What happened

On 23 March 2019, a Luscombe Aircraft Corp 8A departed Bunbury, Western Australia, to conduct a training flight with an instructor and a student on board. During approach to land back at Bunbury, the aircraft encountered unexpected turbulence and windshear^[1] and as a result, the aircraft landed heavily. The crew exited the aircraft without injury and conducted an inspection to check for any damage. The post-flight inspection did not reveal any damage and the aircraft subsequently conducted two more flights.

On 25 March 2019, the aircraft was sent to a Licensed Aircraft Maintenance Engineer (LAME) to conduct a more detailed and thorough inspection. The engineering inspection revealed that the aircraft had sustained substantial damage with some slight creasing at the attach point of one of the undercarriage legs, some dimpling on top of a wing and skin dimpling behind the rear door post. The LAME found the aircraft to be unserviceable and it was consequently grounded.

Safety message

All pilots, regardless of their experience levels, should be prepared to undertake a go-around rather than continuing with an unstable approach. The Flight Safety Foundation released a briefing note Approach-and-landing accident reduction Briefing Note 6.1 to remind pilots of the importance of being prepared to conduct a go-around during all approaches. This occurrence also serves as a reminder that after any hard landing or other related incidents, where the integrity of the airframe or structure may be compromised, a detailed and thorough engineering inspection should always be carried out to ensure the serviceability of the aircraft and all of its components.

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. Windshear: a change in wind velocity or direction that can be an extremely dangerous because, when encountered at a low altitude, windshear can cause a sudden and potentially disastrous difference to airspeed and thus lift.

What happened

On 3 February 2019, a Cessna 206 departed Aldinga, South Australia, to conduct parachuting operations. There was one pilot and four parachutists on board. At 1345 Central Daylight-saving Time, the aircraft was passing through 8,000 ft on climb when the engine failed. The pilot attempted to restart the engine and switched fuel tanks, but the attempt was unsuccessful.

At approximately 6,500 ft, the parachutists exited the aircraft and the pilot started to track back towards Aldinga. The pilot was able to restart the engine at 5,000 ft and conducted a straight in approach to Aldinga. After landing, the fuel tanks were dipped and it was found that the right tank was empty while the left tank had 110 litres of fuel on board. The pilot said that he likely forgot to change fuel tanks because he was distracted due to radio calls and high workload.

Safety message

Pilots are reminded to follow published procedures when operating any aircraft system in accordance with the manufacturer’s recommendations. Accidents involving fuel mismanagement are an ongoing aviation safety concern. Pilots need to:

• understand how their aircraft fuel system works
• know how much fuel is in each tank
• ensure that the appropriate tank is selected at all times.

In this instance, selecting the appropriate fuel tank during checks would have avoided the pilot having to manage fuel during a high workload period. This in turn, would reduce the risk of a fuel starvation event.

Issue number 5 in the ATSB’s Avoidable Accident Series, Avoidable Accidents No. 5 - Starved and exhausted: Fuel management aviation accidents (AR-2011-112), provides more detail on these scenarios and is available from the ATSB website.

What happened

On 27 February 2019, at approximately 1800 Western Standard Time, a Cessna 172M with one pilot on board was conducting a private flight from Lindon, Western Australia (WA) to Carnarvon, WA. During cruise at approximately 6,000 ft, the pilot heard a loud bang and observed oil on the windscreen of the aircraft. The engine subsequently ran rough for two minutes before failing completely. The pilot located an appropriate landing area at Middalya Station, WA and conducted a forced landing. The pilot was uninjured and there was no damage to the aircraft as a result of the forced landing. The engineering inspection determined that one cylinder in the engine had broken in half.

Safety message

This incident highlights the importance of frequent emergency procedures training. The pilot’s handling of the forced landing contributed positively to the outcome of this incident. The ATSB investigation report, Engine failure and forced landing involving Gippsland GA-8 Airvan, VH-BFL, 8.5 km NNW or Bellburn Airstrip Western Australia, on 15 May 2018 (AO-2018-036) states, ‘Although, as a minimum, flight reviews are required every two years, pilots and operators are reminded of the benefits of more frequent practice of emergency procedures.’

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 morning of 26 March 2019, a Sikorsky S92 crew was conducting a search-and-rescue/medevac training sortie in conjunction with a contracted training vessel. On arrival at the rendezvous location, the crew established themselves in a stable hover over the vessel that was underway in relatively calm conditions. At approximately 0900 Western Standard Time, the crew commenced a winching operation to lower an Intensive Care Paramedic (ICP) onto a clear exposed area of the deck. As the ICP came over the intended landing area he was slightly spinning, which is normal in winching operations. The ICP’s foot contacted a fitting on the boat and with the momentum of the spin his knee struck a hatch cover causing a serious knee injury. After some consideration of the situation, the crew recovered the ICP and transported him to Broome for medical assistance.

