AVA20023 - 102866518 - Assignment 1

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Oct 30, 2023

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Prop Wash Accident involving Beechcraft Super King Air 350I, VH-MAT McArthur River Mine Airport, Northern Territory, Australia, on 16 th August 2021 (Source: beechcraft.txtav.com)

Cape York Airways Accident Report Final – 15th April 2022 Safe ty summary What happened On 16th August 2021, a contractor working for Drax Mining was deceased on the tarmac at McArthur River Mine Airport. The aircraft involved in the accident was Beechcraft Super King Air 350I, registered VH-MAT and operated by Cape York Airways. The tools/toolbox had been left on the aircraft's wing and thrown back to the victim's head when aircraft engines started up to do the engine ground run after maintenance. Findings With the tight turnaround schedule, the maintenance crew worked more than 24 hours to ensure the on-time performance for the next flight. The engine ground testing area had not been secured correctly and followed enough safety protocols during the testing activity. The Tarmac area was not equipped with enough lighting systems, and continuing heavy rain reduced the available visual of people on the ground. Safety Messages In this accident, flight and LAMEs are advised to always be aware of their surroundings and clear of the aircraft's rear while operating or testing an aircraft, especially when other aircraft or employees are nearby. This means there must be sufficient distance between aircraft and other obstacles that will not be affected by jet blast from engine ground run. This highlights the importance of more safety protocols, such as displaying the green ground running cones at various locations during the test. Airways must ensure the person towing an aircraft to a ground running location is a holder of qualified ground crew to assist maintenance activity.

The investigation The occurrence The accident occurred on Monday, 16th August 2021, at about 0400 Australian Central Standard Time, on the tarmac of McArthur River Mine Airport. While one pilot and two maintenance workers of Beechcraft Super King Air 350I (Figure 1), registered VH-MAT and operated by Cape York Airways, were doing the engine ground run, a contractor working for Drax Mining Company was walking behind the aircraft. Suddenly, he was struck by tools left on the aircraft's wing and thrown back when the aircraft had started up. Figure 1: Exemplary King Air 350i (Source: Evojets 2022) On Sunday, 15 th August 2021, at 1630ACST, the pilot reported to Licensed Aircraft Maintenance Engineer (LAME 1) that the King Air (VH-MAT) aircraft's left bleed air warning light illuminated on her arrival at McArthur River Mine Airport (IATA: MCV). LAME 1 instructed the pilot to try to clear the warning, but the pilot could not clear it and requested help. Later that day, at 1730ACST, LAME flew from Cairns to McArthur to rectify the fault. During the examination from 2030 to 2230ACST, LAME 1 found that the pressure switches were cross-connected in the bleed air warning system, and there was a leak in the right bleed air system. However, LAME 1 did not have the parts at his disposal to repair the leak, so he called Cape York to request the parts. After that, Cape York sent another LAME 2 from Cairns to McArthur with the parts required to repair the leak. At 0300ACST, another LAME 2 arrived then both LAMEs started to fix the leak on the right bleed air system. After 1 hour of maintenance, they towed an aircraft to the tarmac area and performed an engine test. Either LAME 1 or LAME 2 left tools/toolbox they were using on the aircraft's right wing. At 0400ACST, a pilot and a LAME 2 in the cock pit performed an engine ground test. The test involved increasing and decreasing power to the engine to ensure the pressure gauges and

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other instrument readouts were correct . At the same time LAME 1 was assisting in the engine test, he noticed the victim walking across the apron from left to right, and his walking path was behind the aircraft when the engine test was being performed. LAME 1 called out to the victim to keep away as they performed a test. The victim was walking closer to the aircraft, but the victim could not hear because of wearing noise-cancelling headphones and the lousy weather. When the right engine power increased, a loud clanging noise was heard. The victim was hit by tools/toolbox after the power of the right engine threw the tools/toolbox off the right- wing. The victim was located lying on the tarmac 3 to 4 metres from the aircraft's rear. Figure 2: Accident Location - McArthur River Mine Airport Immediately, LAME 1 called out to Pilot and LAME 2 to suspend the test. Then, LAME 1 walked to the victim's area and saw blood on the tarmac around him and a smashed pair of headphones. The pilot contacted the Doctor about the situation. Later Doctor arrived and pronounced the victim dead. At 0525ACST, police arrived, took witnesses' statements, and arranged to collect the body. Context Personnel The pilot who is Line Pilot on the Beechcraft King Air with Cape York Airways, have been working for over 3 years. Aircraft Maintenance Engineers are both holding Aircraft Maintenance Engineer License. A victim is a contractor from Drax Mining Company who was not expected to be in the tarmac area and involved in the testing operation.

