What happened

On 6 August 2019 at approximately 1910 Western Standard Time, a Textron Aviation Cessna 172S was conducting night circuits on a private-hire arrangement at Jandakot Airport, Western Australia, with one pilot on board.

After the aircraft had landed back at Jandakot, the pilot carried out a post-flight inspection and detected damage to the propeller (Figure 1). The damage had resulted from the tow bar not being removed during the pre-flight inspection and remaining attached to the aircraft after departure. The tow bar was found within the aerodrome confines; however, it is unknown exactly when it detached.

Figure 1: Damage to the propeller

Source: Aircraft operator

Pilot comments

The pre-flight check was carried out in the hangar before towing the aircraft onto the apron, as the pilot could not access the exterior hangar lights. The pilot reported that this altered his workflow pattern, distracting him from the fact the tow bar remained attached to the aircraft.

The pilot also reported feeling tired as he had worked at his primary occupation earlier in the day, prior to the incident, and had also been on night shifts preceding the incident.

Safety action

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

• The introduction of a policy for private night hirers to undertake a 30-minute one off induction course, which includes instructions on accessing all areas of the facility after hours, including the use of external lights.
• The development of a final precautionary checklist to be completed and signed pre- and post-flight 

Safety Message

This incident highlights the risk associated with operating aircraft when fatigued. Hours of work outside of flying that are not counted in flight and duty limitations can lead to a reduction in human performance and increase the risk associated with missing critical details prior or during flight. This risk could also be reduced by undertaking thorough pre-flight preparation.

Information for pilots on managing the risk of fatigue is available on the CASA website – Fatigue-fighting tips.  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 priorities is fatigue. 

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 August 2019 at about 1045 Eastern Standard Time, a Kawasaki BK117 helicopter was conducting a medical retrieval from a suburban park in Pendle Hill, New South Wales. The crew consisted of the pilot in the front right seat, an additional crew member in the front left seat and a paramedic and doctor in the rear of the helicopter.

During normal operations, the paramedics are trained to open both rear doors and provide clearances and guidance into the hover. To enable movement between the doors they have a harness attached to a wander strap to allow for better visibility.

As the helicopter approached the intended landing spot, the paramedic observed a small two-strand wire running from a light pole across the approach path. The paramedic alerted the pilot of the hazard and the landing was aborted. At the time the landing was aborted, the wire was approximately 30 metres in front of the helicopter and below skid height. The helicopter subsequently made an approach to an open area clear of the wire.

Figure 1: Landing area and surrounds

Source: Google Earth, annotated by ATSB

Operator’s comments

The operator has well-defined standard operating procedures that apply to unknown landing site operations and training is provided to all members of the crew to be able to contribute to safe operations. In this instance, the following factors worked as designed to prevent a potentially major accident:

• Crew resource management:
  The presence of a healthy ‘challenge and response’ environment is regularly reinforced and encouraged by the air crew with the medical crew.
• Wire awareness:
  When operating into unknown landing sites, wire hazard awareness is kept top-of-mind.
• Approach power margin:
  The requirement to have the power margin to enable a slow approach, allowing for careful scanning for obstacles/hazards and consideration of an immediate abort of the approach if required.
• Approach type:
  A steep angle of approach with a limited rate of descent, meaning power was applied early in the approach. In the event there is a need to arrest the descent and climb or go-around, this transition can be accomplished quickly and with only a modest additional power application.
• Training:
  The training provided to all medical crew members emphasises wire awareness as a major threat, and ensures that paramedics achieve the ability to be able to visualise the approach path of the helicopter and scan this path for hazards.

Safety message

This incident highlights the importance of having clear standard operating procedures and a mature crew resource management culture. In this instance, the crew were disciplined and used the correct, defined approach profile which resulted in the paramedic having sufficient time and opportunity to detect the wire and manage the threat. Appropriate training enabled all involved parties to become valuable contributors to safe operations.

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 31 August at about 1700 Western Standard Time, a Cessna 152 departed Jandakot Airport, Western Australia for a training flight with an instructor and a student pilot on board. The lesson was planned to conduct practice climbs in the training area. The student had a total of 2.4 hours flying experience but did not have experience flying the Cessna 152.

While returning to the aerodrome, the instructor experienced a medical episode due to an unknown and undiagnosed condition before subsequently losing consciousness. The student took over control of the aircraft and contacted Jandakot air traffic control (ATC) tower. After informing ATC of the situation, the student was instructed to conduct a few flyovers of the runway to gain situational awareness. The operator arranged for an instructor to assist the student from the tower. In addition, ATC ensured all other aircraft remained clear of the aerodrome while the student was able to practice approaches.

