What happened

On 8 July 2019, at about 1800 Eastern Standard Time, a Fairchild Industries SA227-AC departed Coffs Harbour, New South Wales (NSW) to conduct a charter freight flight to Port Macquarie, NSW. The pilot was the only occupant on board.

During cruise at 9,000 ft, approximately 37 km south of Coffs Harbour, the pilot noticed the right engine fire warning lights had illuminated on the warning panel and immediately commenced the memory items required for an engine fire warning. The pilot shut down the right engine, feathered^[1] the propeller to reduce drag and shortly after, the engine fire warning lights extinguished. The pilot then conducted a return to Coffs Harbour.

After landing, the aircraft was taxied to the parking bay and shut down. Fire services attended and conducted a heat test on the right engine using heat-sensing cameras. No excessive heat was recorded. The pilot then opened up the engine nacelle^[2] to visually inspect the engine. The inspection did not detect any heat damage.

Engineering inspection

The engineering inspection did not reveal any faults with the engine. The fire detector was repositioned with better clearance from surrounding assemblies. The operator has advised that they will be undertaking a feasibility assessment of an enhanced engine wiring harness replacement program.

Safety message

This incident highlights the importance of flight crews maintaining awareness of all system states and being prepared to act at the first sign of trouble. Although there was no in-flight fire in this incident, the crew followed procedures and commenced memory items for the fire warning ensuring a safe 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.

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1. 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.
2. Nacelle: a housing, separate from the fuselage that holds engines, fuel, or equipment on an aircraft.

What happened

On 3 February 2019 at 2245 Central Standard Time, a Gates Learjet Corp 35A was operating a medevac^[1] flight with two crew and four passengers on board from Darwin, Northern Territory to Adelaide, South Australia.

During the take-off run, the crew noticed a moderate shimmy in the right hand main wheel resulting in the aircraft slightly veering to the right of the runway. The crew suspected a blown tyre; however, as there were no abnormal indications they elected to continue to Adelaide.

While en route to Adelaide, the crew were notified by Air Traffic Control that rubber tyre and metal fragments had been recovered from the runway in Darwin. The crew then requested a local standby^[2] for their arrival into Adelaide.

At 0150 Central Daylight-saving Time, the aircraft landed safely at Adelaide Airport with aviation rescue and firefighting teams in attendance.

Upon landing it was found that both the right hand tyres had blown and damage was sustained to the aircraft’s right wheel and brake assemblies (Figure 1) and to the right flap (Figure 2).

The operator suspects that the cause of the blown tyres was due to foreign object debris (FOD) on the runway at Darwin. However, Darwin Airport did not find any FOD apart from tyre debris.

Figure 1: Damage to the right main landing gear and fuselage

Source: Adelaide Airport

Figure 2: Damage to the right flap

Source: Adelaide Airport

Safety message

This occurrence highlights the importance of communicating any suspected FOD, including a blown tyre, to airport authorities to ensure that a runway inspection is carried out in a timely matter. Boeing, in Foreign Object Debris and Damage Prevention, estimate that FOD damage costs the aviation industry $4 billion per year.

All aerodromes are encouraged to have an active FOD management program in place. Aerodrome staff and pilots are reminded to keep an active lookout and retrieve any identified FOD before it becomes a hazard.

Further information about FOD management at aerodromes can be found on the Australian Airports Association website, Foreign object debris.

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.

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1. Medevac by ambulance aircraft. Medical evacuation, or medevac, is the transportation of seriously ill patients by air.
2. Local standby: declared when only airport-based agencies are required in the AEP (e.g. the on-airport Rescue and Fire Fighting Service and the Aerodrome Safety Officer). A Local Standby will be the normal response when an aircraft approaching an airport is known or is suspected to have developed some defect, but the trouble would not normally involve any serious difficulty in effecting a safe landing (This generally equates to a PAN PAN).

What happened

On 3 June 2019, an Avro RJ100 departed for a commercial passenger flight from Port Augusta to Adelaide, South Australia. During approach into Adelaide, performance data and speeds were entered into the flight management system (FMS). The configuration selected for this particular approach was a flap 24 landing, due to the aircraft’s low landing weight. While conducting the approach, the crew observed that the speed was too low for a flap 24 approach and received an amber speed indication. The crew subsequently adjusted the speed setting.

