What happened

On 1 May 2018, a solo training flight was conducted in a Diamond DA 40 at Coffs Harbour Airport, New South Wales. On returning to Coffs Harbour, air traffic control (ATC) cleared the aircraft for a visual approach to join the final leg of the circuit for runway 21. ATC also instructed the pilot to follow a Piper PA-28, which at that time was on a left base leg for runway 21. The pilot of the DA 40 confirmed that they had sighted the PA-28, and ATC instructed the pilot to follow the PA-28 and report when they joined the final approach leg of the circuit.

As the DA 40 joined the final approach, the pilot advised ATC that they were on a 3 NM final, however the aircraft was unable to be sighted. ATC subsequently observed the DA 40 on final approach to taxiway E5. The controller advised the pilot that the aircraft appeared to be on final for taxiway E5, and that runway 21 location was to their left. The pilot turned left and reported runway 21 in sight. The aircraft landed without further incident.

Figure 1: Coffs Harbour Airport Chart

Source: Airservices Australia DAP155 Aerodrome & Procedure Charts

Safety message

Pilots should be aware of the layout of aerodromes and runways they are using. At Coffs Harbour aerodrome, warnings exist in the aerodrome charts regarding the potential confusion of taxiway E5 and runway 21, including a notice on how to avoid this confusion by confirming the presence of a Precision Approach Path Indicator at the end of the 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.

What happened

On the afternoon of 27 April 2018, a BRM Aero Bristell was conducting flight training at Bathurst Airport, New South Wales. During final approach to runway 17 at, the crew observed a Van's RV-8 on short final approach to runway 35. The crew of the Bristell conducted a go-around^[1] and manoeuvred to the dead side^[2] of runway 17 to maintain separation and visibility of the RV-8 on final for runway 35 while trying to contact the RV-8 by radio with no response. The Bristell re-joined the circuit and both aircraft landed without further incident.

It was later established that the pilot of the RV-8 had not selected the appropriate radio frequency for Bathurst and was distracted by glider operations on runway 08 and had not seen the Bristell until after landing.

Figure 1: Separation sequence of events at Bathurst Aerodrome 

Source: Google Earth image annotated by ATSB

Safety action

As a result of this occurrence, the RV-8 pilot advised the ATSB that they will in future write the relevant frequencies of the destination aerodrome on the flight plan in the pilot notes area, to have them readily available in flight.

Safety message

Maintaining situational awareness of your surroundings is a key element of safe operations in the vicinity of non-towered aerodromes. Pilots should:

• maintain effective lookout
• use radio to supplement un-alerted see and avoid
• be aware that other aircraft may not be on the correct frequency or broadcasting.

Appropriate radio broadcasts made on the correct frequency within 10 NM of non-towered aerodromes whilst maintaining good visual scanning is eight times more effective than normal lookout in detecting and avoiding other traffic.

The ATSB booklet A pilot’s guide to staying safe in the vicinity of non-controlled aerodromes outlines many of the common problems that occur at non-controlled aerodromes, and offers useful strategies to keep yourself and other pilots safe.

The Civil Aviation Safety Authority (CASA) has produced several publications and resources that provide important safety advice for operations at, or in the vicinity of non-towered aerodromes.

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. To abandon the landing and make a fresh approach [Cambridge Aerospace Dictionary]
2. Side of airfield or active runway away from that of the circuit pattern in use. [Cambridge Aerospace Dictionary]

What happened

On 27 April 2018 at approximately 0905 Eastern Standard Time, a Glaser-Dirks DG-1000S glider aircraft (the glider) was conducting solo training in the left-hand circuit of runway 08 at Bathurst Airport, New South Wales. As the glider made its downwind radio call, a Cessna aircraft broadcast that it was taxiing for runway 35. The pilot of the Cessna acknowledged a further call made by the glider ground controller that there was a glider training in the circuit area.

Several seconds later the glider turned onto the left base of the circuit and broadcast, “turning left base, runway 08”.

