What happened

On 12 August 2018, a Pilatus PC-12 was being used to transport a patient from Wiluna, Western Australia (WA) to Jandakot, WA. It departed Wiluna at about 2053 Western Standard Time.

About 40 minutes into the flight, the pilot felt ill and vomited. During this time, the autopilot was engaged. After vomiting, he felt considerably better and was able to continue the flight to Jandakot. The only time that the pilot was not monitoring the flight instruments was whilst he was physically ill.

The pilot took sick leave for the rest of his shift and a Designated Aviation Medical Examiner (DAME)^[1] checked him before he returned to work again.

It was reported that the pilot had been unwell for the previous few days and had reported for duty on the day of the incident saying that he felt well again.

Safety action

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

• The operator will update their manuals to reinforce the need to take the time to recover from illness. If a pilot reports in sick at the start of a shift, they will be required to remain on sick leave for the rest of the shift unless a DAME deems that they are fit for work. They will incorporate this change into the next edition of their manuals, which they will publish in due course.
• The operator has already included this information in their pilots’ briefs and a formal written notification, by email, has been sent to all pilots in the organisation.

Safety message

This incident highlights the importance of flight crew being adequately recovered from illness before returning to work. This is particularly pertinent for single-pilot 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.

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1. Designated aviation medical examiners (DAMEs) are practitioners approved to perform medical examinations to meet the provisions of the Civil Aviation Act 1998, the Civil Aviation Regulations 1988 and the Civil Aviation Safety Regulations 1998.

What happened

On 3 July 2018 at approximately 1330 Central Standard Time, two Robinson helicopters were conducting flights at the boundary of the Darwin control zone, in class C airspace. One of the Robinsons, an R44, had just departed Charles Darwin National Park to conduct a charter flight and was tracking via Elizabeth River Bridge. The other, an R66, was engaged in a general aviation flight and had departed Wishart Road, also tracking towards Elizabeth River Bridge. Both aircraft were operating under VFR^[1] and ATC were aware of their operations.

The helicopters were approximately less than half a mile apart before ATC passed traffic information to either helicopter. The crew of the R44 had sighted the R66 approaching from an 8 o’clock position and was tracking at the same level, approximately 1,000 ft AGL. The pilot of the R44 conducted an avoidance manoeuvre, turning right of the approaching helicopter to maintain separation.

Both aircraft proceeded on their flights with nil further impact.

Safety message

In class C airspace, controllers will pass traffic information between VFR aircraft and the aircraft must maintain communication with ATC.

This incident highlights the importance of always maintaining situational awareness. ATC provided late traffic information, however the two VFR aircraft were able to sight each other and were able to conduct avoiding manoeuvres to maintain separation.

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.

What happened

On 24 July 2018, a single engine Cessna was conducting a sightseeing charter flight with one pilot and two passengers on board. During a stop for lunch, the pilot refuelled the aircraft prior to conducting the second leg of the charter.

The pilot used a ladder to gain access and incrementally refuelled both wings. The pilot stepped off the ladder several times to check the bowser gauge. The pilot recalled hastening the left-wing refuelling because two people had arrived to use the bowser.

The pilot recorded the fuel load, checked the fuel for water and repositioned the aircraft closer to where the passengers were having lunch. The pilot was concerned about daylight time constraints so hurried up as much as possible to begin the second leg of the charter.

After take-off, the aircraft tracked to the sightseeing area. At cruise altitude, the pilot identified the fuel level in both wing tanks was lower than expected. The pilot cross checked the fuel indications and confirmed the position of the fuel selector.

The pilot observed fuel siphoning from both wings and realised he did not secure the fuel caps after refuelling.

The pilot elected to return to the airport, reducing power to conserve fuel. He could not ascertain the rate of fuel loss, and proactively identified suitable landing areas en route. The pilot was confident of reaching the airport and did not declare an emergency. He briefed the passengers and landed safety with 92 litres of fuel remaining.

Safety message

Distraction in flight; or when carrying out safety critical tasks on the ground, has contributed to a number of aviation accidents and incidents. The sources of most pilot distractions are not unique to any one type of operation. The findings from ATSB publication Dangerous distraction: An examination of accidents and incidents involving pilot distraction in Australia between 1997 and 2004 suggest that distractions can arise unexpectedly, during periods of high or low workload, or during any phase of the flight.

