What happened

On 9 September 2018 at approximately 0845 Eastern Standard Time, a Textron Aviation Inc. 172S departed Moorabbin, Victoria (Vic.), to conduct a Flight Instructor’s rating flight to Tooradin, Vic. There were two crew on-board, the flight instructor as pilot monitoring (PM) and a student as the pilot flying (PF).

The aircraft was configured for a short-field take-off. On line-up, the crew reported the engine was run-up to full, showing 2,350 RPM and nil issues. The crew reported a normal take-off run, however on rotation, engine RPM and performance was observed to degrade. The RPM had dropped to approximately 2,000 RPM and minor engine vibrations were detected. The PF confirmed that the throttle was still fully open.

The crew determined that a landing back at Moorabbin was necessary and the PM took over as PF. Following this, multiple severe engine vibrations began to occur. An assessment to land on the remaining runway was made from approximately 100-150 ft from above the runway. The landing was reported as normal; however, the crew observed engine vibrations while taxiing and determined the vibrations did not occur between 700-800 RPM. The remaining taxi was completed with minimal braking and throttle adjustment, to roll the aircraft back to the apron.

While standing, the crew opened the throttle to 1,000 RPM and did not observe any vibrations. They also completed a magneto check with nil further issues.

The company maintenance inspection revealed the number 2 cylinder exhaust valve was partially stuck open contributing to the engine abnormalities. The cylinder was subsequently replaced. The inspection also found scorching on the exhaust valve with carbon deposits inside the guide.

At the time of the incident, the aircraft was at a flight switch of 98.2 from the last 100-hour service and 46.6 from the last 50-hour service.

Safety message

When emergencies present themselves, pilots need to be familiar with how to handle their aircraft as per their aircraft’s pilot operating handbook (POH).

If any aircraft malfunctions or abnormalities are detected, pilots should discontinue the flight and conduct a precautionary landing if it is safe to do so. In this instance, the crew followed their standard operating procedures and a safe outcome was achieved. Decisive actions by the crew meant that this situation was handled safely before the issue could escalate.

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 August 2018 at about 1400 Eastern Standard Time, an Airbus A380 departed Sydney, New South Wales for a regular public transport flight to Dallas, US.

Passing FL 250 on climb, a loud noise was detected coming from a door on the upper deck. The door was locked correctly and not at risk of opening, however due to the passenger discomfort and the unknown nature of the issue the decision was made to return the aircraft to Sydney. The crew conducted a fuel dump and an uneventful approach and landing into Sydney.

The post-flight engineering inspection revealed damage to the door, caused by contact with a catering truck while the aircraft was loaded. The door seal retainer and seal on the underside of the door was damaged. Due to distraction of the non-normal operation of the catering truck, the damage to the door seal and seal retainer was not observed by the catering crew and therefore not reported to the flight crew or engineering. This resulted in the aircraft departing with the damaged door.

Figure 1: Damage to the door seal and door seal retainer

Source: Operator

Safety action

The operator launched an investigation into the ground handling incident.

Safety message

All persons working in and around aircraft have a responsibility to notify the operating crew about any damage to the aircraft. Ground crew should always be on the lookout for damage or anything abnormal. If any doubt exists, it is imperative to notify flight and/or ground crew for an engineering inspection.

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 7 August 2018, at about 1120 Central Standard Time, a Cessna 210M was departing Mount Ive, South Australia, for aerial work with only the pilot on board.

During initial climb from runway 04 after retracting the landing gear and turning onto a left crosswind leg, the pilot detected an abnormal engine noise described as popping and a reduction in engine power. The pilot adjusted the throttle that did not result in any improvement. The pilot then turned the aircraft toward runway 17 and slowed the aircraft sufficiently to extend full flap. During landing, the pilot flared, and the aircraft skidded down the runway. The landing gear was left in the retracted position. The cause of the abnormal engine indications was not able to be determined.

Pilot comments

The pilot stated that he did hear a noise during the approach, however, was not familiar with the sound of the landing gear warning horn. This in addition to the high workload and pressure of landing the aircraft contributed to the landing gear not extended prior to landing.

Safety message

During times of high workload, simple tasks such as selecting the landing gear could be unintentionally omitted. Pilots should be mindful that during an abnormal situation that all normal pre landing checks are completed. Pilots should also be familiar with all aircraft systems and warning devices.

For more information about managing partial engine failures after take-off, see ATSB research report, Avoidable Accidents No. 3 - Managing partial power loss after take-off in single-engine aircraft

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 28 August 2018, the crew of a Cessna 172S departed Tamworth, New South Wales (NSW) to conduct a training flight. There was an instructor and a student on board.

