What happened

On 21 November 2018, the crew of a Cessna Aircraft Company 152 departed Bankstown, New South Wales to conduct a training flight with two crew members on board.

Returning from the Bankstown training area, the aircraft was cleared by air traffic control (ATC) to join downwind for runway 29R. Whilst on downwind, at 1,500 ft above ground level, the aircraft’s engine RPM started to reduce uncommanded. The instructor took over from the student and applied full throttle and carburettor heat to attempt to increase engine RPM and performance. The engine’s RPM increased momentarily and reduced again.

The instructor advised the tower of the engine issues and requested a glide approach. ATC cleared the aircraft for a glide approach for runway 29R. During the glide approach, the engine failed and the propeller stopped windmilling.^[1] The aircraft landed safely on the runway.

Engineering inspection

Following the incident, the engineering inspection revealed the right fuel tank was empty and the left fuel tank had 15 L of fuel remaining. The remaining fuel failed to feed through the fuel lines, resulting in fuel being starved from the engine. The engineers inspected the fuel lines and vents for blockages but could not find any fault or blockage in the fuel system.

The Cessna 152 has a gravity fed fuel system that does not have a fuel tank selector switch. Asymmetric (uneven) fuel delivery is a well known phenomenon in single engine Cessna aircraft. It is very common for a 10 to 15 L difference to be found between left and right tanks. Once the aircraft reaches a fuel level equal to or below this common difference, and one tank is dry, the likelihood of fuel starvation increases significantly.

A company investigation identified a non-vented fuel cap on the left tank as a possible contributing factor. The right tank had a vented fuel cap. The Cessna 152 has an underwing vent on the left-hand side. The dual vented caps have become standard as a back up to this vent due to complicated pressure forces created within the fuel system and the tendency of the underwing vent to become blocked.

Airworthiness Directives have been released previously regarding the replacement of non-vented caps on Cessna 150 aircraft (predecessor to Cessna 152), however none have been released for the Cessna 152 as all but the very early models (first year of production) were released from the factory with dual vented fuel caps; and Cessna no longer provides the non-vented fuel cap as a replacement part. Although the majority of Cessna 152 were released from the factory with dual vented caps, many fuel system diagrams still show a vented cap on the right-hand tank only.

Figure 1: Example of Cessna unvented fuel cap

Figure 2: Example of Cessna vented fuel cap

Safety action

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

• They will be replacing the left fuel cap with a vented fuel cap.
• They will also inspect their entire Cessna fleet to ensure all aircraft have vented fuel caps on both tanks.
• Additional training for staff and students in measuring fuel levels on uneven ground will take place.
• Additional training for staff regarding total fuel and fixed fuel reserves will be implemented.

Safety message

Simulated total loss of power and a subsequent practice forced landing is at the core of a pilot’s emergency training. It is important that pilots remain aware that despite conducting comprehensive pre-flight checks, unanticipated failures can still occur during flight. Following a complete engine failure, a forced landing is inevitable. In this instance, the crew followed standard emergency procedures to ensure a safe outcome was achieved.

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. Windmilling - The continued rotation of a propeller after the engine is shut down in flight. Aerodynamic forces act on the propeller to keep it turning, or windmilling, with no power from the engine.

What happened

On 25 May 2018, a 178 m general cargo ship was anchored at Anchorage B, at the Port of Bunbury. At 0800 Western Standard Time, the ship was dragging its anchor due to weather. The ship’s master requested permission from Southern Ports pilots to heave up the anchor and return to the anchorage. At 0808, the Bureau of Meteorology issued a severe weather warning for the Bunbury coast, with damaging winds and very rough seas forecast in the evening. At 1120, Southern Ports pilots also issued this warning, citing expected gale force winds,^[1] with ships at anchorage given permission to take their ships to sea, due to the poor holding ground. The ship was contacted by the Southern Ports pilots at midday by VHF radio, and warned the weather was expected to worsen. The ship’s master elected to remain at the anchorage.

