What happened

On 8 September 2018, at 0700 Central Standard Time, a Da-Jiang Innovations (DJI) Inspire 2 remotely piloted aircraft (RPA) was conducting a test flight above Fort Hill Wharf, Northern Territory.

During the test flight, the operator flew the RPA near a cruise ship. The RPA lost signal and the operator initiated the return-to-home procedure. During this procedure, at a height of 120 feet above ground level, the RPA deviated from the return-to-home path and collided with the ship, resulting in the aircraft being destroyed.

The pilot speculated that the ship caused interference with the datalink signal, resulting in the RPA deviating off course and subsequently colliding with the ship.

Safety message

This incident highlights the importance of ensuring that while operating RPAs, a sufficient distance is maintained from vehicles, ships, buildings and people at all times. The Civil Aviation Safety Authority has published an extensive amount of information on flying drones/remotely piloted aircraft in Australia.

Further information about flying your RPA safely can be found on the ATSB website, under the news item: Know your drone and the rules to fly safely.

About this report

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

What happened

On 20 November 2018, a Yamaha RMAX remotely piloted aircraft (RPA) was conducting an air work flight in a paddock near Muswellbrook, New South Wales. A ground support officer and navigator/spotter aided the RPA pilot.

The pilot climbed the RPA to provide ample clearance above trees and put the RPA into a hover. The pilot then moved to position himself better for the area of operation. The pilot unknowingly stepped over an electric fence. He received an electric shock, dropping the controller as a result. In the process of dropping the controller, the throttle moved to full negative. The pilot quickly picked up the controller and increased the throttle. The RPA’s descent reduced as a result but not enough to avoid contacting trees. The RPA subsequently collided with the ground resulting in substantial damage. The pilot and support personnel positioned at a safe distance from the accident were not injured.

Safety action

As a result of this occurrence, the operator has made changes to the way electrical fencing is identified and labelled. Crews will also carry an electric fence testing meter to be used at relevant sites.

Safety message

Electric fences along with other distractions and trip hazards need consideration when operating an RPA. Any operation that requires the operator to reposition themselves while operating an RPA increases the risk of trip hazards.

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 29 October 2018, the pilot of a Cessna 172 was conducting a solo navigation flight from Tamworth, New South Wales (NSW) to Mudgee NSW. On the same day, the pilot of another Cessna 172 was conducting a solo navigation flight to Mudgee, NSW.

At about 1500 Eastern Daylight-saving Time, the pilot of the first 172 was conducting a non-standard left-hand circuit for runway 22 on the dead side^[1]. At the same time, the pilot of the second 172 was descending on the dead side of runway 22 with the intension of joining the right-hand crosswind.

The two aircraft came within close proximity of each other, with one aircraft passing under the other, resulting in a vertical separation of 83 feet and approximately 100 metres horizontal distance.

The pilot conducting the left-hand circuit was unware of the local traffic regulations at Mudgee Airport where the standard circuit direction is to the right instead of to the left for runway 22. Both pilots reported broadcasting on the common traffic advisory frequency (CTAF).

Safety message

This incident highlights the need for pilots to maintain situational awareness and a vigilant lookout at all times. This is especially important when operating at non-controlled aerodromes where pilots are responsible for monitoring and broadcasting their intensions on the CTAF. Research conducted by the ATSB has found that insufficient communication between pilots and breakdown of situational awareness were the most common causes of safety incidents near non-controlled aerodromes.

Additionally, this incident highlights the need for pilots to consult the En Route Supplement Australia when flying to an unfamiliar aerodrome. As illustrated by this incident, not all non-controlled aerodromes follow the same procedures. Being aware of local traffic procedures not only helps to ensure safe operation but also helps pilots to anticipate the likely position of other aircraft.

Further information about operating safely at non-controlled aerodromes can be found on the ATSB website, A pilot's guide to staying safe in the vicinity of non-controlled aerodromes and the CASA website, Operations at non-controlled aerodromes.

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 Non-controlled airspace.

About this report

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

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1. Dead side: The area on the opposite side of the runway to where the circuit is flown.