The ICP’s knee injury required admission to hospital for surgery.

The operator conducted a review, identifying and confirming that all controls in place for this exercise are effective. No causal human factor has been identified that would contribute to, or instigate, an injury to the ICP, and no shortfall or omission in any existing formal documentation, training, competencies or operator processes could indicate a root cause.

Safety message

The company has established policy, procedures and training for conducting winch operations. This crew had seemingly done everything to conduct the training correctly. Weather and sea conditions were suitable to carry out the winching practice. So what can be learnt?

This occurrence is a first for this operator and from the collective prior experiences of aircrew staff members, it was noted that bump/impact injuries are not uncommon, and have occurred with most operators in similar roles. The occurrence of injury has been as low as reasonably practicable and the likelihood of a re-occurrence, whilst it is considered possible, is remote. This brief indicates that there were no faults in the performance of the crews during the training exercise, and despite all conditions being suitable, it still resulted in an accidental serious injury. Although this incident is comparable to a slip/trip/fall in the workplace environment with causal factors that are unlikely to be able to be ‘trained’ for, it is the recognition and understanding that winching operations are inherently hazardous.

This incident therefore provides a reminder to operators and crews to ensure all organisational policy, procedures and training mediums are current and comprehensive. For all crews undertaking any complex exercises, it is important to review, understand, and brief the hazards involved and recovery actions to follow in the event of an unplanned incident.

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 19 January 2019 at approximately 1800 Eastern Daylight-saving Time, a Boeing 737-800 carrying 155 passengers was approaching Sydney, New South Wales from the north. Due to an oversight in planning and briefing for the approach, an incorrect waypoint crossing altitude was entered and the crew did not notice that the aircraft was high on profile for much of the initial descent. The crew noticed the discrepancy at approximately 30 NM, and took action to rectify the profile. Despite earlier than normal speed limitations from ATC due to slower preceding traffic on the same runway, the profile was not regained which lead to the aircraft remaining consistently high on the final approach profile.

The aircraft was above glideslope and descending on autopilot to 2,600 ft, when approaching the set altitude, the crew selected 3,000 ft on the autopilot in preparation for a potential go around. Due to the autopilot mode, this resulted in a thrust increase and the aircraft pitched up and commenced climbing to 3,000 ft. The crew decided to conduct a go around, during which the aircraft pitch changed and an accompanying decay in airspeed continued to a point that the warning “airspeed low” sounded. At approximately the same time as the crew received the warning they noted the low airspeed and ensured increased thrust was applied. The crew addressed the pitch attitude and as airspeed stabilised and flap was retracted, the go around was carried out according to the published procedure. The crew completed the required checklists and made a cabin announcement as the aircraft was vectored for a subsequent approach and landing.

Safety message

This incident highlights the need for crew to make early positive decisions to regain the required performance or profile when operations are not normal. Making a positive early decision may assist in avoiding forced decisions later when there is less margin for error. It is important to recognise the compounding effects that non-standard operations can produce, and that increased vigilance is required to successfully manage the situation.

Comprehensively pre-briefing a procedure and then monitoring progress is an effective way to minimise mistakes and recognise early that desired performance is not being achieved. Once a departure from the desired performance is recognised, a positive corrective action should be taken.

If ATC instructions are affecting your ability to meet the desired performance – speak up. An orbit or a vector for more track miles in a similar situation may be preferable to a forced go-around or missed approach.

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 priority is Data input errors.

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 5 December 2018, a NOTAM was current for a displaced threshold (DT) at the western end of runway 29 (runway 11 threshold) for cable maintenance at Darwin airport, Northern Territory. A Fairchild Industries SA227, undertaking a passenger charter, conducted an intersection departure from taxiway E on runway 29 and passed low over the maintenance crew working on the upwind end of the runway. The intersection chosen for the departure was approximately at the midpoint of the runway, therefore significantly reducing the runway available.

Figure 1: Aerodrome Chart – Darwin, NT

Source: Airservices Australia, annotated by the ATSB

Pilot comments/considerations

The crew carried out calculations to determine that the aircraft could clear the obstruction described in the NOTAM. Their calculations demonstrated that the aircraft would be able to clear all obstacles even in the event of one engine failing during the take-off. Sufficient stopping distance was available for a rejected take-off (RTO) at low speed and actions required for an engine failure at or near V1^[1] was to continue the take-off.