Once the student felt confident, ATC remained in contact to assist the student with landing the aircraft. Upon landing, emergency services vehicles attended the aircraft to assess the instructor.

At all times, communication between ATC and the student was concise, informative and positive.  

Safety message

This incident highlights the importance of how effective communication is crucial to aviation safety.

During the time the flying instructor was incapacitated, both ATC and the student pilot communicated clearly, calmly and proactively, 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 23 August 2019 at approximately 1620 Western Standard Time, the crew of a Fokker 100 was commencing take-off from Perth Airport, Western Australia for a regular public transport flight. The captain was pilot monitoring and the first officer was pilot flying.

During the take-off run, the first officer’s seat suddenly moved back. As the seat slid back, the first officer released the control column so as not to pull it back with him, and was unable to reach the pedals once the seat had stopped at the aft limit.

The aircraft then veered slightly to the right of the runway centreline and the first officer declared, ‘Handing over’. The captain immediately took over control of the aircraft and conducted a rejected take-off.

The operator suspected that the locking mechanism on the seat had failed.

Safety message

This incident highlights the importance of a rapid and decisive handover/takeover procedure undertaken by the crew, which was demonstrated in this occurrence.

The US Federal Aviation Administration publication, Aviation Instructor’s Handbook, includes further information and guidance on the positive exchange of flight controls.

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 26 August 2019, a Piper PA-28-180 aircraft departed Moorabbin, Victoria, to conduct a training flight with an instructor and student on board. The instructor was pilot monitoring and the student was pilot flying.

During the approach at approximately 100 ft AGL, the student inadvertently moved the mixture control instead of the throttle resulting in the mixture moving to the idle cut-off position. As a result, the engine lost power. The instructor advised the student to increase power to stay on the correct approach path. As the student increased the throttle, no power increase was observed. The instructor looked down to identify that the engine mixture control was at idle cut-off and that the engine was not producing power. The instructor then moved the mixture lever to full rich in an attempt to regain power, but was too late and the aircraft touched down short of the runway threshold.^[1]

The crew restarted the engine and taxied the aircraft back to the apron. There were no injuries and the aircraft did not sustain any damage.

Safety message

This incident highlights that when conducting training flights, instructors need to remain vigilant at all times. This includes being aware of the aircraft state and the actions of the pilot flying. Being prepared to take over control of the aircraft and intervene at a moment’s notice can reduce the risk of further incident or accident.

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. Threshold - The runway thresholds are markings across the runway that denote the beginning and end of the designated space for landing and take-off under non-emergency conditions.

What happened

On 14 August 2019 at approximately 1500 Eastern Standard Time, an Aeroprakt 32 was conducting a training flight from Moorabbin Airport, Victoria, with an instructor and a student on board.

During the take-off run, the crew detected that the airspeed indicator (ASI) was indicating zero and subsequently rejected the take-off. The aircraft then taxied off the runway.

Following the incident, an engineering inspection was carried out. It was determined that the pitot tube was blocked, likely from water. A blocked pitot tube affected the accuracy of the ASI, resulting in fluctuating or zero speed indications.

A test flight was subsequently conducted, and the aircraft was returned to service.

Safety action

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

• ensuring all aircraft are allocated pitot tube covers
• issuing a safety reminder to all pilots to fit pitot tube covers after all flights and report if a pitot tube cover is missing.

Safety message

This occurrence highlights the importance of pre-flight checks, as well as the use of pitot tube covers to minimise the risk of the aircraft departing with an unserviceability. Pitot tube covers are designed to prevent foreign objects from entering the pitot tube while the aircraft is stationary.

It also serves as a reminder to be aware of unreliable or erroneous airspeed indications during the take-off run. If detected and it is safe to do so, abort the 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 18 July 2019, the pilot of a Piper PA-28 was conducting a private flight from Jandakot to Meekatharra, Western Australia.

During the flight, the pilot identified that the fuel in the left-hand tank was lower than, and being consumed at, a greater rate than expected. Shortly after, the engine failed and due to the remote location of the aircraft, the pilot advised that he declared a MAYDAY^[1] to air traffic control. The pilot commenced troubleshooting as per the aircraft’s flight manual to attempt to resolve the engine issue. After changing the fuel selector and activating the fuel pump, power was restored to the engine.

Rather than proceed with the planned flight, the pilot diverted and landed the aircraft to Paynes Find Airport for further assessment. There were no reported injuries or damage to the aircraft.

A post-flight inspection revealed that the left-hand fuel drain was not in the fully closed position leading to fuel leaking from the left tank.