What happened

On 12 November 2018 at approximately 1300 Eastern Daylight-saving Time, the pilot of a Cessna 441 was on a westerly approach to Dubbo Airport, New South Wales. On the same day, a Beechcraft B200 and a Piper PA-31 were also on approach to Dubbo; with the B200 inbound from the south-east and the PA-31 from the south-west. Both the 441 and the B200 were given aircraft traffic by Melbourne Centre^[1], advising both crews that the B200 was arriving first for runway 05 followed by the 441 and PA-31.

Just prior to reaching the 5 NM point from the airport, the crew of the B200 reported their position on the Dubbo common traffic advisory frequency (CTAF) and requested a position update from the 441. The crew of the 441 advised that they were passing WI. Upon realisation of the potential confliction, the crew of the B200 informed the 441 of their converging track and requested the 441 conduct an orbit to maintain separation. At about the same time the crew of the 441 received a TCAS alert alerting them that the conflicting traffic was 1 NM away. They immediately conducted an orbit to the left until it was clear to resume their approach.

Pilot comments

Pilot of Cessna 441

The pilot advised that throughout their approach, they were in communication with the crew of the PA-31 coordinating their approach via the CTAF. Because of the multiple radio transmissions on the CTAF and with Melbourne Centre, they were unable to communicate with the crew of the B200 earlier.

Safety message

This incident highlights the need for pilots to maintain situational awareness and a vigilant lookout at all times. This is especially important when operating at non-controlled aerodromes where pilots are responsible for monitoring and broadcasting their intensions on the CTAF. Research has found that the most hazardous phases of flight are within 5 NM of an aerodrome and at an altitude below 3,000 ft, as there is a higher traffic density within this area.

Further information about operating safely at non-controlled aerodromes can be found on the ATSB website A pilot's guide to staying safe in the vicinity of non-controlled aerodromes and CASA website Operations at non-controlled aerodromes.

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 Non-controlled airspace.

About this report

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

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1. The Melbourne flight information region (FIR) includes the southern half of Australia and the Southern and Indian oceans. The centre is directly responsible for en route services throughout the FIR.

What happened

On 22 August 2018 at 0730 Eastern Standard Time, the pilot of a Kavanagh G-450 balloon was on final approach to land near Kooralbyn Queensland with a pilot and 23 passengers on board. Passing 2,500 ft, the wind was 17 kts with calm conditions on the surface. The pilot did not expect to experience windshear during approach nor was he aware that the envelope was subject to deformation in-flight. Passing 500 ft on approach, the balloon encountered windshear and the turning vent lines were singed by the burner flame as a result of descending with speed from altitude into calm conditions. This resulted in minor damage to the turning vent lines.

As a result of this incident, the operator has conducted training with the pilot and has contacted the manufacturer to look at replacing the turning vent lines with a more flame resistant material.

Safety message

The Australian Ballooning Federation's Pilot Training Manual Part 5 "Aerostatics and Airmanship" describes the responsibilities and duties of the pilot in relation to weather conditions in detail. The manual reminds balloon pilots that when conditions change suddenly and unexpectedly, even a slight vertical movement of air due to local turbulence effects will tend to carry a balloon with it, dramatically reducing vertical (and therefore directional) control. The manual notes that is therefore essential to have a sound knowledge of weather systems and their likely effects on a balloon, and to constantly monitor weather developments while flying.

About this report

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

What happened

On 12 September 2018, the crew of a Beech Aircraft Corp 76 departed Jandakot, Western Australia to conduct a flight test with two crew members on board.

Just after take-off, the crew proceeded 28 km south of Jandakot, WA, operating under Visual Flight Rules^[1] (VFR). Whilst in the local training area, the crew conducted some training manoeuvres, which also included three in-flight gear extensions. The first two gear extensions were performed without incident. During the third gear extension, the nose gear failed to extend and lock into place. The crew attempted to extend the gear using the emergency procedures checklist located in the aircraft’s flight manual. After completing the landing gear manual extension checklist (Figure 1), the crew were unable to extend the nose gear. This was confirmed by the nose gear light not being illuminated and by visual inspection in the form of a mirror located on the inside of the left engine cowling. The crew conducted a return to Jandakot, declared a PAN-PAN^[2] call to Jandakot tower and instructed the Tower that they would be performing a nose gear up landing.