Fuel exhaustion or starvation can and do occur in any phase of flight, including take-off. Most reported occurrences have been in the cruise or in the descent, approach and landing phases of flight. However, a quarter of fuel starvation occurrences involved the taxi, take-off and climb phases.

ATSB publication Avoidable Accidents No. 5 - Starved and exhausted: Fuel management aviation accidents found of the reported fuel exhaustion occurrences from 2001 to 2010, most (82 per cent) led to a forced or precautionary landing off an aerodrome or ditching (but no fatalities or serious injuries).

This incident reinforces the need to:

• avoid interruptions when completing safety critical tasks on the ground
• conduct a thorough pre-flight inspection
• determine prior to flight the expected rate of fuel consumption
• monitor fuel consumption 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.

What happened

On 28 June 2018 at 1125 Central Standard Time, the pilot of a Robinson R44 Raven II helicopter departed for a return charter flight from Connellan Airport, Northern Territory, to Mt Conner, NT. The originally scheduled, larger aircraft, a Bell JetRanger experienced an unserviceability, and the Robinson R44 was allocated to the flight. There were three passengers on board. When the pilot departed Connellan Airport, the helicopter was at its maximum gross weight of 1,134 kg. This was the pilot’s first trip to Mt Conner.

Mt Conner, known as Attila to the Pitjantjara people, is a mesa standing 2,818 ft above mean sea level, and 984 ft above ground level. On the day, a high-pressure weather system pushed the pressure altitude^[1] slightly lower to around 2,600 ft. There was a light wind from the east-northeast. The flight to Mt Conner took just under 40 minutes, using 25 kg of fuel on the way. The landing weight of the helicopter at Mt Conner was 1,109 kg. According to flight manual performance charts, the helicopter was capable of performing an out of ground effect hover at the landing site.

The pilot wasn’t comfortable with his first approach and correctly aborted it. The second approach felt better to the pilot and he flew the helicopter at a 300 ft/min rate of descent towards the western ridgeline. At 40 KIAS^[2], 50 ft above and 10 m from the ridge, the pilot noticed a sudden increase in rate of descent. The pilot thought he had entered vortex ring state^[3] (VRS) and initiated a technique known as the Vuichard Recovery. This involves using full power, tail rotor thrust and lateral cyclic to move the helicopter sideways out of the downwash of the main rotor. The Vuichard Recovery technique had not been taught to the pilot, nor was his proficiency in its use tested.

At 40 knots, the helicopter’s downwash flows out behind the aircraft and VRS will not develop. The VRS recovery initiated did not arrest the rate of descent. The aircraft was now in a state whereby the power required to arrest the rate of descent exceeded the engine power available. Cancelling the lateral movement to avoid sideways contact with the ground, the pilot initially lowered the collective^[4] before pulling full collective to reduce the rate of descent.

Pulling collective increases the pitch on the main rotor blades to increase lift and increases the power demand on the engine. The low RPM light and horn activated as aerodynamic drag on the main rotor blades exceed the available power from the engine, slowing the rotor; a situation known as overpitching. The aircraft landed heavily in a level attitude 20 m to the right of the helipad. The skids absorbed the impact and there were no injuries.

Safety message

Pinnacle approaches bring complexity not encountered on level ground. Particularly, a change in the way groundspeed is judged on approach. Visual references are further away than usual and do not provide adequate groundspeed reference. Approaching a pinnacle too fast will result in ground rush. The sudden availability of rate of closure cues is perceived as a rapid increase in rate of closure. The pilot must instead manage their approach through use of attitude, instruments and observation of the expansion rate of the sight picture around the aiming point.

Pinnacle approaches are an example of a sequence that requires practice and maintenance of skill. Practice allows a pilot to develop a suitable conceptual model of the sequence. This then allows the pilot to manage the current state of the aircraft against the desired state; using pre-determined gates^[5] to manage the profile and detect divergence in the absence of normal visual cues. Development of the correct mental model through practice will support well-timed initiation of a correct course of action. Flight schools play a fundamental part in developing these mental models in new pilots.

Before using new techniques in flight, pilots need training in their use. Training sessions designed and conducted by pilots proficient in both instruction and the technique of interest, create a safe environment for pilots to develop new skills and test new techniques. All pilots are encouraged to discuss their needs with respect to training in new methods or techniques with their Chief Pilot prior to employing new manoeuvres 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.