During cruise, while the student was flying and tracking towards Wakefield, NSW, the instructor noticed uncommanded control movement and pitching^[1] of the aircraft. The instructor decided to observe the elevator^[2] movement and saw that it was moving abnormally. The instructor took control of the aircraft to ascertain the integrity of the elevator and found that the aircraft was pitching without any pilot input.

Although the degree of movement was minor, the aircraft was not operating within prescribed performance parameters. The instructor performed further elevator control and trim checks and decided the best course of action was to conduct a return to Tamworth, NSW. The instructor contacted Air Traffic Control (ATC) to notify them of the control issues, and the aircraft was cleared to track direct to Tamworth. The instructor decided to land without flaps^[3] to avoid exacerbating the control issues. The aircraft landed without incident.

Engineering inspection

Following the incident, the engineering inspection revealed that the elevator trim inspection panel had been partially installed causing an airflow disturbance over the right-hand elevator and trim.

Safety action

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

• handover procedures to be reviewed and improved
• refresher training regarding the maintenance organisation exposition (MOE) procedures
• MOE procedures to be reviewed and updated
• more regular maintenance audits.

Safety message

This incident highlights the importance of ensuring that all pre-flight checks and procedures are carried out comprehensively and systematically. It also highlights the importance of ensuring that while the aircraft is in maintenance, all aircraft components are refitted and reinstalled in accordance with the aircraft’s maintenance manual and to verify the functionality of all critical aircraft components before returning it to service. The flight crew, in this instance, took all appropriate actions in-flight by assessing the situation, notifying ATC and conducting a return to the aerodrome resulting in a safe outcome.

About this report

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

__________

1. Pitching: the motion of an aircraft about its lateral (wingtip-to-wingtip) axis.
2. Elevator: Elevators are flight control surfaces, usually at the rear of an aircraft, which control the aircraft's pitch, and therefore the angle of attack and the lift of the wing.
3. Flaps: Flaps are a type of high-lift device used to increase the lift of an aircraft wing at a given airspeed. Flaps are usually mounted on the wing trailing edges of a fixed-wing aircraft. Flaps are used for extra lift on take-off. Flaps also cause an increase in drag, which can be beneficial during approach and landing, because it slows the aircraft.

What happened

On 28 August 2018, the pilot of the American Aircraft Corp. AA-5B departed Lilydale, Victoria to conduct a private flight. The pilot was the only occupant.

During initial climb, at about 300 ft above ground level, the engine failed. The pilot lowered the nose of the aircraft and searched for a suitable landing area, finding a nearby paddock to be suitable. The pilot conducted a successful forced landing on the surface of the paddock. The aircraft did not sustain any damage as a result of the landing.

Following the incident, the engineer suspects the likely cause of the engine failure was an unserviceable air filter, parts of which were missing. The air filter had not been replaced in accordance with the manufacturer’s recommendation. Metal contamination was also detected in the residual fuel in the carburettor. The source of the contaminants were rusty metal fragments traced back to the electric fuel pump which was found to have an incorrectly installed filter.

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. It is also important that aircraft are maintained in accordance with the aircraft’s maintenance manual, to ensure aircraft performance is maintained.

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 5 August 2018 at about 1545 Western Standard Time, a Boeing 717-200 operating between Perth and Broome, Western Australia, departed from runway 21 at Perth Airport.

Following a normal departure, Air Traffic Control (ATC) advised that the Standard Terminal Arrival Route (STAR)^[1] speed and altitude restrictions were cancelled. The aircraft captain (AC) briefed the first officer that the crew would maintain normal programmed departure speeds. Shortly thereafter, the AC was alerted to a low-speed warning on the primary flight display (PFD). The AC stated that as slat retraction had not been called for, the AC initially thought that the crew were experiencing an unreliable airspeed event. The AC checked the thrust and altitude parameters and identified they were within expected limits. As the airspeed was increasing at a normal rate, and there was no stick shaker or under-speed protection engagement, the AC elected to leave the autopilot engaged and monitor the situation. The AC then identified that the slats had been retracted prior to the AC calling for that action. As all flight parameters appeared normal, the crew continued the flight to Broome. Subsequent discussions identified that the first officer misinterpreted the AC’s instructions to maintain normal departure speeds and prematurely retracted the slats.

Safety action

As a result of this occurrence, the aircraft operator has advised the ATSB that they have issued an Operational Safety Alert, reminding flight crews of the importance of positively identifying and confirming actions prior to selection and taking the time to ensure tasks are done correctly.

Safety message

This incident highlights the importance of inter-crew communication to preventing, trapping and mitigating error. Flight crews should ensure they use procedures such as cross check, or identify and confirm to support effective communications and develop a shared understanding of the aircraft state.

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. STARs are procedural methods to control the flow of traffic within the vicinity of an aerodrome. Flight crews are to comply with published speeds and altitudes unless they are specifically cancelled or amended by ATC

What happened

On 11 September 2018 at approximately 1400 Eastern Standard Time, a Mooney Aircraft Corp, M20C, was on final approach into Bankstown, New South Wales, after completing a private flight.

