Airport on 15 October 2023, when the pilot estimated the aircraft was too high for a landing and elected to conduct a go-around.

An experienced pilot on the ground adjacent to the runway, who witnessed the accident, recalled hearing the engine running at a low power setting, before producing a loud bang or ‘pop’, about half way down the runway, which sounded like the throttle had been pushed forward too quickly.

The Cessna pilot, meanwhile, believed the aircraft had not responded with adequate power as they commenced the go-around, although the ATSB investigation found it was unlikely the engine was not producing power.

“The pilot assessed they had insufficient power to climb and that there was insufficient runway remaining to land,” said ATSB Director Transport Safety Stuart Macleod.

“Accordingly, the pilot elected to conduct a forced landing in a field about 1 km to the north of the airport.”

During the forced landing, the aircraft was substantially damaged, and the pilot sustained minor injuries.

“Prior to the forced landing, the pilot advised they were concerned about an aerodynamic stall, so kept the flaps at 40 degrees to reduce the stall speed,” Mr Macleod explained.

“This would have created a large amount of drag and subsequently impaired climb performance.”

Mr Macleod noted the 40 degrees flap setting was not in line with the 20 degrees prescribed for a go-around in the Cessna 172M Pilot Operating Handbook.

“This accident highlights the importance of pilots appropriately actioning checklists and following procedures in the Pilot’s Operating Handbook.

“The improper or non-use of checklists has been cited as a factor in several aircraft accidents.”

While not contributory in the accident, the ATSB also found an unsecured nose-wheel steering tow bar in the aircraft increased the risk of serious injury to the pilot.

“Loose items in the baggage area or cockpit can become dangerous projectiles and may cause serious injuries during an abrupt stop, turbulence or an accident sequence.”

Read the report: Collision with terrain involving Cessna 172M, VH-JUA, 1km north-east of Murwillumbah, New South Wales on 15 October 2023

Publication Date: 14/02/2024

Lake Macquarie runway near collision highlights the importance of effective radio communications and an effective visual scan at non-towered aerodromes



The pilots of two aircraft involved in a runway accident at Lake Macquarie did not hear each other on the radio, nor see one another, before a near collision occurred and one aircraft struck the ground while taking avoiding action, an ATSB investigation report details.

On 12 May 2023, an instructor and student pilot were conducting wheel balance exercises in a gyroplane on runway 07 at Lake Macquarie Airport.

Following one of these exercises, the student made a radio broadcast while the instructor turned the gyroplane around, about halfway down the runway, and taxied back toward the western threshold, to repeat the exercise.

“Meanwhile, an Extra EA 300L aerobatic aircraft with a pilot and passenger on board had taxied from the apron toward the eastern end of the runway to conduct a commercial joy flight,” ATSB Director Transport Safety Stuart Macleod said.

“The Extra pilot made two radio broadcasts before entering the runway, and beginning to taxi down the runway toward the western end, for a planned take-off from runway 07.”

At about this time, the gyroplane commenced another exercise, and accelerated down runway 07, toward the taxiing Extra.

“Neither aircraft’s pilots heard the radio broadcasts of, or saw the other, until the pilots in the gyroplane observed the Extra about 20 m in front of them on the runway,” Mr Macleod said.

In reaction, the gyroplane’s instructor pilot took control and banked right to avoid collision.

The aircraft’s rotor blades impacted the runway surface before the gyroplane veered off the runway and struck the ground, coming to rest on its side. The gyroplane was substantially damaged, the instructor was seriously injured, and the student pilot sustained minor injuries.

“When none of the pilots heard radio calls from the other aircraft, aircraft separation became reliant solely upon visual acquisition,” Mr Macleod explained.

“As such, several factors likely reduced the ability of the pilots to then visually identify each other, including the small angular size of each aircraft, the complex background features with low relative contrast, and minimal relative movement between the aircraft.”

In addition, the Extra’s tailwheel configuration limited the pilot’s forward visibility while taxiing, while sun glare likely also affected the Extra pilot’s ability to detect the gyroplane.

“This accident highlights the limitations of unalerted see-and-avoid around non-towered aerodromes,” Mr Macleod said.

“Reducing the collision risk around non-towered airports is one of the ATSB’s key SafetyWatch concerns, and this accident serves to remind pilots of the importance of effective radio communications to increase traffic awareness, and to ensure an effective visual scan to identify conflicting traffic.”

The ATSB’s publication A pilot’s guide to staying safe in the vicinity of non-controlled aerodromes outlines many of the common problems that occur at non-controlled aerodromes, and offers useful strategies to keep yourself and other pilots safe.

Additionally, the Civil Aviation Safety Authority's Pilot Safety Hub also has extensive information on non-controlled operations.

Since the accident, Lake Macquarie Airport’s operator released a bulletin to all aircraft operators highlighting the importance of visual lookout in addition to radio discipline. The airport operator has also acquired radio recording equipment to allow communications to be periodically reviewed.

The operator of the Extra updated operational procedures, and the representative body for gyroplanes, the Australian Sport and Rotorcraft Association, has advised ATSB of its intent to replace the one-off human factors exam with a recurrent exam.

Read the report: Collision with terrain involving Magni M16C Tandem Trainer gyroplane, G1850, while avoiding Extra EA 300L, VH-IOG at Lake Macquarie Airport, New South Wales on 12 May 2023

Publication Date: 13/02/2024

Blah..blah..blah!! - Why? Let the report talk for itself - FDS!