Later, as the glider was turning final for runway 08, the Cessna broadcast its rolling call on runway 35. Recognising the potential separation issue at the intersection points of runways 08 and 35, the glider ground controller called “ABORT, ABORT, ABORT, glider on final runway 08”.

The Cessna pilot brought the aircraft to a full stop prior to the intersection and the glider landed on runway 08 without incident. The Cessna pilot then backtracked and departed from runway 35.

Figure1: Diagram of Bathurst Airport showing indicative aircraft position 

Related occurrences

A search of the ATSB database revealed a similar occurrence that took place at Bathurst Airport in 2016:

AO-2016-034

On 13 April 2016, an instructor and student of a Jabiru J170-D aeroplane, registered 24-7750 (7750), conducted a local training flight from Bathurst Airport, New South Wales. At about 1446 Eastern Standard Time, the aircraft arrived in the circuit, and the instructor broadcast that they were joining the circuit on an early downwind for runway 17, for a full-stop landing.

Powered aircraft were operating on runway 17 and gliders (and towing aircraft) were operating on runway 08.

Meanwhile, a student pilot of a Glaser-Dirks DG-1000S glider, registered VH-NDQ (NDQ) was conducting a solo flight at Bathurst. At about 1449, about 90 seconds after the pilot of 7750 had communicated with Glider Ground regarding glider traffic in the air, the pilot of NDQ broadcast on the Bathurst CTAF that they were on left downwind for runway 08.

After 7750 touched down on runway 17, about 100 m before the intersection with runway 08, the pilot sighted a glider (NDQ) on short final for runway 08, at an estimated 100 feet above ground level. The pilot applied full power to cross runway 08 as quickly as possible.

As 7750 landed, the pilot of NDQ assessed that there was the potential for a collision, closed the glider’s airbrakes and initiated a climb to pass over 7750. The glider then landed ahead on runway 08.

The instructor in 7750 lost sight of NDQ as it passed overhead. As 7750 accelerated with a high power setting, the instructor elected to continue a take-off and conducted a circuit before landing safely.

Safety message

While in this case, the incident did not result in a near collision, the safety message remains the same between the two occurrences.

Simultaneous operations on crossing runways can be problematic, particularly where the operation types are different (such as powered flight and gliding operations). Organisations responsible for the coordination and conduct of such activities are encouraged to carefully assess and manage the risks involved. This is particularly important when operations are likely to involve instructional flights and less experienced pilots, where workload and the potential for pilot distraction may be elevated.

This incident highlights the importance of effective communication. The primary purpose of communications on the CTAF is to ensure the maintenance of appropriate separation through mutual understanding by pilots of each other’s position and intentions. Where a pilot identifies a risk of collision, that pilot should alert others as soon as possible to allow a coordinated and effective response.

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 26 March 2018, a Raytheon Aircraft Company B200 aircraft was flying from Kowanyama, Queensland (Qld) to Cairns, Qld. At 2000 Eastern Standard Time, passing 3,700 ft on approach to runway 15 using the instrument landing system (ILS), the pilot reported that the ILS flagged intermittently and then permanently. The co-pilot side had a glideslope flag. The pilot subsequently elected to conduct a missed approach.

The pilot turned left onto the missed approach heading of 030 earlier than detailed in the published missed approach procedure. The air traffic control tower expected the aircraft to continue to overhead the middle marker before making the turn. The pilot reported that he chose to turn early to remain well clear of the hills on his right side and because of the lack of lateral guidance. He also took into consideration that there was a 28 kt westerly wind.

During the missed approach circuit, the pilot hand flew the aircraft on the co-pilot’s instruments. He communicated further with the air traffic control tower, who confirmed the correct operation of the ILS. The aircraft landed without further incident.