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1. Pressure Altitude: The elevation experienced relative to the International Standard Atmosphere used for calculating aircraft performance.
2. KIAS: indicated airspeed expressed in knots, used by pilots as a reference for all aircraft manoeuvres.
3. Vortex Ring State: The ingestion by a rotor system of its own downwash, causing loss of lift.
4. Collective: a primary helicopter flight control that simultaneously affects the pitch of all blades of a lifting rotor. Collective input is the main control for vertical velocity.
5. Gates: A series of targets for flight parameters used to manage aircraft performance. I.e. a desired combination of airspeed, rate of descent, altitude and power available achieved at a predetermined point. Missing a gate would result in discontinuation of the manoeuvre.

What happened

On 15 June 2018, at 1050 Eastern Standard Time, a Robinson R44 conducting a charter flight experienced an engine RPM governor^[1] failure.

The charter was for a scenic tour of Brisbane, Queensland. On board the helicopter was a pilot and three passengers. Halfway through the flight at an altitude of 1,000 ft, the rotor RPM began to decay and the low rotor RPM horn^[2] sounded. The pilot applied a low rotor RPM recovery technique^[3] of lowering the collective and increasing the throttle. The aircraft descended to 800 ft before climbing back to 1,000 ft.

The pilot explained what was happening to the passengers who remained calm, then made a PAN^[4] call to Air Traffic Control (ATC). ATC cleared a route for the aircraft to return direct to the airport. The pilot was not certain of the cause of the drop in RPM. Rather than turning off the governor as the flight manual instructs for governor failure, he elected to manually control engine RPM by overriding the clutch in the governor.

The aircraft’s magnetos had undergone a 500 hour service immediately prior to the scenic charter flight. An engineering inspection following the incident flight found that a problem with the tachometer points of the magneto^[5] caused the governor to read a higher RPM than existed and wind down the throttle, subsequently slowing the rotor system.

Safety message

The right hand magneto provides a signal to the engine RPM governor. The tachometer points that provide the signal must be set precisely to avoid governor issues. In response to reports of governor malfunction between service intervals, Robinson issued service letter SL-62 stating, “Strict adherence to published magneto maintenance practices is essential for proper governor operation”. The service letter also refers to governor trouble-shooting advice in the aircraft maintenance manual.

In the normal course of operation, prior to the failure, the pilot had identified two potential forced landing areas, and during trouble-shooting the pilot steered the helicopter to maintain access to open ground. The pilot also alerted ATC and other aircraft in the vicinity to the problem by declaring PAN. This is another important element in managing an abnormal situation, which brings support to a pilot when they need it. On this occasion, the pilot had correctly determined that it was not necessary to land the helicopter as soon as possible. However, they had created options that allowed for doing so if required.

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. Engine RPM Governor – This system senses engine RPM and makes adjustments to the throttle control to maintain a constant engine RPM, which leads to a constant rotor RPM in flight.
2. Low rotor RPM horn – Maintaining correct rotor RPM is critical to sustained rotary wing flight. The low rotor RPM horn alerts the pilot to a reduction in rotor RPM. In the Robinson R44 it alerts the pilot if rotor RPM decays below 97%.
3. Low rotor RPM recovery technique – For minor decay of rotor RPM, the pilot will lower the collective control, reducing aerodynamic drag on the rotor blades. Simultaneously they will open the throttle to increase the engine RPM providing increased drive to the rotor system.
4. PAN call – Transmitted as “pan-pan” it is an internationally recognised distress call that alerts others to a problem aboard the aircraft that is currently less urgent than mayday.
5. Magneto – A magneto is a device that provides a self-generated charge to the spark plugs of a piston engine. Two magnetos operate on the engine of an R44 and the engine’s right hand magneto provides the signal to the governor.

What happened

On 27 May 2018, a student pilot undertaking their second solo flight in a Piper Aircraft 28-161 aircraft departed Moorabbin Airport, Victoria to conduct three circuits.

During the first touch-and-go landing on runway 35R, the pilot inadvertently missed retracting the landing flap. Immediately upon becoming airborne, the pilot noticed the incorrect flap setting and retracted the flaps resulting in the aircraft sinking onto the runway. The pilot then rejected the take-off, veered off the runway and collided with a sign resulting in minor damage.

Safety action

As a result of this occurrence, the flying school where the student pilot is conducting training has advised the ATSB of the following:

• The pilot will undertake additional training prior to any additional solo flights.
• This incident has been used as an example to educate other student pilots about threat and error management and potential loss of control.

