What happened

On the afternoon of 14 October 2019, the solo student pilots of two Diamond DA 40 aircraft were approaching Coffs Harbour, New South Wales 20 minutes apart at the conclusion of a navigation exercise. The exercise was under visual flight rules and both aircraft were flying in visual meteorological conditions.

As the first DA 40 approached the airport from the north, the student pilot was cleared by air traffic control (ATC) to conduct a visual approach to runway 21. As the aircraft became closer to the airfield, ATC questioned the final heading of the aircraft and requested confirmation from the pilot that they had the runway environment in sight. This made the pilot aware that they were aligned on final approach to taxiway E3-E5 (Figures 1 and 2).

Approximately 20 minutes later, the second inbound DA 40 approached the airport from the same heading and was cleared by ATC to conduct a visual approach to runway 21. ATC also questioned the final heading of this aircraft which notified the pilot that they were also aligned on final approach to the taxiway.

Both pilots made the necessary corrections to successfully land on runway 21.

In the navigation exercise briefing, the students were made aware of the potential to misidentify the runway as it is not an uncommon occurrence at this aerodrome. They were thoroughly briefed and provided with methods to confirm the correct runway, particularly when approaching from the north. The possibility of misidentifying the runway is also annotated as a warning in Airservices publications, En Route Supplement Australia (ERSA) and Departure and Approach Procedures (DAP).

Figure 1: Aerodrome Chart – Coffs Harbour, NSW

Source: Airservices Australia

Figure 2: Aerial image of Coffs Harbour Airport, NSW

Source: Google Earth, annotated by the ATSB

Safety action

As a result of this occurrence, the training organisation has advised the ATSB that they will provide further information in the navigation briefing for students to mitigate against the misidentification of taxiway E3-E5 for runway 21 at Coffs Harbour. They now also require supervising instructors to provide special pre-flight briefings for all solo flights into this location regarding positive identification of the runway.

Similar occurrences

In the previous five years, there have been seven additional similar occurrences reported to the ATSB involving the E3-E5 taxiway being mistaken for runway 21 during approach into Coffs Harbour.

Safety message

Pilots and operators should be aware of documented and well-known issues when identifying particular features critical to navigation and airfield operations. In this situation, identifying the runway environment would have benefited from using secondary features to confirm identification – runway heading, surrounding topographical features and visible runway infrastructure (runway approach lighting and runway markings).

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 18 October 2019, a Piper PA-28-140 operated a private return flight from Archerfield, Queensland to Narrabri, New South Wales with one pilot on board. The flight was to be operated under visual flight rules (VFR)^[1] by day.

At 1915 Eastern Daylight Time, the aircraft returned to Archerfield after last light^[2] at 1,500 ft, which was below the lower safe altitude (LSALT) of 2,900 ft that is applied after last light. Air traffic control subsequently issued a safety alert to the pilot.

Pilot comments

At the time of the occurrence, the pilot was yet to undertake night VFR and instrument flight rules training. He had planned to arrive back at Archerfield before last light, however had miscalculated the time and had a subsequent delayed departure from Narrabri. The pilot was unaware of the night VFR procedures for Archerfield, in particular the LSALT and therefore the approach was flown at 1,500 ft as per day VFR procedures.

The pilot advised that in response to this occurrence he plans to undertake night VFR training.

Safety message

This incident highlights the need for pilots to carry out thorough flight planning and have an understanding of the risks associated with flying at night. Further information on the risks inherent to visual flight at night can be found in the ATSB publication, Avoidable Accidents No. 7 - Visual flight at night accidents: What you can't see can still hurt you.

It is recommended that VFR pilots should also use a personal minimums checklist to identify and manage risk factors. A personal minimums checklist is an individual pilot’s own set of rules and criteria for deciding if and under what conditions to fly or to continue flying based on their knowledge, skills and experience.

The ATSB SafetyWatch highlights the broad safety concerns that come out of our investigation findings and from the occurrence data reported to us by industry. One of the safety concerns is inflight decision making.

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. Visual Flight Rules (VFR) are the rules that govern the operation of aircraft in Visual Meteorological Conditions (VMC) (conditions in which flight solely by visual reference is possible).
2. Last light is regarded as the time when the ambient light value falls below that required for aircraft operating underday visual flight rules and is defined as the time when the setting sun is six degrees below the western horizon.