After landing, the crew identified that incorrect data was entered into the FMS. Specifically, a flap 33 landing was selected, resulting in a lower approach speed. When entering the data into the FMS, standard operating procedures dictated that both crewmembers needed to crosscheck the performance data to ensure that it is correct prior to executing. In this instance, neither crew member crosschecked the data that was entered. The crew reported multiple contributing factors relating to this incident, including fatigue at the end of a long duty day, low arousal levels due to benign conditions and expectation bias as a flap 33 landing was used for all previous sectors that day.

Safety message

This incident highlights the importance of ensuring that the FMS is programmed correctly for all phases of flight, in particular critical phases, to reduce the risk of an aircraft approaching and landing with incorrect performance data. It also provides a reminder for crewmembers to monitor with each other during the flight to identify any potential decline in performance levels or alertness.

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 2019 at 1300 Central Standard Time, the pilot of a Cessna 210L aircraft was conducting a chartered passenger flight between Tindal and Hodgson Downs, Northern Territory.

Once established in the circuit area at Hodgson Downs, the landing gear was selected down as the aircraft manoeuvred to land. The pilot confirmed that the gear was down by visually checking the undercarriage was extending, hearing that the gear pump had stopped and identifying three green lights indicating gear down. The pilot continued the approach and completed the pre-landing checks, which included checking the landing gear again on final.

The landing roll felt normal until the aircraft slowed and more weight was applied to the landing gear, at which point the aircraft began to yaw to the right. The yaw was countered with rudder input, however the aircraft continued to yaw right and veered off the runway, coming to rest inside the flight strip.

Once the aircraft was shut down and secured, the pilot evacuated the passengers safely. No one was injured, however the aircraft sustained substantial damage.

Figure 1: Damage sustained to the aircraft after landing

Source: Operator

Engineering Inspection

The engineering inspection revealed one of the gear down indication switches was jammed in the closed position. On L-model Cessna 210 aircraft, when all three switches (left main, right main and nose) are closed, the gear down light is illuminated and the gear pump will stop. Upon further inspection, it appeared the switch was jamming intermittently.

During this incident, the pilot reported that he had lowered the landing gear, completed all checks as appropriate and received three green undercarriage lights. It appeared from the visual check at the time of lowering that the gear was down and locked. It is likely that the left main gear and the nose gear locked before the right main gear, however due to the right main gear switch being stuck in the closed position, the light illuminated and the pump stopped before the right main gear had fully locked in the down position.

Safety action

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

The incident has been examined and debriefed with the pilot and company’s training captains.

A company-wide memo was released regarding the importance of the visual undercarriage checks on final approach. As part of ongoing updates to the company flight crew operating manual, a revised final approach procedure has been included to clearly specify that visual gear checks must be conducted on final approach as part of the ‘UNDERCARRIAGE’ item on the checklist.

Safety message

This incident highlights the importance of pilots being familiar with all aircraft systems. This allows them to be aware of the possible effects of the failure of an interacting or interrelated component in those systems and provides them with a greater understanding of the aircraft’s operation in both normal and emergency situations.

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 2019, a Cirrus SR20 departed Moorabbin, Victoria (Vic.) with one pilot and two passengers on board. The pilot hired the aircraft from an operator for a private scenic flight that was planned to orbit Melbourne city before landing at Tooradin, Vic. During the initial stages of landing, the pilot observed the aircraft to be slightly high before it sank heavily onto the runway and bounced. After the second bounce, the pilot applied full power and retracted the flaps to conduct a go-around.

The aircraft yawed to the left and the pilot observed the indicated airspeed to be at 65 kt. The pilot received a stall warning annunciation and assessed that the aircraft had become airborne, and she therefore elected to pitch the nose of the aircraft down to land on the remaining runway. However, the aircraft rolled abruptly to the left and the wing struck the ground. The aircraft then collided with a drainage ditch to the left of the runway and was subsequently destroyed (Figure 1). The pilot and passengers exited without injury.

Operator’s investigation

The operator retrieved and reviewed the data from this private-hire flight and confirmed from the position of the flap transmission worm drive that, during the go-around procedure when full power was applied, the flaps were fully retracted. The pilot operating handbook recommends 50 per cent and indicates approximately 10 kt increase in stall speed from flaps 100 to zero per cent.