Safety message

After take-off a partial or complete retraction of the flaps at very low airspeed can result in a loss of lift, resulting in the aircraft settling back onto the ground. To avoid such an outcome, it is essential for the pilot to ensure that the flaps are retracted incrementally to allow time for the aircraft to accelerate progressively as they are being raised.

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 27 May 2018, the pilot of a SOCATA TB-20 was conducting circuits at Cambridge, Tasmania. The pilot was the only occupant on board.

The pilot was conducting his first circuit. Soon after take-off, Air Traffic Control (ATC) advised that another plane was joining the base leg and the SOCATA would be second in the landing sequence. The pilot extended his circuit accordingly. ATC observed that the wheels of the aircraft were extended on the base leg and final approach. The pilot said that he decided to leave the gear down to aid in slowing the aircraft and maintaining separation.

When the pilot turned the aircraft onto final approach, the sun was in his eyes, requiring him to use sunglasses. This impaired his vision of the instrument panel. The pilot then performed the final landing checks, whilst monitoring the preceding traffic and with the sun in his eyes. He inadvertently selected gear up.

The pilot subsequently landed the aircraft with the wheels retracted and was observed to come to a stop half way down the runway. He then reported the incident to ATC and emergency services were called.

The aircraft sustained damage to the propeller.

Safety message

This incident highlights the importance of managing distraction. During times of high workload, distraction can often lead to human error.

External pressures and distractions are sometimes unavoidable, however, there are effective ways to manage them, as discussed in the ATSB research report B2004/0324, ‘Dangerous distraction: An examination of accidents and incidents involving pilot distraction in Australia between 1997 and 2004’.

Wheels up landings are not uncommon; the Flight Safety Australia article, Those who won’t: avoiding gear-up landings includes valuable information to assist pilots in avoiding these incidents. Tip number 3 and 4 are particularly pertinent to this incident. Tip number 4 is about recognising that modified or interrupted traffic patterns frequently contribute to gear-up landings and for the pilot to be extra vigilant in these situations. Tip number 3 is about ensuring that all final approaches have a short, final gear position check.

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 13 June 2018 at 1957 Eastern Standard Time, a Diamond DA 40 was conducting solo night circuit training at Bankstown Airport, New South Wales. Bankstown is a class D metropolitan airport, with fixed wing and rotary pilots. The circuits were conducted on runway 29C, during tower hours with a left circuit direction.  Meteorological conditions were reported as night (bright), visibility greater than 10 km with wind speeds a top of 5 kts.

The DA 40 was on upwind runway 29C and was instructed by air traffic control (ATC) to follow a Fairchild SA227 that was joining downwind. The pilot of the DA 40 sighted the SA227, which was positioned joining the circuit left downwind. The DA 40 pilot conducted a rate one turn^[1] crosswind in front of the SA227. While conducting the turn, the pilot was focused on his instruments and lost visual contact with the SA227. ATC then instructed the DA 40 to conduct a left turn and re-join the circuit upwind.

The pilot continued his rate one turn and once established on the upwind leg for runway 29C, ATC instructed the pilot to follow a Piper PA 28, which had just become airborne off runway 29C. The pilot of the DA 40 reported sighting an aircraft ahead and below of his position and incorrectly assumed that was the PA 28, but it was another aircraft in the circuit.

As the PA 28 was climbing upwind, the crew sighted the DA 40 overhead and in close proximity. The pilot of the PA 28 pitched the aircraft’s nose down to increase separation and informed the tower of the DA 40’s position. ATC issued the DA 40 a safety alert and an immediate climb instruction to 1,500 ft.

The DA 40 had overtaken the PA 28 and had come into close proximity.

Both aircraft continued circuit training without further incident.

Figure 1: Bankstown runway layout with standard circuit arrows as guide only 

Source: Airservices, annotated by ATSB

Safety message

Pilots and ATC have a dual responsibility in maintaining situational awareness of other traffic. When conducting flight in class D airspace, pilots must sight and maintain separation from other aircraft. If pilots lose situational awareness, ATC are available to pass traffic, however ATC must be notified immediately if aircraft crew cannot sight and maintain their own separation.

In this instance, the crew reported ATC had given them instructions to follow a Piper that had just become airborne, leading the crew to follow the incorrect aircraft. If any doubt exists as to the instruction given, whether it be a phrase used or the inability to comply with an instruction, crew are reminded to seek clarification from ATC immediately.