What happened

On 27 October 2019 at approximately 1740 Eastern Daylight-Saving Time, the crew of a foreign-registered Airbus A380 was conducting a regular public transport flight to Sydney Airport, New South Wales (NSW).

During cruise at FL 390 abeam Broken Hill, NSW the crew observed the cockpit oxygen bottle pressure of 487 psi. After referring to the flight crew operating manual (FCOM) for oxygen limitations, it was determined that this was below the minimum pressure for a two-person flight crew.

The crew discussed the situation, taking into account fuel on board, distance to the destination, weather and an en route alternate, and decided to continue the flight to Sydney.

The crew notified air traffic control of the oxygen issue and were cleared to descend to 10,000 ft. Maintenance control centre was also contacted and the cabin crew were advised of an early descent.

On approach at 800 ft, the pressure dropped to 350 psi and the crew received an oxygen cockpit low pressure caution on the electronic centralised aircraft monitor. The aircraft landed safely at 0755 UTC.

Engineering inspection

Following the incident, an inspection on the oxygen bottle system revealed a leak at the filling port cap. Replacement components were placed on board the aircraft as a preventative measure in case of a further valve leak.

Safety message

This incident highlights the importance of positive crew resource management when handling unanticipated failures during flight. In this instance, the crew proactively identified the oxygen bottle pressure and took all appropriate actions by consulting the FCOM, discussing the situation, assessing their options and communicating with external stakeholders to ensure a desirable 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 the 4 October 2019, an Agusta A109S helicopter was on approach to Sydney Airport, New South Wales. During approach, air traffic control (ATC) issued the pilot a clearance to track from the clearance limit to overhead the threshold runway 07. The pilot read back, ‘from the clearance limit track overhead the 07 threshold’. The pilot reported to the ATSB that he believed he was cleared to track overhead the 07 threshold (for the heliport).

A Boeing 737 waiting on the crossing runway for an intersection departure was provided with the helicopter traffic and advised ATC that the helicopter was in sight. ATC subsequently issued the take-off clearance.

ATC then advised the helicopter pilot that the clearance limit was the runway 07 threshold and passed traffic on the 737, however the transmission was blocked.

As the 737 began its take-off, ATC observed the helicopter continue past the runway 07 threshold and immediately issued instructions to the helicopter to expedite through the runway intersection.

Safety action

As a result of this occurrence, Airservices Australia advised the ATSB that they are taking the following safety action:

The air traffic controller will be counselled on the appropriate phraseology when issuing a clearance limit.

Safety message

This incident shows the effectiveness of the conflict resolution training received by ATC to resolve loss of separation events resulting from radio transmission errors or miscommunication between controllers and flight crew.

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 20 September 2019, a Pilatus Britten-Norman BN2A-21 Islander operated a return charter flight from Horn Island to York Island, Queensland. There was one pilot and four passengers on board.

During taxi after landing at York Island in the morning, the pilot turned the fuel pumps on and switched the tank selector from main tanks to tip tanks. After the passengers disembarked and the aircraft was parked on the apron, the pilot completed his flight log and dipped the fuel tanks, confirming his estimate of remaining fuel on board.

The passengers returned late afternoon and the aircraft departed for its return flight to Horn Island at about 1600 Eastern Standard Time.

During cruise, the pilot observed the no. 1 engine surging. He immediately turned on both fuel pumps and monitored all instruments. He noticed that the fuel gauges were indicating that the tip tanks were almost empty and the main tanks had gained a significant amount of fuel. The pilot switched from tip tanks to main tanks and the surging stopped. As a precaution, he conducted a diversion to Warraber Island.

After landing, the pilot checked the fuel in the tip tanks and discovered that the tanks were empty and the fuel had transferred into the main tanks.

Engineering inspection

Following the incident, engineers determined that after switching the fuel selector from the main tanks to the tip tanks, the aircraft was shut down without allowing adequate time for the fuel transfer lines to close. This resulted in the fuel from the tip tanks to drain into the main tanks.

Safety action

As a result of this occurrence, the aircraft operator has advised the ATSB that they are taking the following safety actions:

• An internal company document was raised to review procedures by dipping the fuel tanks before take-off when on the ground for 30 minutes or more.
• A safety meeting was held to raise awareness and discuss the importance of fuel procedures, including allowing 5 to 10 minutes before shut down when switching to tip tanks on the ground.
• A note has been included in the aircraft close to where the switches are, advising the importance of allowing time for the fuel selection change.