Figure 1: ILS Approach for Cairns 

Source: Airservices Australia, annotated by the ATSB

Safety action

As a result of this occurrence, the aircraft operator has advised the ATSB that they contacted the equipment vendor who advised a range of tests to carry out. The operator conducted the tests and narrowed the problem down to small green particles on the cannon plugs on the rear of the instrument. These plugs were replaced, and no further fault could be found with the instrument. The aircraft has subsequently flown the ILS into Cairns several times without fault.

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 22 June 2018, a Jabiru J160-C was conducting a training flight. The crew consisted of a student (the pilot flying) and an instructor (the pilot monitoring).

Approximately 90 minutes into a planned two hour flight, the student attempted a touch and go. The engine failed on the runway and the aircraft rolled to a stop. The instructor advised Air Traffic Control and attempted unsuccessfully to restart the engine.

The instructor and student pushed the aircraft onto an adjacent grass taxiway. The crew were able to restart the engine and taxi to the apron area.

Post-flight, the right wing fuel cap was found to be loose. After refitting the cap, the aircraft returned to service.

Safety message

ATSB publication Avoidable Accidents No. 5 - Starved and exhausted: Fuel management aviation accidents found from 2001 to 2011, accidents involving fuel starvation resulted in 10 fatalities and 18 serious injuries.

Fuel starvation happens when the fuel supply to the engine(s) is interrupted although there is adequate fuel on board.

This incident reinforces the need to:

• conduct a thorough pre-flight inspection
• determine prior to flight the expected rate of fuel consumption
• monitor fuel consumption during flight
• be fully familiar with the fuel systems operation.

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 July 2018, at 1119 Eastern Standard Time, the pilot of a Piper PA-28 aircraft was conducting a touch-and-go^[1] at Warrnambool Airport, Victoria.

During the flight, the pilot noticed that although the engine was idling within the green arc it was running slightly rougher than normal. After completing a circuit and landing on the runway, the engine idled to a halt. The pilot subsequently tried to restart the engine and noticed that the pump sounded sluggish and had lost volume. The mixture was set to full rich at all times.

During the second attempt to restart the engine, fumes and smoke were detected emanating from the engine compartment and liquid could be seen draining onto the runway. The pilot immediately shutdown the engine, switched off the aircraft electrical system and vacated the aircraft.

A fire started in the front section of the engine compartment and spread to the aft of the aircraft. As a result of the fire, the aircraft was destroyed.

Safety message

This incident provides a reminder that priming a hot engine can result in an engine fire. Most aircraft manuals will have a checklist to follow for engine fires on start-up. It is important for pilots to memorise this procedure specific to the aircraft they are 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.

__________

1. Touch-and-go: The combination of a landing and take-off, performed as one fluid operation through touchdown, rolling reconfiguration, and lift-off.

What happened

On 9 May 2018, around 1150 Central Standard Time, the pilot of a Diamond DA 40 departed from Parafield South Australia (SA) on a solo-training visual flight rules (VFR) navigation exercise. The pilot planned to fly from South Para Reserve to Tori Hills, SA. As the flight progressed, the pilot lost directional awareness and subsequently conducted the 1 in 60-correction tracking ^[1] in the wrong direction taking the aircraft off course. The pilot then followed the operator’s lost procedure and contacted Air Traffic Control (ATC) for assistance. ATC directed the aircraft to Lameroo Aerodrome and from there the pilot was able to continue on the rest of the navigation without assistance.

Figure 1: Map of Area

Source: Airservices Australia

Safety action

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

• The trainee pilot conducted a dual sortie involving a more complex lost procedure.
• The operator held discussions on the use of the Global Navigation Satellite System (GNSS) as an aid in visual flying.

Safety message

This incident highlights the importance of requesting assistance from ATC when flight crew are unsure of the aircraft’s position. ATC are able to assist crew in locating positions using transponder codes, prominent landmarks and radio navigation. It is better to ask for assistance before fuel reserves are compromised.

__________

1. A basic rule of thumb, which states that if a pilot has travelled sixty miles then an error in track of one mile is approximately a 1° error in heading. Utilised by single pilots with many other tasks to perform, often in a basic aircraft without the aid of an autopilot.

