Controlled flight into terrain Near Bathurst Island Aerodrome, Northern Territory
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ATSB TRANSPORT SAFETY REPORT
Cessna Aircraft Company 310R
Publishing information Published by
Ownership of intellectual property rights in this publication
SAFETY SUMMARY What happened
What has been done as a result
CONTENTS SAFETY SUMMARY iii THE AUSTRALIAN TRANSPORT SAFETY BUREAU vi TERMINOLOGY USED IN THIS REPORT vii
THE AUSTRALIAN TRANSPORT SAFETY BUREAU
Purpose of safety investigations
Developing safety action
TERMINOLOGY USED IN THIS REPORT Occurrence
Contributing safety factor
Aviation Occurrence Investigation –AO-2011-017
Controlled flight into terrain
Near Bathurst Island Aerodrome, Northern Territory
VH-XGX, Cessna Aircraft Company 310R
Aviation Occurrence Investigation
AO-2011-017
Controlled flight into terrain –
VH-XGX
Released in accordance with section 25 of the Transport Safety Investigation Act 2003
Report No. AO-2011-017
Publication date 14 June 2012
Published by: Australian Transport Safety Bureau
Postal address: PO Box 967, Civic Square ACT 2608
Office: 62 Northbourne Avenue Canberra, Australian Capital Territory 2601
Telephone: 1800 020 616, from overseas +61 2 6257 4150
Accident and incident notification: 1800 011 034 (24 hours)
Facsimile: 02 6247 3117, from overseas +61 2 6247 3117
Email: atsbinfo@atsb.gov.au
Internet: www.atsb.gov.au
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Source: Australian Transport Safety Bureau
Copyright in material obtained from other agencies, private individuals or organisations, belongs to those agencies, individuals or organisations. Where you want to use their material you will need to contact them directly.
SAFETY SUMMARY
On 5 February 2011, the pilot of a Cessna Aircraft Company 310R aircraft, registered VH-XGX, was conducting a return flight to Darwin, Northern Territory, following a charter flight to Bathurst Island. The pilot departed from Bathurst Island Aerodrome at approximately 2140 Central Standard Time and the aircraft collided with terrain shortly thereafter – approximately 1 km from the upwind end of the departure runway. The pilot, the sole occupant of the aircraft, sustained fatal injuries and the aircraft was destroyed by the impact forces and a post-impact fire.
What the ATSB found
The ATSB did not identify any technical deficiencies within the aircraft that may have contributed to the impact with terrain. The location of the wreckage, together with the dark night conditions and the relatively light load of the aircraft suggested that it was likely that the pilot was influenced by the effects of somatogravic illusion following takeoff. The somatogravic illusion is a powerful human physiological illusion that produces an upward-pitching sensation under conditions of acceleration accompanied by limited visual or other references.
Following the accident, the subcontracted operator (the pilot's employer) advised of increased night operational checks of new pilots and low/medium time pilots operating from Darwin. These increased checks were implemented in November 2011.
Safety message
The somatogravic illusion can affect any pilot, and the ATSB highlights the importance of pilots being aware of the conditions under which the illusion may occur and the importance of understanding the ways in which they can manage the associated hazard. This includes strict vigilance in the use of the attitude indicator (artificial horizon) as the primary source of aircraft pitch angle information, and correct instrument scanning techniques to verify the attitude and performance of the aircraft.
Websites of the ATSB, the Civil Aviation Safety Authority and the US Federal Aviation Administration provide a number of sources of information on spatial disorientation and illusions.
SAFETY SUMMARY iii
THE AUSTRALIAN TRANSPORT SAFETY BUREAU vi
TERMINOLOGY USED IN THIS REPORT vii
FACTUAL INFORMATION 1
SAFETY ACTION 17
APPENDIX A: SOURCES AND SUBMISSIONS 19
The Australian Transport Safety Bureau (ATSB) is an independent Commonwealth Government statutory agency. The Bureau is governed by a Commission and is entirely separate from transport regulators, policy makers and service providers. The ATSB's function is to improve safety and public confidence in the aviation, marine and rail modes of transport through excellence in: independent investigation of transport accidents and other safety occurrences; safety data recording, analysis and research; fostering safety awareness, knowledge and action.
The ATSB is responsible for investigating accidents and other transport safety matters involving civil aviation, marine and rail operations in Australia that fall within Commonwealth jurisdiction, as well as participating in overseas investigations involving Australian registered aircraft and ships. A primary concern is the safety of commercial transport, with particular regard to fare-paying passenger operations.