Safety message

Keeping fuel supplied to the engines during flight relies on the pilot’s knowledge of the aircraft’s fuel supply system and being familiar and proficient in its use. Accidents and incidents involving fuel mismanagement are an ongoing aviation safety concern, particularly those involving complex fuel delivery systems. The ATSB publication, Avoidable Accidents No. 5 - Starved and exhausted: Fuel management aviation accidents (AR-2011-112), is available from the ATSB website.

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 September 2019, the pilot of a Piper PA-25 was conducting glider-tow operations at Benalla Airport, Victoria. After releasing the glider at about 4,000 ft AGL, the pilot began a descent to 1,000 ft. During the descent, the engine failed. The pilot subsequently switched fuel pumps and activated the emergency power system^[1], however experienced no restoration of engine power. He assessed that the aircraft was too low to conduct a glide approach to the runway and elected to land in a paddock near the airport. After the forced landing, he checked the fuel tank and identified that it was empty.

Pilot comments

The procedure for refuelling the aircraft was to refuel at the beginning of the day, and again after one hour of towing time. The pilot advised that he took over the aircraft and inspected the log, observing a total of 35 minutes towing time logged. This was consistent with the number of tows completed for the day. The pilot’s expectation was that there was sufficient fuel for another four or five glider tows. He did not visually inspect the fuel tank to confirm the fuel levels during the pre‑flight walk-around and mentioned the fuel gauge indication is difficult to read.

Safety action

As a result of this occurrence, the aircraft operator has advised the ATSB that they are taking the following safety actions:

The operator sent an email to all glider-tug pilots reminding them of the requirements in regards to fuel checks. Additionally, the fibreglass fuel gauge indicator was polished to allow for easier visual indication so accurate readings can be taken. The operator advised that they are looking into options for replacing the fuel gauge.

Safety message

This incident serves as a reminder that is in the pilot in command’s responsibility to ensure there is sufficient fuel quantity on board the aircraft.

The Civil Aviation Safety Authority advisory publication,

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. The emergency power system is an independent source of electrical power that supports important electrical systems upon loss of normal power supply. The incident aircraft has a back-up battery fitted that was switched on in this instance, in case the engine stopped due to failure of the primary electrical system.

What happened

On 22 September at about 0700 Eastern Standard Time, a Kavanagh E-240 balloon was operating a charter flight over Melbourne, Victoria with a pilot and 10 passengers on board.

While landing at a reserve, the pilot deployed the handling line to ground crew. The pilot then determined that the balloon was unable to land in the available space and instructed the ground crew to let go of the handling line in order to manoeuvre to a different landing site.

The balloon continued the descent and the basket subsequently made contact with the roof of a house. The balloon then landed in the original landing site with the assistance of the ground crew utilising the handling line, which was still attached to the basket. The pilot and passengers were uninjured.

Pilot comments

The pilot stated that the main contributing factor to the occurrence was the use of the handling line in an attempt to guide the balloon into the landing site. Although this is common practice, during this particular landing the pilot ran out of sufficient space in the landing site.

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 15 September 2019, a Diamond DA40 was operating a dual training flight with an instructor and a student pilot on board from Strathalbyn to Parafield, South Australia. The pilot of a de Havilland Canada DHC-1 was also airborne at the same time after departing Parafield on a private flight.

The crew of the DA40 reported that during cruise at 2,500 ft on track for Dam Wall, they received a TCAS alert on an aircraft directly ahead on a reciprocal heading. Shortly after, the instructor observed the outbound DHC-1 at the same altitude, took control of the aircraft, and turned left to increase separation.

The pilot of the DHC-1 reported that upon leaving Sub Station and setting a course to the east, he saw an aircraft in the distance and perceived it not to be a risk as he judged his track would take him south of the inbound aircraft for Parafield. At the position given by the other pilot, he reported he was on climb to 3,500 ft and would have been clear of any aircraft operating at 2,500 ft.

Both the instructor and student of the DA40 and the pilot of the DHC-1 report monitoring the Adelaide Approach radio frequency and did not hear any radio calls from the other aircraft.