The cheese, courtesy the UK AAIB, via X:

AAIB
@aaibgovuk

A report has been published into a serious incident involving a Leonardo AW189 (G-MCGT) which sounded a terrain warning during a go-around due to rising ground ahead at Ballintoy Harbour, County Antrim on 26 July 2021
https://www.gov.uk/government/news/aaib-...-july-2021

From the AAIB link (above):

Report into a serious incident involving a Leonardo AW189 (G-MCGT) which sounded a terrain warning during a go-around due to rising ground ahead at Ballintoy Harbour, County Antrim on 26 July 2021.


From:  Air Accidents Investigation Branch

Published 15 February 2024

The Search and Rescue helicopter was on its third approach, in poor visibility, to collect a casualty from a site adjacent to high ground. The Pilot Flying (PF) selected a mode of the Automatic Flight Control System (AFCS) which would bring the helicopter to a hover. As he did so, the helicopter unexpectedly yawed towards the high ground. When a further selection was made on the AFCS to effect a go-around, the helicopter accelerated towards the terrain while maintaining height. The Helicopter Terrain Awareness Warning System (HTAWS) triggered a visual and aural caution terrain alert. The crew immediately made a climbing turn onto their planned escape heading during which a warning terrain alert triggered. The helicopter recovered to a safe height and returned to its home base.

The unexpected yaw was caused by a mismatch between the previously selected AFCS heading reference and the heading flown by the PF. While the helicopter and the flight control system were found to be serviceable and performed as designed, the crew did not have a complete understanding of the functionality of all the AFCS modes. Other factors included:

• Overriding the engaged modes by manually flying the helicopter.
  
• A lack of clarity between the role of PF and Pilot Monitoring (PM).
  
• Ineffective communication and co-ordination between the pilots.
  
• Imprecise application of Standard Operating Procedures (SOPs).
  

The operator took a number of safety actions to raise awareness of the event, improve knowledge of the autopilot modes and include the event as part of their initial and recurrent training.

Read the report.

Simple, just the facts, no self-aggrandisement, no biased opinion and no attempted cover-ups; or arse-covering - TOP STUFF!   

MTF...P2 

PS: I know it's not our area but you can't keep a good muppet down - 'Popinjay to the RESCUE!!':

Train collision highlights shared responsibility of train drivers and operators in managing fatigue
An ATSB investigation into a fatal collision between freight trains north-east of Perth highlights the shared responsibility of train drivers and operators in managing fatigue.

In the early morning of 24 December 2019, the driver of a Pacific National intermodal freight train was fatally injured when it collided with the rear of a stationary grain train at Jumperkine.
The freight train driver had passed a signal at caution, and a signal at danger – instructing them to stop – prior to the collision, but emergency braking was only applied when the grain train came into view.

“Despite being closely behind another train, the driver had passed 33 consecutive green signals over the two hours prior to reaching the signal at caution,” Chief Commissioner Angus Mitchell said.

“The driver was likely experiencing a level of fatigue known to adversely affect performance, and was almost certainly unaware they had passed the signal at caution, and then the signal at danger,” Chief Commissioner Angus Mitchell said.

The driver’s responses to the locomotive vigilance system timed alerts became slower as the journey progressed, but – consistent with the known limitations of these systems – it did not identify when the driver was fatigued and not attentive to rail signals.

“The ATSB concluded several fatigue-related factors, relevant to both individuals and organisations, either contributed to, or increased risk, in this accident.”

The driver’s fatigue was likely due to a combination of insufficient sleep in the 48 hours prior to the accident, and operating in the window of the circadian low, the investigation found.

“This accident highlights the consequences that can arise when train drivers perform their duties without sufficient sleep, and that the responsibility for managing fatigue in the rail sector is shared between drivers and operators,” said Mr Mitchell.

“Drivers have a responsibility to effectively use rostered breaks to rest, and self-report if they have had less sleep than required, and operators should promote an environment in which identification of fatigue concerns is encouraged, and any barriers to fatigue reporting are examined and understood.”
Since the accident, Pacific National has taken a range of safety actions to address issues with its fatigue assessment and reporting processes, as well as the limited controls available to manage the risk of signals being passed at danger during driver-only operations, including incidents associated with fatigue.
The investigation also noted that, like much of Australia’s freight rail network, the railway between Kalgoorlie and Perth lacks an automatic safety system to prevent a train from passing a signal at danger, or to stop a train which has passed such a signal.

This means the safeworking system is reliant on rail traffic crews observing and complying with displayed signal aspects.

“Although reliance on signal compliance has been central to the rail safety system in Australia for many years, it is fundamentally limited in situations where the driver is not fully attentive to the rail corridor or misperceives a signal,” Mr Mitchell said.

“Until automatic train protection or similar technology is considered viable, rail transport operators should ensure that the set of risk controls they have in place provides sufficient assurance to minimise the risk associated with signals passed at danger (SPADs) or other overruns of authority.

“The ATSB encourages rolling stock operators, industry bodies and others to develop technological improvements to vigilance systems or other technologies to enhance the ability to identify when drivers are fatigued or otherwise inattentive.”

Since the accident, the rail infrastructure manager, Arc Infrastructure, has also taken a number of safety actions, including amending its rules to require NCOs to make an emergency radio call to all rail traffic on the corridor when a train exceeds its limits of authority.

“Additionally, in response to this accident both Pacific National and Arc Infrastructure entered into enforceable voluntary undertakings with the Office of the National Rail Safety Regulator (ONRSR), prescribing a range of safety steps to be taken in response to the accident,” Mr Mitchell said.

Read the report: Collision between freight trains 7MP5 and 2K66, at Jumperkine, Western Australia, on 24 December 2019.

Publication Date
15/02/2024

Hmm...good to see that elongated investigations of 2+ years is not isolated to aviation...

MTF...P2