Pilots should always:

• sight and maintain separation from other aircraft
• comply with ATC instructions whilst ensuring separation is maintained from other aircraft
• notify ATC if a change in clearance is required
• immediately advise ATC if unable to comply with an instruction.

Below are some tips to remember when flying in class D airspace:

• Develop an easy, repeatable scanning technique. Be aware of your relative position and the movement of other traffic.
• Communicate clearly and listen for key words that indicate other aircraft’s position and intentions.
• Recognise the symptoms of losing situational awareness (distractions, fixation).
• Think ahead. Anticipate what will happen several minutes into the future.

For more information about flight tips at Bankstown, visit www.airservicesaustralia.com/publications/safety-publications/ and follow the links under the heading Runway Safety for Tips for flying at Bankstown and Operating in Class D 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. In turning flight, the number of degrees of heading change per unit of time (usually measured in seconds) is referred to as the rate of turn. A rate one or standard rate turn is accomplished at 3° / second resulting in a course reversal (180°) in one minute or a 360° turn in two minutes.

What happened

On 10 May 2018, at 1110 Western Standard Time, a student pilot took-off from runway 06L at Jandakot Airport for a solo flight to the training area to the south. The flight was in a Cessna A152. Shortly after take-off, the engine failed to produce adequate power. The student was able to maintain 500 ft yet unable to climb further. The student declared an emergency to Jandakot Tower, conducted a low-level left-hand circuit, and landed safely.

The engine powering the Cessna A152 is a four cylinder Lycoming O-235 producing up to 82 kW in normal operation. Lycoming supplied the engine directly to the operator and it had a 2,400 hour time between overhauls (TBO) limit. The power loss occurred 2,146 hours into the engine’s life.

The engineering inspection showed that a burnt valve with a 2 mm hole on the edge of the face at the point of failure caused the power loss. A valve can sustain burning when it no longer turns in operation, exposing the face to a hot spot. Wear was evident on the associated exhaust lobe on camshaft, which could contribute directly to such an event.

Safety message

The student carried out all actions as taught and completed a successful low-level circuit and safe landing. Announcing the emergency to Air Traffic Control allowed them to put emergency services on standby to respond. The successful management of the situation demonstrates the value of solid instruction in the basics of flight.

There are currently 120 Cessna 152s on the Australian Register. Many of them in flight schools, and operated by new pilots. Reduction of camshaft wear and other engine problems can be achieved by ensuring all pilots accurately follow the manufacturer’s recommendations and observe the procedures and limitations in the Pilot’s Operating Handbook. Additionally, owners should ensure regular operation of their aircraft to avoid build-up of contamination on engine components, which can prematurely age the engine.

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 afternoon of 19 May 2018, a Cessna Aircraft 425 departed Archerfield Aerodrome, Queensland. There was one pilot and four passengers on board. Shortly after take-off, at about 1525 Eastern Standard Time, the pilot received an annunciator warning, indicating the right engine starter generator was engaged in its starting function. The annunciator in this instance is illuminated when the starter is in the ‘start’ function and not acting as a generator and is normally illuminated during the start sequence only.

After identifying the problem, the pilot conducted the actions required to shut down and secure the right engine as detailed in the aircraft checklist procedures. The pilot declared a PAN PAN^[1] and informed Archerfield tower that the aircraft would require an immediate return to the runway.

With clearance from the tower received, the crew then conducted a non-standard right circuit to runway 10L and landed safely. A subsequent engineering inspection found the starter annunciation to be a false indication, due to a chafed wire in the engine electrical system.

Safety message

Although this occurrence was an indication issue, not an actual fault, it demonstrates the importance of identifying system failures as presented to the pilot and carrying out the corrective actions required. It also demonstrates the knowledge required by the pilot, having to conduct non-standard operations and to state their intentions to the controllers, to enable a safe return to the airfield.

The ATSB has published a research report, Power plant failures in turboprop-powered aircraft (AR-2017-017), which is available from the ATSB website. It highlights the importance of reporting all power plant-related occurrences. By doing so, the ATSB hopes that the wider aviation industry will be able to learn from the experience of others.

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. PAN PAN: an internationally recognised radio call announcing an urgency condition which concerns the safety of an aircraft or its occupants but where the flight crew does not require immediate assistance.