At 1730, west-north-west winds had increased to over 34 knots^[2] and swell to 3.5 m and the ship began to drift. The ship’s master then requested permission from Southern Ports pilots to heave up the anchor and head to sea. The heavy pitch and roll^[3] of the ship resulted in the anchor chain being tensioned, preventing release of the anchor chain cable stopper bar. At 1738, the main engine was started and was used to manoeuvre the ship ahead, thereby releasing tension on the anchor chain. Shortly afterwards, the chief mate advised the master that the anchor chain had parted, resulting in loss of the anchor and 12 shackles of chain.^[4] Subsequent to the incident, the deputy harbour master advised that the ship’s anchor and chain had been located and was awaiting retrieval. At the time of the occurrence brief, the southern portion of Bunbury Anchorage B was unavailable for use due to the hazard posed by the detached anchor and chain.

Figure 1: Anchorage B at Port of Bunbury

Source: Australian Hydrographic Office, annotated by Australian Transport Safety Bureau (ATSB)

Safety message

A lost anchor and chain can pose a hazard to other ships at anchorage through entanglement during anchoring. In addition, the loss of an anchor reduces the options of a ship to anchor safely. The ATSB investigation report into the Collision between Royal Pescadores and Da Heng Shan (308-MO-2014-003) is one such example, and 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.

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1. Wind speeds between 34 to 40 knots, or 8 on the Beaufort scale.
2. One knot, or one nautical mile per hour equals 1.852 kilometres per hour.
3. Rotation along the lateral and longitudinal axes respectively.
4. One shackle equals 90 feet or 27.43 m.

What happened

On 2 December 2018, an Airbus A330 aircraft departed Melbourne, Vic. on a scheduled passenger service to Kuala Lumpur, Malaysia.

Prior to take-off, the crew noted prevailing weather conditions could be challenging and it was decided that the captain would be pilot flying for the take-off and hand over to the first officer later during climb. The crew received a departure clearance from runway 16 on the BISON 5 Standard Instrument Departure (SID).

As the aircraft lined up, the crew received a report that the last aircraft to land encountered windshear. The captain assessed that it was safe to depart. Due to possible windshear, it was decided to use maximum take-off thrust^[1]. The crew reported a normal take-off. Passing 500 ft above mean sea level (AMSL), the captain engaged the autopilot and reduced the power to climb thrust. The climb rate of the aircraft then reduced and the aircraft levelled off around 760 ft AMSL. The crew, suspecting windshear, retracted the flaps and then set take-off/go around (TOGA)^[2] power. The ground proximity warning system “DON’T SINK” alert triggered and the airspeed increased beyond the flap retraction speed up to a maximum of 236 kts until the flaps fully retracted.

The aircraft continued to fly level to a position 4 NM from the airport, 400 ft above ground level, with an airspeed of 276 kts. 45 seconds after initial engagement of the autopilot, the captain then disengaged the autopilot and flew the aircraft manually. The captain commenced a climbing turn to follow the SID. During the turn, the angle of bank increased to a maximum of 46 degrees. The aircraft regained the SID, the autopilot engaged, and the flight continued to depart for Kuala Lumpur.

Post-flight, it was determined that altitude (ALT) mode^[3] was selected on the autopilot. This caused the aircraft to level off and accelerate. The crew were not aware of this at the time. It is suspected that the captain inadvertently pushed the ALT button which was not detected by the crew. This resulted in the aircraft levelling off at low altitude and allowed the speed to increase, resulting in an airframe overspeed.

Safety action

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

The details of the event have been shared with all crews to highlight the incident and the need for crews to be autopilot mode aware.

The operator has also conducted further simulator training for the crew involved.

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. Maximum take-off thrust: the maximum thrust the engine can deliver for a maximum of 5 minutes.
2. Take-off go around (TOGA): A setting that can be selected by the pilots to increase power to maximum.
3. Altitude (ALT) mode: When ALT mode is selected, the autopilot will hold the current altitude.

What happened

On 22 November 2018 a Cessna 210 was conducting a freight charter flight to Kilarney Station, Northern Territory (NT). The pilot was the sole occupant on board.