Safety message

This incident highlights the need for pilots to maintain situational awareness and a vigilant lookout at all times. Most aircraft conflicts in uncontrolled airspace are due to ineffective communication between pilots operating in close proximity, the incorrect assessment of other aircraft’s positions and intentions, and relying on the radio as a substitute for an effective visual lookout.

The ATSB’s SafetyWatch highlights broad safety concerns that come out of our investigation findings and from the occurrence data reported to us by industry. One of those priorities is Non-controlled airspace.

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 12 September 2019, a Robinson R44 II helicopter landed at Parachilna, South Australia to unload passengers after conducting a scenic flight in the Wilpena Pound area. The landing area was a raised disused railway platform that the pilot had used previously as it allowed the tail rotor to be maintained well clear of any possible obstacles.

At approximately 1540 Central Standard Time, after the passengers were unloaded and had moved away from the helicopter, the pilot commenced the lift into the hover. As the helicopter became light on the skids, the helicopter‘s nose pitched up and it began to roll to the left. The tail rotor impacted the ground and the main rotor struck the tail boom (Figure 1 Insert A).

After securing the helicopter, the pilot determined that a section of steel on the edge of the platform had dislodged and caught on the rear of the left hand skid (Figure 1 Insert B). This resulted in the unanticipated pitch and roll during the take-off sequence.

Figure 1: Accident site showing aircraft and platform

Source: Aircraft operator

Safety action

As a result of this occurrence, the aircraft operator advised the ATSB that they ceased operations to the landing site. The operator advised that operations may recommence in the location after the necessary maintenance has been completed on the platform and a site inspection is carried out to confirm the suitability and safety for future operations. They will also ensure that periodic inspections are performed at any helicopter landing sites to ensure ongoing safe operations.

Safety message

The assessment of suitability and safety of helicopter landing sites does not end after the initial reconnaissance or even after operating from the site for a period of time. Pilots must be aware of all potential hazards to operations, particularly in the critical phases of flight such as lifting to the hover, taxiing and commencing take-off.

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 12 September 2019, a Diamond DA 40 departed Bankstown, New South Wales (NSW) for a solo navigation training flight with a student pilot on board.

During approach into Dubbo, NSW at about 500 ft AGL, the pilot extended full flap to prepare the aircraft for landing. Once full flap had been extended, the pilot noticed that he was unable to move the control stick to the left and as a result, the aircraft was unable to roll to the left. He immediately retracted the flaps to the take-off position, regained aileron authority and landed without further incident.

Engineering Inspection

Following the incident, the engineering inspection revealed that a spacer under the flap actuator control rod (Figure 1) was incorrectly re-installed above the flap actuator rod during a routine 200-hourly maintenance inspection.

During the inspection, the bolt attaching the idler arm to the actuator control rod was removed to allow for a bonding cable to be repaired. The flap system was inadvertently activated, resulting in the idler arm and the actuator control rod separating. When this was re-assembled, the spacer was incorrectly positioned on top of the actuator control rod. As a result, the bottom of the flap control rod was displaced downwards by the incorrectly placed spacer causing the cam to catch on the underlying aileron control rod when the flap was extended to the fully deflected landing position. Consequently, the control stick was unable to be moved left of the central position when the flaps were fully deflected.

Although a post-maintenance check flight was conducted before the incident flight, the problem was not detected. The manufacturer’s aircraft flight manual does not require a check of the flight controls in the landing position prior to take-off or during the check flight. Company standard operating procedures called for the extension of landing flap once established on final approach, but as the weather conditions were smooth, the flaps were not extended fully and therefore the fault was not detected.

The manufacturer’s post-maintenance check flight checklist also did not require a check of the flight controls with flap fully extended. 

Figure 1: Flap actuator installation

Source: Diamond DA 40 Aircraft Maintenance Manual

Safety action

As a result of this incident, the training organisation has advised the ATSB that they have taken the following safety action:

• Pre-flight checklists for all DA 40 flights have been updated to include an item to check that flight controls are full, free and functioning correctly at all flap positions.

Safety message

This incident highlights the importance of maintenance procedures and post-maintenance checks being carried out comprehensively and systematically. While the aircraft is in maintenance, all components must be refitted and reinstalled in accordance with the aircraft’s maintenance manual. Once tasks are completed, it is vital to verify the functionality of all critical aircraft components before returning it to service.

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.