The ATSB performs its functions in accordance with the provisions of the Transport Safety Investigation Act 2003 and Regulations and, where applicable, relevant international agreements.
The object of a safety investigation is to identify and reduce safety-related risk. ATSB investigations determine and communicate the safety factors related to the transport safety matter being investigated. The terms the ATSB uses to refer to key safety and risk concepts are set out in the next section: Terminology Used in this Report.
It is not a function of the ATSB to apportion blame or determine liability. At the same time, an investigation report must include factual material of sufficient weight to support the analysis and findings. At all times the ATSB endeavours to balance the use of material that could imply adverse comment with the need to properly explain what happened, and why, in a fair and unbiased manner.
Central to the ATSB's investigation of transport safety matters is the early identification of safety issues in the transport environment. The ATSB prefers to encourage the relevant organisation(s) to initiate proactive safety action that addresses safety issues. Nevertheless, the ATSB may use its power to make a formal safety recommendation either during or at the end of an investigation, depending on the level of risk associated with a safety issue and the extent of corrective action undertaken by the relevant organisation.
When safety recommendations are issued, they focus on clearly describing the safety issue of concern, rather than providing instructions or opinions on a preferred method of corrective action. As with equivalent overseas organisations, the ATSB has no power to enforce the implementation of its recommendations. It is a matter for the body to which an ATSB recommendation is directed to assess the costs and benefits of any particular means of addressing a safety issue.
When the ATSB issues a safety recommendation to a person, organisation or agency, they must provide a written response within 90 days. That response must indicate whether they accept the recommendation, any reasons for not accepting part or all of the recommendation, and details of any proposed safety action to give effect to the recommendation.
The ATSB can also issue safety advisory notices suggesting that an organisation or an industry sector consider a safety issue and take action where it believes appropriate, or to raise general awareness of important safety information in the industry. There is no requirement for a formal response to an advisory notice, although the ATSB will publish any response it receives.
TERMINOLOGY USED IN THIS REPORT
Occurrence: accident or incident.
Safety factor: an event or condition that increases safety risk. In other words, it is something that, if it occurred in the future, would increase the likelihood of an occurrence, and/or the severity of the adverse consequences associated with an occurrence. Safety factors include the occurrence events (e.g. engine failure, signal passed at danger, grounding), individual actions (e.g. errors and violations), local conditions, current risk controls and organisational influences.
Contributing safety factor: a safety factor that, had it not occurred or existed at the time of an occurrence, then either: (a) the occurrence would probably not have occurred; or (b) the adverse consequences associated with the occurrence would probably not have occurred or have been as serious, or (c) another contributing safety factor would probably not have occurred or existed.
Other safety factor: a safety factor identified during an occurrence investigation which did not meet the definition of contributing safety factor but was still considered to be important to communicate in an investigation report in the interests of improved transport safety.
Other key finding: any finding, other than that associated with safety factors, considered important to include in an investigation report. Such findings may resolve ambiguity or controversy, describe possible scenarios or safety factors when firm safety factor findings were not able to be made, or note events or conditions which 'saved the day' or played an important role in reducing the risk associated with an occurrence.
Safety issue: a safety factor that (a) can reasonably be regarded as having the potential to adversely affect the safety of future operations, and (b) is a characteristic of an organisation or a system, rather than a characteristic of a specific individual, or characteristic of an operational environment at a specific point in time.
Risk level: The ATSB's assessment of the risk level associated with a safety issue is noted in the Findings section of the investigation report. It reflects the risk level as it existed at the time of the occurrence. That risk level may subsequently have been reduced as a result of safety actions taken by individuals or organisations during the course of an investigation.
Safety issues are broadly classified in terms of their level of risk as follows:
Critical safety issue: associated with an intolerable level of risk and generally leading to the immediate issue of a safety recommendation unless corrective safety action has already been taken.
Significant safety issue: associated with a risk level regarded as acceptable only if it is kept as low as reasonably practicable. The ATSB may issue a safety recommendation or a safety advisory notice if it assesses that further safety action may be practicable.
Minor safety issue: associated with a broadly acceptable level of risk, although the ATSB may sometimes issue a safety advisory notice.
Safety action: the steps taken or proposed to be taken by a person, organisation or agency in response to a safety issue.
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steps taken
early identification
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safety factors related
safety issue
atsb prefers
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