During approach to Kilarney Station, the landing gear failed to extend. The pilot attempted to extend the landing gear using emergency procedures with no success. The pilot then decided to conduct a return to Tindal Airport, NT and contacted the chief pilot and engineer in-flight. After unsuccessfully conducting troubleshooting procedures, it was decided the pilot would have to conduct a wheels up landing at a private airstrip with a grass runway area near Katherine, NT.

While the runway was prepared and emergency services were organised, the pilot entered a holding pattern to burn off fuel. At 1400 Central Standard Time, after multiple practice approaches, a wheels up landing was conducted on the grass strip resulting in a propeller strike and minor damage to the fuselage.

Engineering inspection

Following the incident, an inspection of the landing gear revealed that the hydraulic line connected to the nose wheel actuator had separated from its fitting. This subsequently resulted in a loss of hydraulic fluid in the gear down hydraulic line.

Figure 1: Damage sustained to aircraft after landing

Source: Operator

Figure 2: Broken hydraulic line from nose wheel actuator

Source: Operator

Safety message

Unanticipated failures can occur at any given time during flight. In this instance, the pilot took all appropriate actions by following non-normal procedures, communicating and coordinating with ground staff to conduct additional checks to assess the situation, and ensuring that he was well prepared for the wheels up landing resulting in a safe outcome.

This accident not only highlights the importance of comprehensive and periodic maintenance inspections, but also the importance of following emergency checklists and procedures and using every resource available to help resolve an issue.

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 30 September 2018, a Beechcraft A36 was conducting a flight from Lilydale, Victoria (Vic.) to Euroa, Vic.

At about 1800 Eastern Standard Time, at approximately 800 ft, the pilot turned onto the base leg of the circuit in preparation to land at Euroa, at which time the engine lost power. The pilot reported that he suspected fuel exhaustion in the right tank, currently in use, and changed tanks. He was unable to get the engine re-started. Due to the low altitude, he did not have enough time to troubleshoot or turn the aircraft back to the Euroa aircraft landing area. He selected a nearby paddock as a suitable location for his emergency landing; however, due to the high sink rate he was unable to make this location and instead landed early in a rough area.

The aircraft skidded about 70 m upon landing and the impact caused the front wheel to buckle and the nose to impact with the ground, bending the propeller blades. The pilot was uninjured.

After landing, the pilot called a nearby friend. The pilot’s phone battery ran out before he gave details of his exact location. The pilot’s friend contacted the chief pilot of Euroa airstrip, who called emergency services. Emergency services attended the site and foamed the aircraft as a precautionary measure.

The pilot said that he likely forgot to change fuel tanks because he was distracted – he was trying to land before last light and he was checking the runway for kangaroos.

Figure 1: Beechcraft A36 after landing

Source: Victoria Police

Safety message

Accidents involving fuel mismanagement are an ongoing aviation safety concern. Pilots need to:

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

In this instance, and others like it, selecting the appropriate fuel tank during pre-descent checks would avoid having to manage fuel during the higher workload period of approach. This would reduce the risk of a fuel starvation event.

For more information on fuel management, see ATSB research report, Starved and Exhausted: Fuel management aviation accidents (AR-2011-112).

About this report

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

What happened

On 18 November 2018 an Airbus A330-202 aircraft was being operated on a scheduled passenger flight from Jakarta, Indonesia, to Sydney, New South Wales.

During take-off, the flight crew detected improper adjustment to the trim controls. After take-off, the flight crew received an aircraft communications addressing and reporting system (ACARS) message advising that there was a discrepancy between the weight of a loaded cargo pallet on the load sheet and the actual weight of the pallet.

During the loading of the aircraft, all pallets had been packed and weighed correctly. The Load Control system requires a ground handler to enter the load data (pallet weights) into an electronic messaging system for transmission to the regional load control who generate the aircraft load sheet and load instruction report. The ground handler made an error when entering this data.