Aircraft information According to Global Air 2022: “ Exterior Exterior Height: 14 ft 4 in Wingspan: 57 ft 11 in Length: 46 ft 8 in Interior Cabin Height: 4 ft 9 In Cabin Width: 4 ft 6 In Cabin Length: 19 ft 6 In Internal Baggage: 71 cu ft Occupancy Crew: 1 Passengers: 11 Operating Weights Max T/O Weight: 15000 Lb Max Landing Weight: 15000 Lb Operating Weight: 10000 Lb Fuel Capacity: 3611 lbs Lb Payload Useful: 5100 Lb Payload W/Full Fuel: 1604 Lb Max Payload: 2500 Lb Range Normal Range: 1739 nm Max Range: 1806 nm Service Ceiling: 35000 ft Distances Take-off Distance: 3300 ft Balanced Field Length: 3300 ft

Landing Distance: 2692 ft Performance Rate of Climb: 2731 fpm Climb Rate One Engine Inop: 552 fpm Max Speed: 312 kts Economy Cruise: 313 kts Avionics: Collins Aerospace Pro Line Fusion Power Plant Engines: 2 Engine Mfg: Pratt & Whitney Canada Engine Model: PT6A-60A” Weather The pilot and LAMEs of VH-MAT stated that the weather conditions were terrible on Sunday 15th August, and it continued raining heavily with strong gusts of wind on Monday 16 th August. Post occurrence maintenance (Source: Cape York Airways)

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Safety analysis Findings According to LAME 1's statement, LAME 1 & LAME 2 worked continuously from 8 am on Sunday 15 th August to 4 am on Monday 16 th August without taking a break. This resulted in the LAMEs' fatigue and working effectiveness. McArthur River Mine Airport is not a usual maintenance base for Cape York Airways LAME, so there was a lack of equipment and tools and proper lighting systems to ensure the maintenance procedure. Safety protocol was not maintained before and during the engine ground test, leading to the tools/toolbox left on the wing, the missing warning signs around the testing area and safety ensure for aviation and non-aviation workers. Based on Cape York Operations Manual, there was no appropriately qualified ground crew to do the aircraft towing from hangar to tarmac. As a result, the action towing aircraft by LAME is against the airways operations manual. Despite the failed safety protocols, a tight turnaround schedule put pressure on the maintenance team to finish the aircraft maintenance work on time for the next flight. Safety Action There are some necessary proactive safety actions that Cape York Airways needs to make to mitigate the risk and in response to this occurrence:  Adjusting flight plans to ensure that necessary maintenance is planned to prevent maintenance issues from happening during normal aircraft usage while maintaining a high utilisation rate for each aircraft.  HR Management Department reviews staff work schedules to verify that duty hours are not exceeded so that employees can work effectively at their total capacity.  The current safety procedures for ground testing operations need to be reviewed to consider equipment limitations such as external lighting, maintaining the effective surroundings check, and continual awareness of the aircraft's surroundings.  In accordance with CASA warnings, additional training is required for bleed air systems and how pressure switches can be cross-connected.  Invest in infrastructure and maintenance bases at airports that are often used, such as essential lighting systems and engine ground running cones (Figure 3). This will reduce the need to fly in parts.

         In any department, a safety culture needs to be promoted at Cape York Airways to ensure all employees are protected from breaching the operations manual. Sources of information - Witnesses - Cape York Airways - The maintenance report of VH-MAT - Australian Transport Safety Bureau - Northern Territory Police Force - Beechcraft Website - Global Air Website - Melbourne Airport Figure 3 : engine ground running cones (Source: Melbourne Airport 2018)

Accident Mapping Organisational & System Factors Contextual Conditions Human Involvement Absent or Failed Defences Accidents Fatal Injury Lack of lighting No awarness of left toolbox Fatigued LAME and pilot Roster Management Communication during test Maintenance Management Rushed Following Flight Schedule Economics Pressure No barriers between aircraft and victim Fail to warn victim No proper safety protocol LAME Training Infrastructure and Equipment Night time and lighting limitation Bad weather Victim was wearing noise-cancelling headphones

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General details 1. Occurrence details Date and time 16th August 2021 Occurrence class 0400 ACST Location Tarmac Area of McArthur River Mine Airport State Northern Territory Release date 15 th April 2022 Report status Final Investigation status Completed Investigation level Short Investigation phase Final report: Dissemination Occurrence type Prop wash Occurrence category Accident Highest injury level Fatal 2. Aircraft Details Aircraft manufacturer Beechcraft Aircraft model King Air 350i Aircraft registration VH-MAT Operator Cape York Airways Damage to aircraft None Sector Turboprop Persons on board Crew – 2 Passe ngers – 0 Grou nd: 2 Injuries Crew – 0 Passe ngers – N/A Grou nd: 1 (Fatal )