Air Traffic Control (ATC) acknowledged the PAN-PAN and instructed the crew to hold south of the airport to process all arriving traffic in anticipation that the runway would become unserviceable, and to give the crew time to attempt to extend the gear and prepare for their approach. The crew conducted a fly-by of the tower for a visual inspection of the landing gear. ATC confirmed that the nose gear was not extended. Emergency services and procedures were activated and the aircraft was holding in the circuit area

As the aircraft approached for landing, the crew completed the gear up landing checklist (Figure 2), which instructs them of the proper configuration the aircraft needs to be in to perform a gear up landing to minimise injury and damage to the aircraft. Prior to touching down on the runway, at about 200 ft above ground level, the crew pulled the engine throttles back to idle, the engine fuel mixtures to idle cut-off, the propeller pitch controls to feather and all electrical systems were turned off to prevent any damage to the engines, propellers and also to reduce the risk of a fire. As the main landing gear wheels touched down on the runway, the crew kept backpressure on the control column to keep the nose of the aircraft off the ground as long as possible and to slow the aircraft down. As the aircraft’s speed started to slow down, the nose slowly started to drop onto the runway and came in contact with the runway surface. The aircraft came to a complete stop shortly after. The crew disembarked the aircraft unharmed. The aircraft sustained minor damage to the nose section.

Engineering inspection

Following the incident, the inspection of the nose gear section revealed that the landing gear pivot bolts and leg pins on the landing gear doors were worn, which caused it to malfunction and prevented the doors from opening, therefore not allowing the nose gear to extend.

Figure 1: Landing gear manual extension checklist 

Figure 2: Gear up landing checklist 

Safety message

Unanticipated failures can occur during flight. In this incident, although the aircraft was within the necessary distance from the runway to complete a nose gear up landing, it is safer to wait until the main landing gear has touched down on the runway before shutting down and feathering the engines. This is to ensure that if the aircraft has to go around or take-off again due to safety reasons or obstructions on the runway, the aircraft will have the necessary engine performance it requires to perform this task.

The crew, in this instance, took all possible precautions by following non-normal procedures, conducting additional checks to assess the situation, providing clear communications to ATC and returning the aircraft to land.

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) - are a set of regulations under which a pilot operates an aircraft in weather conditions generally clear enough to allow the pilot to see where the aircraft is going. Specifically, the weather must be better than basic VFR weather minima.
2. PAN-PAN - The radiotelephony message PAN-PAN is the international standard urgency signal that the crew on board an aircraft uses to declare that they have a situation that is urgent but, for the time being at least, does not pose an immediate danger to anyone's life or the aircraft itself.

What happened

On 20 October 2018, the pilot of a de Havilland Aircraft Company DH-82A Tiger Moth departed Mackay, Queensland to conduct a joy flight. There was one pilot and one passenger on board.

During cruise, while returning to Mackay, the engine failed. The pilot declared a MAYDAY^[1], lowered the nose of the aircraft and searched for a suitable landing area, finding a nearby road to be suitable. The pilot conducted a successful forced landing on the surface of the road. The aircraft did not sustain any damage as a result of the landing.

Engineering Inspection

Following the incident, the engineering inspection revealed the crankshaft had broken at the no. 1 cylinder aft main bearing web.

Figure 1: de Havilland DH-82A broken crankshaft

Source: Pilot in Command

Safety message

Simulated total loss of power and a subsequent practice forced landing is at the core of a pilot’s emergency training. Following the engine failure, the pilot involved in this incident had to make important decisions in a short space of time, including where to land and how to manage the remaining altitude. Pre-flight self-briefing is an important tool in reinforcing planned emergency actions, including in circumstances of unfavourable terrain immediately past the aerodrome.

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. MAYDAY - Mayday is an emergency procedure word used internationally as a distress signal in voice-procedure radio communications. It is used to signal a life-threatening emergency.