What happened

On 1 August 2018 at 1530 Western Standard Time, the crew of a Fokker F28 aircraft was conducting a revenue passenger transport flight between Perth and Kalgoorlie, Western Australia. The flight crew comprised a captain and a first officer. The first officer was on his second day of training.

During approach, the captain briefed the first officer for a flap 25 configuration for the landing.

Later in the approach, the captain inadvertently called for the flaps to be extended to 42. The first officer questioned this call, and the captain confirmed the call for a flap 42 configuration. The first officer did not further question the captain’s call, and flap 42 was selected.

The captain reported that he was responding to other demands during this approach. There was a crosswind at 40 knots, and conditions were turbulent. The captain reported that during the approach he was focussed on monitoring the flight instruments.

The captain subsequently identified the incorrect flap configuration, and conducted a go-around. A second approach was conducted successfully.

Safety message

This incident highlights the importance of inter-crew communication. There was a breakdown of communication between the first officer and the captain. The flap configuration was not effectively communicated within the cockpit, resulting in an incorrect configuration being set. Although the first officer did query the captain’s initial instruction for a flap 42 configuration, he did not further challenge this call. Flight crews are reminded that active and effective communication, including clarification of unclear instructions, plays an important role in ensuring safe flight.

This incident also highlights the importance of managing operational pressures and 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’.

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 14 April 2018, an Airbus Industrie A320-232 operated as a commercial passenger flight from Melbourne, Victoria to Hobart, Tasmania. The flight crew conducted the area navigation approach (RNAV) for runway 30 at Hobart. Approaching 1,000 ft, the pilot in command (PIC), being the pilot flying (PF) identified that the aircraft glidepath appeared low with reference to the Precision Approach Path Indicator (PAPI)^[1], which was showing four red lights. The PIC disconnected the autopilot, regained the glidepath manually and landed the aircraft without any further issue.

After landing, the first officer, as pilot monitoring (PM) noticed his altimeter QNH setting was incorrect and adjusted it accordingly. This resulted in a NAV ALTI discrepancy ECAM alert. The flight crew realised that both pilots had the same, but incorrect altimeter QNH setting during the RNAV approach resulting in the aircraft being lower than it should have been during the approach.

Safety message

This occurrence reminds pilots that continuously monitoring aircraft and approach parameters and the external environment can assist to ensure they maintain a stable approach profile and make appropriate decisions for a safe landing.

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. Precision Approach Path Indicator (PAPI): a ground based system that uses a system of coloured lights used by pilots to identify the correct glide path to the runway when conducting a visual approach.

What happened

On the morning of 8 September 2018, a Bell 206B helicopter departed a caravan park on a private flight with a pilot and three passengers on board. Approximately 30 minutes into the flight, the pilot conducted an orbit around a cleared area intended for landing and completed his landing checks. During late downwind, the pilot reports that the helicopter experienced an uncommanded yaw to the right. To counteract the yaw, the pilot applied left pedal, however the helicopter continued to yaw to the right and subsequently began an uncontrolled descent into trees. As the helicopter entered the trees, the pilot rolled off the throttle and pulled on the collective^[1] and the helicopter contacted the ground, resulting in the tail rotor severing. The main rotor also sustained damage from contact with the trees. The pilot and passengers exited the helicopter without injury.

At the time of the accident, the pilot reports that gusty, variable winds were encountered which may have caused a loss of tail rotor effectiveness (LTE),^[2] contributing to the accident.

Safety message

There are various factors that can contribute to a loss of tail rotor effectiveness. The NTSB Safety Alert, Loss of Tail Rotor Effectiveness in Helicopters identifies these factors and the subsequent risks associated with LTE.

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. 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.
2. In helicopters, loss of tail rotor effectiveness (LTE), or unanticipated yaw, is an uncommanded rapid yaw that does not subside on its own accord.