What happened

On 4 May 2020, an Aero Commander 500-S was operating a freight charter flight from Port Lincoln Airport, South Australia with a single pilot on board. During initial climb, the pilot noticed that the landing gear unsafe light did not extinguish after the gear was retracted. The pilot contacted aerodrome ground crew to inspect the aircraft’s landing gear during a low-level fly-by. The ground crew, including an engineer, confirmed that the nose wheel was down but did not appear to be locked.

The pilot requested that emergency services attend the aerodrome for a return landing on runway 01, and continued troubleshooting in accordance with the operator’s standard operating procedures and the aircraft flight manual. The pilot conducted a touch-and-go landing on the rear wheels, which resulted in three green indication lights in the cockpit confirming the gear was down and locked. The crew subsequently conducted a further fly-by inspection where ground crew also confirmed the position of the nose landing gear. The aircraft then landed without further incident.

After an engineer inspected the landing gear, the aircraft taxied off the runway. An inspection of the landing gear system revealed that the nose gear actuator shaft had failed.

Figure 1: Failed nose gear actuator shaft

Source: Aircraft operator

Safety action

As a result of previous similar occurrences, the aircraft operator has advised the ATSB that it has been conducting midlife inspections of the nose landing gear area, as well as additional testing of the actuator during overhauls. Additionally, their entire fleet of Aero Commander 500 aircraft has been fitted with underbelly skid blocks to support the nose in the event of a gear failure.

Safety message

This incident highlights the importance of effective cockpit scans for the early detection of any abnormal situations during flight. In this instance, the pilot identified the fault, took all precautionary measures and communicated clearly with ground crews resulting in a safe landing.

About this report

Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.

What happened

On 3 May 2020 at about 1400 Eastern Standard Time, a solo student pilot was conducting a navigation exercise in a Piper PA-28-181 in the vicinity of Scone, New South Wales. The pilot became unsure of the aircraft’s position when he was unable to identify Scone Airport and followed the lost procedure, contacting air traffic control (ATC) for assistance.

As there was poor VHF reception with the aircraft, two other aircraft in the area provided navigational assistance and relayed instructions between ATC and the pilot of the Piper PA-28-181. ATC requested the aircraft climb to 7,500 ft in an attempt to be identified by radar. Once the aircraft was identified, ATC then provided a heading for Scone Airport and the aircraft proceeded without further incident.

Following the flight, the instructor conducted a two-hour incident debrief with the student pilot. The student will undertake further map reading training to ensure proficiency in this area prior to his next flight.

Safety message

This incident highlights the importance of remaining calm and remembering procedures in the face of uncertainty. If a pilot is unsure of the aircraft’s location, ATC is able to assist with locating positions using transponder codes, prominent landmarks and radio navigation.

In this incident, the further assistance provided by aircraft in the vicinity ensured a positive outcome.

About this report

Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.

What happened

On 17 April 2020, a Miles M3A Falcon single-engine piston aircraft was operating a ferry flight from Lilydale to Nelson, Victoria. There was one pilot and one passenger on board.

During cruise, after flying for about 2 hours and 20 minutes, the pilot decided to conduct a diversion to Hamilton for the day due to approaching weather and lighting conditions. Approximately 9 km south-east of Hamilton at 2,000 ft AGL, the engine failed. The pilot attempted to restart the engine by changing the fuel selector from the ‘both’ selection to the left tank but was unsuccessful. The pilot then changed the fuel selector to the right tank and the engine restarted momentarily, before cutting out again.

The pilot identified a large paddock nearby to conduct a forced landing. The aircraft was unable to reach the desired paddock and the pilot subsequently conducted the forced landing in a smaller paddock.

After touchdown, the right wing struck a fence post and the aircraft swung sideways. The aircraft then struck a second wire fence, and the wire pulled the aircraft to a stop. The right landing gear collapsed, the propeller struck the ground and the wing’s leading edge sustained damage. The pilot and passenger were uninjured.

Engineering inspection

The engineering inspection revealed that as the aircraft had not been operated for several years, debris accumulated in the fuel lines resulting in a blockage during flight and the engine failure. The inspection further revealed that there was 60 litres of fuel remaining in the left tank, and no fuel remained in the right tank.

Figure 1: Fuel line blockage and debris

Source: Pilot

Figure 2: Fuel line blockage and debris

Source: Pilot

Pilot comments

The pilot advised that normally, a low-wing aircraft would only have left and right fuel selector positions. This aircraft, which he had recently purchased, is fitted with a fuel selector that has a ‘both’ position and he assumed that fuel was drawing equally from both wing tanks. He therefore believed having the fuel selector set to this position was the best option for the flight. The pilot further commented that it would have been beneficial to have conducted a check of the fuel supply from the left-wing tank 1.5 hours into the flight to ensure there was enough fuel flow for the cruise consumption of 32 litres per hour and to check that fuel was drawing from both wing tanks.