Airfield operators comments/considerations

• The NOTAM did not specify that aircraft can request any men and equipment to be vacated, however if an aircraft’s crew does request this, it can be done, but it is the exception rather than general practice.
• During DT operations ATC will:
  • notify aircrew, through directed transmissions, of the DT or Reduced Operating Length (ROL) when issuing a landing/take off clearance.
  • confirm if aircrew can accept a departure with the ROL that is in place, should they request an intersection departure.

Safety message

This incident highlights the need for pilots and ATC to be cognisant that when temporary changes to normal operations are in place, such as conditions in NOTAMS, increased vigilance is required.

Aircraft operation - Pilots and operators faced with unusual or changed circumstances should fully consider both their performance planning and decision-making processes. If any available option exists to enhance safe operations by increasing safety margins those options should be evaluated fully and applied if appropriate.

Airfield operators / ATC – if works are being undertaken within the runway environment it may be appropriate to restrict operations, for example, no or limited intersection departures. Alternatively, if an intersection departure is required, the maintenance crew should be advised and possibly vacated from the runway environment to provide necessary awareness and safety margins.

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. V1 is the speed by which time the decision to continue flight if an engine fails has been made.

What happened

On 20 December 2018, a de Havilland DHC-8 was traveling from Sydney, New South Wales (NSW) to Dubbo, NSW on a regular public transport flight. During approach to runway 23 at Dubbo, the aircraft encountered heavy showers and unexpected moderate to severe turbulence. The crew disengaged the autopilot and commenced a missed approach procedure. During the missed approach, the aircraft’s indicated airspeed (IAS) dropped to 100, and the crew received a momentary stick shaker alert. While climbing through 3,700 ft, the aircraft again encountered severe turbulence.

After landing, damage to the empennage was evident, with oil canning on the skin of the aircraft. Minor damage between the rudder and elevator was also observed. There were no reported injuries to passengers or crew; however, some passengers reported feeling airsick.

Safety message

The ATSB research report, Staying safe against in-flight turbulence (AR-2008-034), details that while turbulence is normal and occurs frequently, it can be dangerous. Turbulence is rarely a threat to passenger aircraft or to pilot control of the aircraft. In a typical turbulence incident, 99 per cent of people on board receive no injuries. The report outlines what steps passengers can take to mitigate the risk of injury during turbulence.

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 5 January 2019 at approximately 1045 Eastern Standard Time, the pilot of an amateur built aircraft VAN’S RV-6A took off from an unsealed runway at Lakeland Downs airstrip, Queensland for a private flight with one passenger on board.

During the take-off run^[1], at approximately 250 m down the runway, the aircraft began to deviate to the right uncommanded. The pilot then conducted a rejected take-off and lost directional control resulting in the aircraft veering off the runway and colliding with a tree. The aircraft subsequently sustained substantial damage.

Pilot comments

The pilot advised that there had recently been a lot of rain in the area and the airstrip was mainly clay with overgrown grass. Upon landing at the airstrip, he had noticed that the runway had a rough surface, and during take-off he had tried to follow the same track.

After the accident, the pilot walked back along the tracks the aircraft had taken and found a large rock buried in the runway that the landing gear had struck.

Figure 1: Damage sustained to aircraft

Source: Qld Police

Safety message

This accident highlights the importance of identification and management of any risks that might be associated with an unsealed runway. Potential hazards may be hard to identify, with objects possibly obscured by vegetation. Changes in the runway surface can be hard to detect visually and without a vehicle or some means to apply a similar force to that of a landing aircraft.

Further information on being prepared when operating on remote airstrips can be found on the CASA website, Bush strips.

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. Take-off run: Take-off run (ground run) is the portion of the take-off procedure during which the airplane is accelerated from a standstill to an airspeed that provides sufficient lift for it to become airborne.

What happened

On 9 March 2019, the pilot of a Diamond DA 40 was conducting a solo navigation flight from Port Augusta, South Australia (SA) to Parafield, SA. The pilot departed Port Augusta at about 0950 Central Daylight-saving Time (CDT).

About 40 minutes into the flight, the pilot began to feel a headache in his forehead and engaged the autopilot on a heading of 180⁰ and altitude 5,500 ft. Shortly after, the pilot became unconscious.