The data revealed that upon application of full power, a change of track of 15 degrees to the left of the runway resulting in the aircraft exiting the runway onto soft ground. The aircraft continued to diverge from the runway until it contacted the drainage ditch where it came to rest. The main landing gear tyre tracks were evident in the grass from the runway edge to the accident site, therefore confirming that contrary to the pilot’s recollection of events, the aircraft did not become airborne following execution of the go-around.

The operator advised that upon reviewing the data, it became apparent that during final approach, the pilot was pitching to control airspeed. The pilot reported that she used both power and elevator to land the aircraft.

Figure 1: Aircraft damage

Source: Operator

Safety action

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

• teaching pilots the correct go-around technique in this aircraft type from a low airspeed situation, such as after a significant bounce or a series of bounces, which requires right rudder pressure to counteract torque roll and p-factor^[1]
• highlighting this situation to pilots during conversion training, in line with recommendations from the manufacturer.

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.

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1. P-factor, also known as asymmetric blade effect and asymmetric disc effect, is an aerodynamic phenomenon experienced by a moving propeller that is responsible for the asymmetrical relocation of the propeller’s centre of thrust when an aircraft is at a high angle of attack.

What happened

On 17 May 2019, a Piper PA-32RT departed Jandakot, Western Australia, to conduct a training flight. There was an instructor and a student on board.

During initial climb at about 400 ft, the crew reported that the engine began running roughly and surged, and was not producing adequate power to perform a normal climb. The crew contacted Jandakot air traffic control tower and advised them of the engine malfunction, requesting an immediate landing. They also requested to land on runway 06R, as it was the closest runway available to them. The aircraft was able to maintain 100 ft above ground level allowing the crew to conduct a low-level circuit and safe landing on the runway.

Engineering Inspection

Following the incident, an engineering inspection revealed that the turbo waste gate^[1] became stuck resulting in the rough running engine.

Safety message

Partial power loss in a single-engine aircraft is three times more likely to occur than a complete engine failure. When an engine failure occurs at low altitudes, pilots are confronted with minimal options and need to make important decisions in a very short space of time. The ATSB’s publication and YouTube video,

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.

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1. Waste gate: a waste gate is a valve that diverts exhaust gases away from the turbine wheel in a turbocharged engine system.

What happened

On 8 April 2019 at 0725 Eastern Standard Time, the pilot of a Kavanagh E-240 balloon with eight passengers on board was conducting a rapid descent from 2,500 ft to 100 ft at Yarra Glen, Victoria.

At approximately 600 ft, the balloon encountered windshear resulting in the distortion of the envelope. The pilot was unaware the envelope had caved-in due to the windshear and subsequently did not angle the burner to compensate. When he began to arrest the rate of descent by applying heat, the burner flame contacted the balloon fabric close to the mouth of the envelope, resulting in substantial burn damage to the Nomex^[1] and ripstop nylon.^[2] The balloon landed safely and no passengers were injured.

Safety message

This accident highlights the importance of maintaining situational awareness of the environment the balloon is operating in and the state of the balloon to better assess and manage risk. Looking up before applying heat will ensure that the burner is angled away from the envelope in the event of windshear.

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.

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1. Nomex: the bottom of the balloon is normally made from ‘Nomex’ which is a heavy weight flame retardant fabric.
2. Ripstop nylon: hot air balloons are generally made out of a specialised ripstop nylon fabric. The fabric weave is coated to give it better UV protection, make it somewhat flame retardant and to reduce the amount of air that will leak through the fabric weave.

What happened

On 26 March 2019, at 1530 Eastern Standard Time, a Piper PA-32 with a pilot and three passengers on board departed Scone, New South Wales for Caloundra, Queensland. The flight was operating under visual flight rules (VFR).^[1] As the aircraft was in cruise, the pilot, who was IFR^[2] rated, detected a vacuum pump^[3] failure, which prevented all vacuum gyroscopes from providing accurate readings.

Due to the high amount of cloud in the area, the pilot contacted air traffic control (ATC) and requested a lower altitude in order for the flight to continue in visual conditions. ATC granted a descent clearance to 4,500 ft, however due to the descent rate and approaching cloud, the aircraft inadvertently entered IMC.^[4] The pilot contacted ATC and requested a further descent clearance, which was granted. The rest of the flight continued in visual conditions and the aircraft landed in Caloundra without further incident.