Safety message

If an engine fails or runs rough due to fuel starvation, changing the selected tanks should restore power but may take some time to take effect. In this incident, after engine power was restored, the pilot assessed the situation and elected to land the aircraft as soon as possible for inspection, to ensure the safety of the aircraft and its occupants.

Fuel starvation continues to be a common cause of engine failures. More information can be found in the ATSB report, Starved and exhausted: Fuel management aviation accidents, which highlights key messages about accurate fuel management and keeping fuel supplied to the engines.

This incident also highlights the importance of thorough pre-flight inspections to ensure the aircraft is safe for flight. This includes confirming that fuel drains are correctly closed after fuel sampling.

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. MAYDAY: an internationally recognised radio call announcing a distress condition where an aircraft or its occupants are being threatened by serious and/or imminent danger and the flight crew require immediate assistance.

What happened

On the afternoon of 30 July 2019, a local pilot and owner of a DR-107 One Design amateur-built aircraft^[1] commenced flying activities at Narromine Airport, New South Wales. At about 1415 Eastern Standard Time, while conducting aerobatics, the pilot experienced degraded rudder control. The pilot elected to land immediately on runway 22. On landing, the left rudder pedal/cable mechanism collapsed, the aircraft veered to the right of the runway and ground looped,^[2] colliding with a nearby gable marker. The pilot sustained minor injuries, and the aircraft was substantially damaged.

Post-Accident Inspection

Immediately following the accident, the aircraft owner conducted a detailed inspection of the left rudder pedal assembly, including the rudder cable, pedal and the surrounding areas for damage. The pilot discovered that the nut and bolt (with split pin) fastener, connecting the left rudder pedal to the rudder cable, had failed (Figure 1). The left rudder pedal was extended to the maximum forward position (Figure 2). The subsequent walk-around inspection identified additional external damage to the lower side of the forward fuselage, the left-wing tip and the left landing gear.

Figure 1: Left rudder pedal assembly – looking forward

Source: Aircraft owner & pilot

Figure 2: Expanded view – underneath left-hand side heel/foot rest

Source: Aircraft owner & pilot

Safety message

In this incident, the pilot recognised a potential flight control failure while inflight, and successfully recovered the aircraft to the ground as soon as he was able. Aerobatic flying can produce significant stress to flight control mechanisms. This occurrence reinforces the need to complete a diligent pre-flight inspection of all visible flight control components/attachment points, and to act promptly, yet conservatively in the event of any flight control malfunction.

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. Amateur-built aircraft: an aircraft, the major portion of which; has been fabricated and assembled by a person, or persons who undertook the construction project solely for their own education or recreation.
2. Ground-loop: a violent, uncontrolled horizontal rotation of an aircraft while landing, taking off, or taxiing.

What happened

On the morning of 18 June 2019, the pilot of a de Havilland DHC-2 aircraft was conducting a charter flight with three passengers on board. The flight departed from Proserpine, Queensland and planned to land near the Great Barrier Reef before returning to Proserpine. During cruise, the pilot observed a thick, clear substance coating the windscreen but at the time believed it to be cleaning fluid.

As the aircraft approached the landing point, the pilot had trouble seeing the buoys in the water due to the substance and conducted a go-around. At this point, the pilot realised the substance was in fact engine oil and began conducting checks to ensure performance was not compromised, climbing the aircraft to 4,500 ft. The pilot checked the oil dipstick, noting the aircraft was losing oil at a low to moderate rate. Knowing that he had three litres of additional oil carried in the aircraft, he conducted a diversion to Shute Harbour, observing the engine gauges at all times. Once closer to the mainland, he added the remaining oil to the engine and landed without further incident at Shute Harbour.

Engineering Inspection

The engineering inspection revealed that two studs holding the no. 9 cylinder to the engine case were missing and multiple others were loose, resulting in oil spilling from the bottom of the cylinder. The operator advised that an engineering inspection was conducted four days prior to the incident, with no issues identified.

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 11 June 2019, a Cessna 150M departed Lismore, New South Wales to conduct a training flight. There was an instructor and a student on board.

The student was conducting a practice glide approach to runway 15 at Lismore when the aircraft’s approach profile became too low. The instructor took over control of the aircraft to correct the profile, however, was unable to do so in time resulting in the wheel spat colliding with the airport’s perimeter fence. The aircraft sustained minor damage.

Safety message

During training flights, instructors need to be vigilant and prepared to take over control of the aircraft at short notice. When conducting practice glide approaches, correct speed and approach profile need to be maintained, as power is not used. If the approach is too low and intervention is delayed, there is an increased risk of the aircraft colliding with 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.