At about 1100 CDT, the aircraft infringed Class C airspace^[1] and Air Traffic Control (ATC) attempted to contact the pilot numerous times unsuccessfully. The crew of a Diamond DA 42, which was operating in the area, offered their assistance to ATC in identifying and establishing contact with the aircraft. At about 1115 CDT, the crew made visual contact with the DA 40 and reported the pilot had regained consciousness. At this point, the aircraft was over water, 46 km south-south-west of Adelaide. Radio contact was subsequently established and ATC assisted the pilot in returning the aircraft to Parafield whilst under escort by the DA 42.

It is estimated that the pilot was unconscious for approximately 40 minutes.

Pilot comments

The pilot advised that the night prior to the flight he had suffered from a restless night of sleep and was recovering from a mild cold. On the day of the flight, the pilot did not consume any breakfast prior to departing from Parafield to Port Augusta. During the flight from Parafield to Port Augusta, the pilot only consumed a bottle of Gatorade, some water and a chocolate bar during the stopover in Port Augusta.

Safety action

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

• Provide guidance that is more specific to students regarding sleep patterns and practical methods to ensure students are well rested.
• Students will be required to include in their flight authorisation form their hours of sleep in the previous 24 and 48 hours, the time of when their last meal was consumed and the type of meal.
• Conduct a safety briefing to re-emphasize the importance of observing company guidelines and responsibilities of the pilot in command, with more emphasis on fatigue management.

Safety message

This occurrence highlights the importance of flight crew assessing their ability to fly prior to flight. It is the flight crew’s responsibility to monitor their own health and wellbeing, to ensure that they are well rested and adequately nourished, especially during single pilot operations. Research conducted by the ATSB has found that 70 per cent of pilot incapacitation occurrences in general aviation had an effect on flight operations, in particular return to departure aerodrome or collision with terrain.

Further information about assessing your fitness to fly and pilot incapacitation can be found on the ATSB website, Are you fit to fly? and Pilot incapacitation occurrences 2010-2014.

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. Class C airspace: This is the controlled airspace surrounding major airports. Both IFR and VFR flights are permitted and must communicate with air traffic control. IFR aircraft are positively separated from both IFR and VFR aircraft. VFR aircraft are provided traffic information on other VFR aircraft.

What happened

On 16 December 2018, at approximately 1545 Eastern Standard Time, a Fokker Aircraft B.V. F28MK0100 was conducting a regular public transport flight from Brisbane Airport, Queensland (Qld) to Rockhampton Airport, Qld with four crew and eighty-four passengers on board. During landing at Rockhampton, reverse thrust was selected by the crew, however both thrust reversers failed to deploy. The aircraft landed without incident. During taxi, the crew tested the reversers, which did not deploy.

Engineering inspection

Following non‑operation of the thrust reversers during the landing roll, an engineering check revealed that the reverse thrust lockout pins were installed, resulting in de-activation of the thrust reverser system. The lockout pins were installed as part of unscheduled maintenance action and unintentionally not removed prior to flight. It was also identified that the lockout pins did not have safety flags attached to them.

Safety action

As a result of this incident, the maintenance organisation has advised the ATSB that they are taking the following ongoing safety actions:

• General Manager Aircraft Maintenance Organisation:
  • Counsel LAME for effective oversight/management of shift task allocation and regulatory completion of associated documentation.
  • Counsel AME to ensure any unscheduled maintenance is appropriately documented.
  • Highlight to all AMO staff the requirement to record maintenance actions and to notify management and/or rectify any safety issues noted at the time.
• General Manager Airworthiness to review current TRP “Safety Flag” attachment management and associated reference documentation. Consideration should be given to:
  • ensure all F100/70 aircraft TRP have “Safety Flags” attached
  • update relevant Checklists and task references to include “TRP and Safety Flag”
  • update appropriate MEL TRP removal/fitment steps to include “Safety Flag” references
  • review management of Pre & Post maintenance safety tasks
  • review of pre-flight procedures to include checking that pins are not installed and have been removed.

Safety message

This incident serves as a reminder that a failure to follow procedures, such as functional checks, can result in unintended consequences. Functional checks are the last line of defence in maintenance work and can identify a range or errors that may have occurred during the job completion process. The extra few minutes taken to complete a functional check could detect an unsafe situation. This highlights the importance of ensuring that all pre-flight checks and procedures are carried out comprehensively and systematically. Where an aircraft has been out of service for maintenance, it is important to verify the functionality of all critical aircraft components before returning it to service. These checks should be conducted in addition to the routine, pre-flight checks. It is important that pilots remain aware that despite conducting comprehensive pre-flight checks, unanticipated failures can still occur during 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.