What happened

On 9 April 2018, while on taxi for departure at Brisbane Airport, Qld, Air Traffic Control (ATC) instructed the crew of a Bombardier DHC-8 to hold short of runway 01. After a Boeing 737 landed, the DHC-8 entered and lined up on the runway in preparation for departure, without a clearance, whilst another Boeing 737 was on short final.

ATC provided the 737 on final approach a clearance to land at around 500 ft. ATC then issued a conditional clearance for the DHC-8 to line up behind the 737 on short final. The DHC-8 crew informed the tower by radio that they were already occupying runway 01 and were ready for departure.

ATC subsequently instructed the Boeing 737 on short final to conduct a go-around^[1] from about 300 ft. Departure instructions were provided and the Boeing 737 was transferred to the approach frequency for another approach to land. A short time later, ATC provided the DHC-8 with a clearance for take-off.

Figure 1: Sequence of events relating to aircraft movements at Brisbane Airport 

Source: Background image Google Earth; annotated/modified by ATSB

Airservices Australia investigation

An occurrence review conducted by Operational Risk and Assurance, indicated that the runway incursion had not been detected by ATC and that the second Boeing 737 was cleared to land whilst the runway was occupied.

The occurrence review indicated that although the conflict had not been identified by ATC, that when recognised, the actions taken to recover the situation were appropriately managed.

Safety message

Maintaining situational awareness is imperative for both pilots and ATC in busy operational environments. Effective situational awareness is the timely and accurate perception of information pertaining to a situation, comprehension of that current situation and projection of what may occur in the future based on this information.

The risk of runway incursions and other separation events can be minimised through good communication. This incident highlights the importance of:

• ATC and flight crews using correct phraseology
• ATC and pilots challenging instructions which they have not heard or understood fully
• pilots looking carefully for aircraft or other hazards before entering an active runway.

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. To abandon the landing and make a fresh approach [Cambridge Aerospace Dictionary]

What happened

On 7 August 2018, a Boeing 737-8FE was being prepared for a commercial passenger flight from Sydney, New South Wales to Townsville, Queensland. As the flight crew were programming the standard instrument departure (SID) into the flight management system (FMS), an incorrect SID was entered. The flight crew had inadvertently programmed the SYDTSV1 SID into the FMS, instead of the SYDTSV2. Both SID’s commence at Sydney Airport and track to the same waypoint before separating.

A route check had been conducted by the flight crew but the error was not identified prior to take-off. Once the aircraft was airborne, Air Traffic Control (ATC) detected that the aircraft was deviating off track and notified the crew. The aircraft was placed on a heading by ATC while the correct route was entered into the FMS.

The procedure was reviewed and discussed by the flight crew.

Safety message

This incident highlights the importance of ensuring that the flight management system is programmed correctly for take-off. Ensuring that independent cross-checks are undertaken can reduce the risk that an aircraft attempts to take-off with incorrect performance data.

Further information is available from the ATSB research report AR-2009-052, Take-off performance calculation and entry errors: A global perspective.

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 30 August 2018, a Piper Seminole departed Jandakot, Western Australia on a dual IFR training flight.

During an ILS approach to Perth runway 24, the crew became visual at 1,800 ft and reported visual to tower. The crew were issued missed approach instructions to turn left 080 and climb to 2,500 ft visual. At the missed approach point, the crew initiated the missed approach under simulated asymmetric conditions and the instructor restored power to the engines once established in the climb. During the climb, the crew contacted the approach controller who issued an amended visual heading. The instructor then replied not visual to the approach controller who sought to confirm that the aircraft was in cloud, to which the instructor replied yes. The controller then, with the belief that the aircraft was in cloud below the minimum vector altitude, instructed the crew to climb at best rate to 2,800 ft which the crew complied with.

The pilot later reported that the crew were visual at the time they reported not visual, however were unable to maintain visual with the current clearance. As a result, the crew were instructed to climb above the minimum vector altitude of 2,500 ft in Instrument Metrological Conditions (IMC).

Following the incident, the operator advises that an investigation was undertaken and the pilot in command was interviewed and de-briefed.

Safety message

Pilots are responsible to inform ATC if they are unable to comply with a clearance. Doing so early will give more time for a controller to issue an alternative clearance.

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.