Therefore, the final load sheet had included a cargo pallet that was 3,000 kg whereas the actual weight of the pallet was 2,000 kg. This resulted in the zero fuel weight (ZFW) used being 1,000 kg heavier than the actual ZFW. The stabilizer setting from the final load sheet was 4.4 up, but should have been 4.7 up. The crew reported that the out of trim condition was evident during rotation.

Safety action

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

The ground handling agent has added the requirement for a second ground handler to cross- check data entry prior to transmission. Freight scanning has been introduced in a number of airports, and is to be introduced across the whole network including in Jakarta. This will assist in identifying errors such as this.

Safety message

This occurrence highlights the importance of cross-checking all container, pallet and baggage weights when loading an aircraft. The use of a second person or an electronic system will assist in reducing these types of data entry errors. ATSB research report, Aircraft loading occurrences July 2003 to June 2010 (AR-2010-044), documents the number and types of safety occurrences involving the loading of high-capacity aircraft to raise awareness within the industry of the associated issues.

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 6 September 2018, a Boeing 737-476 freighter was in the hanger at Brisbane Airport, Queensland undergoing routine maintenance. The crew reported that the cockpit voice recorder (CVR) was not testing and the circuit breaker was tripping.

While engineers were conducting troubleshooting on the aircraft, they discovered a heat damaged wiring loom located in the aft^[1] lower cargo hold ceiling, adjacent to the CVR mount rack. The wires were severely burnt in a localised area with melted insulation and evidence of a possible fire. Engineers suspect this may have been caused by swarf^[2] damaging the wiring and causing it to arc. Swarf ingress in the wiring loom was discovered from previous cargo conversion work.

Figure 1: Heat damaged wiring loom

Source: Operator’s engineering department

Safety message

This incident highlights the importance of ensuring that while an aircraft is in maintenance, that all aircraft components are checked thoroughly to ensure proper functionality. When conducting any work on an aircraft, it is also vital to ensure that all areas are thoroughly cleaned to ensure no debris is left behind, as it may cause faults to the aircraft and its systems.

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. Aft - situated in or near the rear of the aircraft
2. Swarf - chips of metal, wood or plastic.

What happened

Pilot report

On 11 September 2018 at 1300 Eastern Standard Time, a Piper Aircraft PA-28 was conducting a solo VFR navigation travelling from Canberra, Australian Capital Territory, to Wagga Wagga, New South Wales (NSW).

At approximately 19 km to the north-west of Yass, NSW, the pilot reported that the engine information was not displaying on the multi-function display (MFD). The pilot then reported hearing a loud noise from the auto prompter that announced that the engine sensor unit was not communicating.

The pilot reported commencing the data acquisition unit (DAU) failure checklist and then hearing an engine noise change and feeling a loss in performance, however the checklist was not completed. The pilot also reported that the aircraft began to lose airspeed and struggle to maintain height.

The pilot then reported commencing the engine failure procedures and made the decision to divert to Jindalee ALA, NSW, for a precautionary landing.

During the flight to Jindalee, the pilot attempted to troubleshoot by slowly cycling through the throttle to see if power would increase and attempted to conduct a climb with throttle at full power, with no sign of improvement. Both magnetos were isolated, and the selection was to both. The throttle was left at 2/3 open.

The pilot then made a broadcast to Melbourne Centre and on the local multicom frequency to advise of their engine issue. A safe landing at Jindalee was completed and the aircraft was secured on the ground.

Engineering inspection

Engineers inspected the aircraft and found no defects in accordance with the aircraft engineering manual. The aircraft was approved to return to service.

Safety message

When a suspected engine problem arises on a single engine aircraft, it is vital for crew to maintain control in response to emergencies.

In this scenario, the pilot maintained aircraft control and made the decision to conduct a precautionary landing.

When it is safe to do so, pilots should complete relevant emergency checklists. This will confirm the status of their aircraft’s performance and ensure a more informed decision is made when determining to continue with the flight or make a precautionary landing.

For information on what to do in the event of power loss during flight, the ATSB report and case study on Managing a partial engine power loss after take-off in single-engine aircraft 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 the 26 September 2018 at 0615 Eastern Standard Time, an Airbus 380 was in cruise toward the end of the flight from Los Angeles, United States to Melbourne, Victoria.