The pilot of the M20C has lowered the aircraft’s undercarriage whilst on the downwind leg of the circuit in preparation for landing. The pilot reported not feeling confident about the 1,500 ft circuit height they were established in and raised the undercarriage to conduct a go-around^[1].

ATC observed the landing gear being raised and instructed the pilot to conduct a go-around prior to the pilot being able to communicate their intentions.

The flight proceeded without further incident.

Safety message

If a pilot is not completely satisfied that all the requirements are in place for a safe landing, performing a go-around is a way to ensure safety is not compromised.

The ATSB news article, Have an early decision point for an early and proper go-around has more information about the importance of performing an early go-around when a safe landing is in doubt.

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. A go-around is a safe, standard aircraft manoeuvre, which simply discontinues an approach to landing.

What happened

On 22 August 2018, at 1235 Eastern Standard Time, a Bombardier DHC-8 departed Cairns, Queensland (Qld) for a regular public transport flight to Moranbah, Qld.

During initial climb between 600 ft and 1,000 ft, the crew detected severe engine surging. The crew identified the no. 2 engine as the affected engine and shut it down. The crew completed the relevant checklists, declared a PAN PAN^[1] and continued climb to 7,000 ft. The crew then returned the aircraft for landing on runway 33 at Cairns.

Engineers replaced the propeller control unit and the over speed governor and returned the aircraft to service.

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. 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.

What happened

On the afternoon of 30 April 2018, a GippsAero GA8 Airvan was in cruise at 12,000 ft tracking toward Canberra, Australian Capital Territory when the aircraft lost engine power. There was one pilot and one passenger on board.

The pilot declared a MAYDAY to Canberra air traffic control (ATC) and was instructed to activate the emergency locator transmitter.^[1] The pilot elected to land in a cleared paddock and conducted an emergency landing. During landing, the aircraft travelled through a fence (Figure 1) and struck a log and a depression in the ground, before stopping (Figure 2). The aircraft sustained damage to the propeller and landing gear as well as damage to the windscreen and fuselage from contact with the fence.

There were no injuries and the pilot contacted Canberra ATC, with the assistance of another aircraft flying in the vicinity, to advise of their safe landing.

Figure 1: Aircraft path across paddock 

Source: Copyright owner annotated by ATSB

Figure 2: Final position of aircraft including ground depression struck 

Source: Copyright owner annotated by ATSB

Engineering inspection

The engine was removed and sent to an approved engine facility where it was disassembled and inspected. The inspection revealed that the engine crankshaft had separated between crank cheek number 8 and the number 5 connecting rod journal. A defect report for the crankshaft has subsequently been submitted to the Civil Aviation Safety Authority. The engine had completed approximately 1,055 hours since overhaul.

Safety message

Following a complete engine failure, a forced landing is inevitable. In this instance, the pilot 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.

__________

1. Emergency locator transmitter (ELT): a radio beacon that transmits an emergency signal that may include the position of a crashed aircraft, activated either manually or in the crash.

What happened

On 30 April 2018, at about 1114 Eastern Standard Time, a Beech Aircraft Corporation BE76 was on a dual flying training flight under instrument flight rules^[1], returning to Gold Coast, Queensland (Qld). There were an instructor and student pilot on board the aircraft.

During the cruise, Brisbane air traffic control (ATC) issued a heading vector to the flight crew. The student pilot set the autopilot’s heading bug to the assigned heading but did not change the autopilot from navigation mode to heading mode resulting in the aircraft continuing on the original heading. The instructor did not detect that the student pilot had not selected heading mode and as the autopilot is positioned to the left of the instrument panel, it is difficult for them to see the selected control mode.

The instructor was troubleshooting why the aircraft had not turned onto the required heading when the crew received an instruction from ATC to descend. The student pilot entered the assigned altitude into the assigned altitude indicator and disconnected the autopilot. The aircraft subsequently climbed 100 ft above the assigned altitude. This generated an alert to ATC.

The crew then regained positive control of the aircraft and descended in accordance with the clearance.

Safety message

This incident highlights the importance of all flight crewmembers being aware of the selected autopilot modes during all stages of flight. When changes are made to the selected mode, these should be verbalised and where possible verified by the second crewmember.

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. Instrument flight rules (IFR): a set of regulations that permit the pilot to operate an aircraft to operate in instrument meteorological conditions (IMC), which have much lower weather minimums than visual flight rules (VFR). Procedures and training are significantly more complex as a pilot must demonstrate competency in IMC conditions while controlling the aircraft solely by reference to instruments. IFR-capable aircraft have greater equipment and maintenance requirements.