Safety message

This accident highlights the importance of ensuring all aircraft systems and components are operating as per the aircraft manual.

It also serves as a reminder that keeping fuel supplied to the engine during flight relies on the pilot’s knowledge of the aircraft’s fuel supply system and being familiar and proficient in its use.

More information on fuel management can be found in the ATSB research report, Starved and Exhausted: Fuel management aviation accidents (AR-2011-112).

About this report

Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.

What happened

On 23 April 2020, the student pilot of a Robinson R44 helicopter was returning to Townsville Airport, Queensland, from a solo training navigation exercise.

As the pilot returned the helicopter to the parking position near the hangar and was in the process of landing from the hover, he momentarily lost directional yaw control. At this time, one of the helicopter’s skids was in contact with the ground while the collective^[1] was in a raised position. This resulted in an unstable airframe that commenced a roll about the skid.

Despite the efforts of the pilot to recover, the helicopter continued to rollover and came to rest on its side resulting in substantial damage. The pilot was uninjured in the accident.

Figure 1: Helicopter post-accident

Source: Townsville Airport

Figure 2: Helicopter’s bent tail boom and broken main rotor blade

Source: Townsville Airport

Helicopter static and dynamic rollovers

Static rollover occurs when a helicopter is pivoted about one of its landing skids or wheels and the helicopter’s centre of gravity passes outside the in-contact skid or wheel. Once in this position, removal of the original force that raised the helicopter to that angle will not stop the helicopter from rolling further. This angle is termed the ‘static rollover angle.’

A rotors-running helicopter resting with one landing skid or wheel on the ground may, without appropriate pilot input, commence rolling. Under certain circumstances, this roll cannot be controlled and the helicopter rolls over. This condition is known as ‘dynamic rollover’ and is a function of the interaction between the:

• horizontal component of the total rotor thrust (or lift) acting about the point of ground contact
• weight of the aircraft, initially acting between the helicopter’s skid landing gear or wheels. This second, counter-rolling moment decreases the greater the roll.

Recovery from dynamic rollover is by smoothly lowering the collective lever while controlling any tendency to roll in the opposite direction with cyclic^[2] to re-establish the helicopter’s weight evenly on the ground. In general, the application of smooth collective inputs is more effective in avoiding rollover issues than using the cyclic control.

Safety message

This accident highlights the importance of smooth and controlled flight control inputs in the critical phases of flight. While a helicopter is in contact with the ground and before its full weight is applied to the landing gear, it is subject to various influences such as the possibility of a rollover. A thorough understanding of the principles of, and contributing factors to, both static and dynamic rollover and the recovery methods are essential to conducting safe helicopter lift-offs and landings.

About this report

Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.

__________

1. Collective: a primary helicopter flight control that simultaneously affects the pitch of all blades of a lifting rotor. Collective input is the main control for vertical velocity.
2. Cyclic: a primary helicopter flight control that is similar to an aircraft control column. Cyclic input tilts the main rotor disc, varying the attitude of the helicopter and hence the lateral direction.

What happened

On 28 April 2020 at about 1900 Eastern Standard Time, after last light, a Beechcraft B200 was being prepared for a flight from Brisbane to Rockhampton, Queensland. The aircraft was parked on an apron that required it to be chocked for refuelling.

Shortly after take-off, the pilot heard a noise outside the aircraft and asked a crew member to look out the window to confirm if the wing lockers were visibly closed. The crew member confirmed, and as the source of the noise could not be immediately determined the pilot decided to return the aircraft to Brisbane.

During the approach, the crew member identified that one of the aircraft's wooden chocks was not secured correctly and was hanging outside the aircraft by a rope.

Figure 1: Wheel chock-tie hanging out of the door

Source: Operator

Operator comments

The operator has advised the ATSB that as there is a company requirement to use the chocks while refuelling at Brisbane, they are often stored loose in the cargo area for ease of access rather than in the bung bag, underneath equipment. The aircraft was also being prepared for departure at night, which contributed to the incident.

Safety action

As a result of this occurrence, the operator has advised the ATSB that it is taking the following safety action:

An advisory will be issued to all crew to beware of the possibility of items trapped or falling from the door while being closed, and also to ensure adequate illumination is used when securing doors or items in the aircraft.

The operator is also exploring alternative stowage locations and methods for securing loose chocks.

Safety message

The main cargo area in general aviation aircraft is often located adjacent to doors or hatches. Items stored in these locations have the potential to obstruct or impact the security of the door. This incident highlights the importance of conducting a thorough pre-flight inspection and ensuring loose articles are correctly stowed before departure.

About this report

Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.