Safety message

This incident highlights the importance of pilots being prepared for high workload situations that may arise, such as managing an equipment failure. In this instance, the pilot recognised the risk of entering into IMC with a faulty vacuum pump and effectively communicated with ATC for a safe 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.

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1. Visual flight rules (VFR): a set of regulations that permit a pilot to operate an aircraft only in weather conditions generally clear enough to allow the pilot to see where the aircraft is going.
2. Instrument flight rules (IFR): a set of regulations that permit the pilot to operate an aircraft in instrument meteorological conditions (IMC), which have much lower weather minimums than visual flight rules (VFR). Procedures and training are significantly more complex as a pilot must demonstrate competency in IMC while controlling the aircraft solely by reference to instruments. IFR-capable aircraft have greater equipment and maintenance requirements.
3. The vacuum pump works by drawing air through a fine air filter as it enters the instruments to drive the gyro rotor. The vacuum pump has a limited life span and if it fails a slow drop in suction and gyros will slowly start to tumble in the instruments. This effect is especially noticeable in the attitude indicator.
4. Instrument meteorological conditions (IMC): weather conditions that require pilots to fly primarily by reference to instruments, and therefore under Instrument Flight Rules (IFR), rather than by outside visual reference. Typically, this means flying in cloud or limited visibility.

What happened

On the morning of 14 May 2019, a Robinson R22 helicopter was on descent into a property near Charleville, Queensland to meet the property owner prior to conducting mustering operations. The property owner requested that the pilot land the helicopter in a particular area to the south of the owner’s house.

During descent, the pilot initially conducted an orbit of the property and identified multiple powerlines near the house and shed area. The pilot confirmed with the property owner that there were no powerlines in the vicinity of the landing spot. As the helicopter was coming in to land, the tail contacted a powerline running north to south. The pilot reported that he did not see the powerline as it was unexpected and obscured by a large tree.

The helicopter subsequently collided with terrain and was substantially damaged. The pilot sustained minor injuries.

Figure 1: Damage to helicopter

Source: Queensland Police

Safety message

Wires can be difficult to sight and are often in the most unexpected places in rural areas. The ATSB research article, Avoidable Accidents No. 1 – Low level flying provides information on wire hazards associated with flight below 500 ft.

In this instance, the pilot requested pre-arrival information specifically regarding powerlines on the property and was provided with incorrect information.

Both pilots and property owners are reminded that they can always contact power companies to have wires marked if they could present a hazard to low-level 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 March 2019 at 1225 Western Standard Time, a Vans RV-7 was on approach to Jandakot Airport, Western Australia. When overhead the airport at 1,500 ft, air traffic control (ATC) instructed the aircraft to join downwind for runway 06L.

As the aircraft turned onto the final approach path, the pilot observed reduced visibility due to haze, dust blowing from earthworks adjacent to runway 12/30 and a large portion of the field being covered in dry grass that blended in with the surrounding landscape.

When at a low altitude, the pilot realised that the aircraft was tracking for taxiway B rather than runway 06L (Figure 1). The pilot observed no other aircraft, vehicles or persons occupying or in close proximity to the taxiway, and given the low altitude, elected to continue to land.

Figure 1: Jandakot Airport map

Source: Airservices, annotated by the ATSB

The controller first observed the aircraft was landing on the taxiway as the main landing gear touched down. The controller scanned the taxiway for any potential conflicts, confirmed that it was clear and therefore elected not to issue a go-around instruction.

ATC comments: ‘There is not a huge distance between runway 06L and taxiway B so judging that an aircraft is not lined up with the runway is difficult until the aircraft is in a short final position.’

Safety message

Pilots are reminded that ATC cannot be solely relied upon to mitigate the risks of misidentification of a runway. Pilots should be aware of the layout of the aerodrome and runways where they are operating, and if pilots encounter reduced visibility or lose situational awareness, it is prudent to request assistance from ATC. In a situation similar to this, a request for ATC to activate the runway lights may have assisted in correctly identifying the active runway. It remains the pilot’s responsibility to correctly identify and confirm they are approaching the correct runway prior to 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.