Shortly after a passenger in seat 18B had moved their seat they heard a cracking noise and could not locate their personal electronic device (PED). Smoke and flames were then observed emanating from the seat. Cabin crew confirmed the source of the smoke and flames was coming from under the seat.

Power to the row of seats was cut and cabin crew followed their basic fire drill training and discharged four BCF extinguishers and water to extinguish the fire.

The smoke dissipated and crew were able to distinguish the remains of a mobile phone at the rear of the left hand seat track, but were unable to remove it from its position. The decision was made to continue the flight to Melbourne and a cabin crew member was tasked with remaining seated beside the seat to ensure the phone did not reignite.

There were no injuries sustained and the remainder of the flight proceeded without further incident.

Engineers disassembled and checked the seat and found no damage to the seat, wiring or the surrounding area. The phone had been completely crushed by the seat.

Figure 1. Crushed PED in the seat track

Safety message

Dropping a PED whilst in flight is not uncommon, however passengers are reminded to never attempt to move the seat or extricate the PED themselves. If a PED becomes lost, alert a crewmember immediately. They will employ the appropriate techniques to find and remove the item, to ensure the device does not become a hazard in flight.

This incident highlights the effective response by cabin crew to an emergency situation. By quickly implementing the basic fire drill procedure the incident was effectively contained.

The ATSB investigation report, (AO-2016-066) Personal electronic device fire in-flight involving Boeing 747, VH-OJS, 500 km WNW of John F. Kennedy International Airport, United States, on 21 June 2016, is available from the ATSB website for more information on the hazards PEDs.

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 21 November 2018, a Gippsland GA-8 was operating a charter flight with one pilot and six passengers on board, at Fraser Island, Queensland (Qld).

During the flight on the return to Eli Creek, Qld, at 1520 Eastern Standard Time, the aircraft encountered turbulent conditions at 2,000 feet and the forward cargo door opened. As the pilot conducted a right turn, the door detached from the aircraft.

Post-flight, after the passengers disembarked, the aircraft was inspected. The inspection revealed damage to the rear latch receptacle indicating the door was only partially latched. It is suspected that the door was not correctly secured prior to take-off and that during the turbulent conditions a passenger may have inadvertently unlatched it.

Figure 1: Damage sustained to the rear latch receptacle

Source: Operator

Safety message

There was an Airworthiness Directive (AD/GA8/3) released in 2005 by the Civil Aviation Safety Authority (CASA), and then amended in 2010, advising operators of the GA-8 that excessive wear in the forward cargo door slide may result in the door becoming detached from the aircraft in flight. The operator had been aware of this and had inspected the door a month prior to the event. No defects were found at the time of the inspection.

This occurrence highlights the importance of flight crew ensuring the doors have been correctly secured during the pre-flight checks. Failure to do so could result in the door opening in-flight and objects falling form the aircraft with the potential to cause damage or injury.

Independent research by Transport Canada has found that the two main potential causes for doors opening on piston engine aircraft, have been due to the door being incorrectly closed and excessive wear of the locking mechanism.

It is recommended by CASA in an Airworthiness Bulletin for inadvertent opening of doors in flight that operators and maintainers take the following action:

• Ensure that all aircraft openings “doors and hatches” are inspected to ensure that:
  - the wear of the locking mechanisms are within limits
  - the door or hatch locks with a positive action
  - the aircraft doors still meet the original type certification design.
• Maintenance personnel completing periodic inspections should ensure that all placards detailing door operating instructions are present and clearly visible both internally and external on the aircraft.
• Operators are to ensure that:
  - the flight crew are made aware of the requirement to confirm that all doors and hatches are secured correctly prior to the starting of engines
  - the passengers are briefed correctly in the operation of doors particularly on aircraft types where a passenger is sitting at the only access door to the aircraft.
• It is recommended that operators train flight crew on the appropriate procedures to follow in the event of a door opening in 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.