What happened

On 16 April 2020 at about 1300 Eastern Standard Time, an ATR 42-300 was taxiing to park on the apron at Pormpuraaw Airport, Queensland (Figure 1). The pilot of the ATR was aware that a de Havilland DHC-8 was due to arrive and with this in mind, was manoeuvring the aircraft to allow sufficient clearance for the parking of both aircraft on the limited apron area available.

During the manoeuvre, the right wingtip contacted a frangible flood light pole situated on the perimeter of the apron. The light pole gave way as designed. Initial contact was with the aircraft’s right navigation light’s perspex cover which cracked and became dislodged. Upon further inspection, a small dent was also identified on the leading edge of the right aileron control horn.

Figure 1: Pormpuraaw Airport, Queensland

Source: Google Earth, annotated by the ATSB

Safety message

This incident reinforces the importance of maintaining situational awareness and a good lookout while taxiing, particularly in circumstances when the manoeuvring area available is restricted or confined by infrastructure or other obstacles.

About this report

Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.

What happened

On 27 March 2020 at around 1822 Eastern Daylight-saving Time, a Diamond DA 40 was being prepared for a training flight. There was a student and instructor on board.

During the pre-flight inspection, while the student was conducting the flight controls free and correct movement check, he observed abnormal elevator movement. The elevator required more force than usual to move, and was unable to be deflected through its full and normal operating range. The student notified the instructor of the issue, the flight was cancelled and the aircraft was deemed unserviceable.

Engineering inspection

The engineers removed the right pilot seat to examine the flight control mechanism. They found a plastic navigation ruler lodged within the elevator push rod mechanism, which was restricting the movement of the elevator. It was determined that the ruler fell between the seat and the centre console in the cockpit.

Figure 1: Navigation ruler lodged in elevator push rod mechanism

Source: Operator’s engineering department

Operator comments

It is important that Diamond DA 40 and DA 42 operators and pilots are alerted to the fact that items and equipment placed on the seat or between the seat and centre console can, in some instances, work their way down through the narrow gap between the inner seat edge and the centre console (Figure 2). This could allow thin items and equipment to find their way into the area under the seat which contains the elevator and aileron control push-rods.

Figure 2: Narrow gap between front seats and centre console

Source: Operator’s engineering department

Safety action

As a result of this occurrence, the operator has advised the ATSB that it is taking the following safety actions:

• Providing a briefing and the publication of photos to all instructors for awareness.
• Placing a renewed emphasis in pre-flight briefings to solo students on objects taken into and out of the aircraft, to reduce the instances of foreign object debris (FOD) being left in the cockpit.
• Requiring that all navigation equipment and similar items carried in aircraft be labelled with the owner's name. This will increase accountability and source tracing when FOD is located and help to ensure pilots place the aircraft unserviceable for a FOD inspection if an item is missing at the end of a flight.

Safety message

This incident highlights the importance of ensuring that all pre-flight checks and procedures are carried out comprehensively and systematically. It also serves as a reminder for flight crew to ensure that any misplaced or missing items from their flight bag be identified and located. If unable to locate any missing items, this information should be reported promptly so an aircraft inspection can be carried out.

About this report

Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.

What happened

On 28 February 2020, a Piper PA-44 Seminole was conducting a circuit assessment flight with a student and instructor on board, using runway 17L at Moorabbin Airport, Victoria. the instructor reported, the student had conducted three normal circuits to the required standard including the normal procedure of turning the fuel pumps off once above 500 ft AGL.

After the circuits, the instructor obtained a clearance from ATC to conduct asymmetric operations and planned to carry out a practice engine failure on the upwind leg of the circuit. As the aircraft climbed through 700 ft AGL, the instructor initiated the practice by announcing it and slowly closing the throttle on the right engine. The student carried out all the required initial actions, identifying that it was the right engine and verbalising the appropriate steps to secure the engine.

As the instructor then attempted to set a zero thrust power setting to complete the circuit, he identified that the aircraft was not performing as it normally would and was still yawing.^[1] Upon identifying the right engine was no longer running the instructor took over, feathered^[2] the right propeller, and continued a slow climb. Air Traffic Control was informed of the situation as the instructor continued in the circuit. Once established on downwind, the instructor found that both right engine magnetos were in the off position. Despite returning the magnetos to on and attempting a restart, it could not be achieved prior to landing. The aircraft subsequently landed without further incident. Once the aircraft was on the ground, the right engine was restarted normally.

Crew comments

During the debrief about the incident, I identified that the student had mistakenly turned the right engine’s magnetos off when the practice engine failure was initiated. It appears that the practice emergency had occurred as the student was preoccupied conducting the normal after take-off checks that include turning the fuel pumps off above 500 ft AGL. Under normal circumstances, this would be more readily noticeable as the yaw and noise reduction would immediately alert the crew to the error, however, in a less than zero thrust condition the loss of power from the right engine was not immediately identified. Once the mistake was identified, the propeller had been feathered and a restart in the circuit would have been difficult to achieve.

