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By Alexandria Sage and Paul Lienert SAN FRANCISCO/DETROIT (Reuters) - Tesla Motors alerted regulators to a fatality in one of its electric cars in partial self-driving Autopilot mode nine days after it crashed, the company said on Tuesday, defending...
CQUniversity is very grateful to receive a donation of aircraft accident artefacts for its Accident Investigation Laboratory on Bundaberg campus. The laboratory supports the delivery of CQUniversity’s Accident Forensics and Accident Investigation programs.
On 24 October 2013, the pilot of a modified PZL Mielec M18A Dromader, registered VH-TZJ, was conducting a firebombing mission about 37 km west of Ulladulla, New South Wales. On approach to the target point, the left wing separated. The aircraft immediately rolled left and descended, impacting terrain. The aircraft was destroyed and the pilot was fatally injured.
What the ATSB found The ATSB found that the left wing separated because it had been weakened by a fatigue crack in the left wing lower attachment fitting. The fatigue crack originated at small corrosion pits in the attachment fitting. These pits formed stress concentrations that accelerated the initiation of fatigue cracks.
The ATSB also found that, although required to be removed by the aircraft manufacturer’s instructions, the corrosion pits were not completely removed during previous maintenance. During that maintenance, the wing fittings were inspected using an eddy current inspection method. This inspection method was not approved for that particular inspection and may not have been effective at detecting the crack.
Data from a series of previous flights indicated that the manner in which the aircraft was flown during its life probably accelerated the initiation and growth of the fatigue crack.
Finally, the ATSB also found a number of other factors which, although they did not contribute to the accident, had potential to reduce the safety of operation of PZL M18 and other aircraft. These included the incorrect calculation of the flight time of M18 aircraft and a lack of robust procedures for the approval of non-destructive inspection procedures.
On 6 October 2014, Cape Splendor’s boatswain (bosun) descended to the lower platform of the ship’s accommodation ladder during his lunch break. He intended to fish from this location and asked a seaman to assist. At 1250, the bosun lost his balance and fell into the sea.
The seaman immediately returned to the ship’s deck and threw a lifebuoy toward the bosun, before raising the alarm. The ship’s crew deployed its rescue boat within 10 minutes, and an extensive air and sea search continued for 3 days. However, the bosun was not found.
The ATSB found that the bosun and the seaman were not wearing any flotation devices or fall prevention equipment. The bosun had seen fish below the accommodation ladder that was in the shade, and he probably saw it as a good opportunity to fish without considering the risks involved. The lack of a lifejacket, wet clothing, and possible entanglement with fishing gear, sea conditions, and the current would have adversely affected the bosun’s ability to stay afloat and swim.
The ATSB investigation also identified that the ship’s safety management system procedures for working over the ship’s side were not effectively implemented. Hence, the ship’s crew routinely did not take all the required safety precautions when working over the side. It was also found that the crew had differing attitudes to taking safety precautions during work and recreation times as the safety culture on board was not well developed.
Occasionally pilots become incapacitated during flight. Incapacitations can arise from different reasons. They include the development of an acute medical condition, changes in environmental conditions during the flight, or the effects of a pre-existing medical condition. The effect of incapacitation on a pilot can be restricting their flight duties for the remainder of the flight, or for single-pilot operations, a collision with terrain.
This research report documents pilot incapacitation occurrences in high capacity air transport, low capacity air transport, and general aviation to help educate industry about the causes and risks associated with inflight pilot incapacitation.
Bachelor of Accident Forensics graduate Adam Holstein is on track for his advanced accident investigation specialisation this year.
Thanks to a new relationship between CQUniversity and the Rail Industry Safety and Standards Board (RISSB) Mr Holstein will focus on rail-safety projects as he embarks on his Master of Advanced Safety Science Practice.
After an impressive undergraduate journey based at CQUniversity Townsville, Mr Holstein becomes the inaugural student to progress to the RISSB placement, involving a 22-week internship and generous stipend.
Good fuel management saves the day This incident shows how a pilot’s good fuel management ensured the safe landing of a Piper Chieftain aircraft after an unexpected incident.
On 12 October 2015, the pilot and three passengers were conducting a survey flight over the southern highlands area of New South Wales.
After departure, the pilot reported that clouds (both towering cumulus and cumulus) were beginning to form in the area, producing some light turbulence. The pilot remained concerned about one of the passengers, seated at the rear of the aircraft, who appeared to find the conditions difficult to tolerate.
The pilot’s workload remained high. Apart from flying to each of the pre-arranged waypoints, additional landmarks were being relayed to the pilot from the client’s operator on the ground.
The pilot kept a very detailed fuel log, and continually cross-checked the fuel in each of the four fuel tanks. The weather had deteriorated even further as the pilot prepared to fly to the last waypoint before a return to Bankstown. The pilot delayed a scheduled fuel tank change to maximise the fuel remaining in the main (inboard) tanks.
As the pilot was maneuvering around large banks of cloud and thunderstorms, the left auxiliary (outboard) tank ran dry and the engine surged. The aircraft yawed. The pilot reacted immediately and changed the fuel selectors onto the main tanks. The engine responded and power was restored. The aircraft returned to Bankstown without incident.
In this incident, the pilot followed all the key suggestions in the ATSB’s Avoidable Accident Series No 5 – Starved and exhausted: Fuel management aviation accidents. These being
Knew exactly how much fuel was on board
Knew how much / what rate fuel was being consumed
Knew the aircraft fuel system and keep a detailed fuel log of the four tanks during flight.
Despite a high workload, deteriorating weather, and untimely distractions the pilot was well prepared to handle an unplanned outcome of temporary fuel starvation of the left engine.
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