Figure 1: Cockpit layout of magneto and fuel pump switches

Source: Operator

Safety action

As a result of this occurrence, the operator has advised the ATSB that they have taken the following safety actions:

• All multi-engine instructors have been directed not to initiate a simulated engine failure while the student is preoccupied with other tasks and particularly when the after take-off checks are being carried out.
• Any simulated failure should be conducted either before or after take-off checks and comply with the minimum height restrictions.
• Fuel pumps are now to be turned off one at a time as a further way of mitigating the possible reoccurrence.

Safety message

This incident highlights the need for instructors to comprehensively pre-brief simulated emergency procedures noting potential errors, and closely monitor the actions of their student pilots when they are reacting in a high workload environment to any simulated emergency.

About this report

Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.
__________

1. Yawing: the motion of an aircraft about its vertical or normal axis.
2. Feathering: the rotation of propeller blades to an edge-on angle to the airflow to minimise aircraft drag following an in-flight engine failure or shutdown.

What happened

On 22 March 2020 at about 1030 Western Standard Time, a privately chartered de Havilland DH-82 Tiger Moth commenced take-off for a local flight. As the aircraft became airborne, the aircraft’s attitude pitched up with the high take-off power setting and the pilot was unable to move the elevator control forward. The pilot performed a precautionary landing on the remaining available runway by adjusting power to control aircraft pitch attitude.

The aircraft was taxied back to the parking bay and secured. Upon examination, the pilot observed a hand-held inspection mirror lodged between the elevator control and the frame of the aircraft.

Figure 1: Hand-held inspection mirror lodged in elevator control

Source: Operator

Operator’s investigation

The mirror was not visible during a normal pilot pre-flight inspection and the elevator had full and free movement during both the pre-flight inspection and the pre-take-off checks. The operator concluded that the mirror was therefore inside the cockpit in a position not easily visible prior to the flight. It appeared to have moved during the take-off run into the position inhibiting elevator control.

The operator held a workshop safety briefing into the incident but was unable to confirm how the mirror got into the aircraft.

Safety message

This incident highlights the importance of effective tool control and ensuring any items that are unaccounted for are located. Loose items must also be secured to prevent interference with aircraft controls.

The presence of foreign object debris can pose a significant threat to aircraft safety and has the potential to result in damage during critical phases of flight.

About this report

Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.

What happened

On 22 February 2020 at 0900 Eastern Daylight-saving Time, a twin-engine Cessna 404 with three crew commenced its take‑off run on runway 17 at Essendon Airport, Victoria. During rotation^[1] the right engine fire extinguisher discharged without crew command.^[2] The crew reported hearing a loud ‘whoosh’ sound and an alert light in the cockpit illuminated indicating zero pressure in the right engine fire extinguisher. The crew continued the take-off and observed normal engine indications during the climb to 5,000 ft.

The crew discussed their situation and elected to conduct a return to Essendon Airport. To avoid an overweight landing, they decided to enter a holding pattern to burn off sufficient fuel. The crew contacted air traffic control (ATC) advising them of their decision and were directed to hold at a nearby waypoint.

About 20 minutes into the holding pattern, the crew detected a burning odour in the cockpit but no smoke was evident. The crew advised ATC of the smell and requested to cancel the holding pattern and land at Essendon Airport. ATC initiated an uncertainty phase (INCERFA)^[3] and cleared the aircraft for a straight-in approach to runway 26. The crew pulled the fire detection and extinguishing system circuit breakers, and the odour disappeared temporarily before returning during final approach. Shortly afterwards, a safe landing was completed after which ATC cancelled the INCERFA.

Engineering inspection

Engineers inspected the aircraft after landing and found that the fire extinguisher discharge button in the cockpit was faulty but the source of the odour could not be determined. After replacing the button and the discharged fire extinguisher, the aircraft returned to service.

Safety message

The unintended discharge of the engine fire extinguisher occurred during a critical phase of flight and was not covered by an emergency response procedure. However, the crew’s actions and decisions ensured that aircraft safety was maintained at all times.

Prompt decision making between crewmembers and communication with ATC is critical for timely and effective management of a potential in-flight emergency.

About this report

Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.
__________

1. Rotation: the positive, nose-up, movement of an aircraft about the lateral (pitch) axis immediately before becoming airborne.
2. When the engine fire extinguishers are operating normally, only the crew can discharge them via a button in the cockpit.
3. Uncertainty phase (INCERFA): an emergency phase declared by the air traffic services (ATS) when uncertainty exists as to the safety of an aircraft and its occupants.