What happened

On 7 October 2018 at 1130 Western Standard Time, the pilot of a Mooney M20J aircraft was conducting a private flight from Bunbury to Jandakot, Western Australia.

En route to Jandakot, the pilot observed indications of mechanical problems with the aircraft. The pilot assessed that the engine performance was erratic.

Rather than proceed with the planned flight, the pilot elected to divert to Murray Field Airport, to perform a precautionary landing. The pilot determined that, were he to continue toward Jandakot airport, his options to perform a forced landing closer to his destination would become more constrained. The pilot also assessed that his current location afforded a number of suitable sites for forced landing if necessary, and was away from built-up areas.

The pilot landed the aircraft at Murray Field Airport, approximately 60 km south of Jandakot. There was no reported damage, and no injuries.

A post-flight inspection revealed that a flexible fuel line under the cowl had come loose. This lead to reduced fuel flow to the engine and fuel leakage. The cause of the fuel line becoming loose was not determined.

Safety message

This incident highlights the importance of maintaining awareness of aircraft systems performance. Because the pilot noted indications of erratic engine performance, he was able to take the positive action of diverting the aircraft. Flight crews are reminded that mechanical issues can emerge at any stage, and they must remain vigilant to warning signs.

This incident also highlights the importance of effective pilot decision making to ensuring safe flight. The pilot’s decision to divert when he observed erratic engine performance reduced the risk of injury or equipment damage. If the pilot had elected to continue with the flight, he would have had reduced options to manage those risks. Flight crew are encouraged to identify the hazards and risks they encounter during flight, and to make control decisions to minimise those risks where possible. The FAA provides decision making guidance to pilots in their Aeronautical Decision Making (ADM) training package.

About this report

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

What happened

On 18 July 2018, at about 0620 Eastern Standard Time, a Beech Aircraft Corp B1900D was conducting a charter flight from Cairns Airport, Queensland (Qld) to Skardon River Airport, Qld with two crew and 16 passengers on board.

Just after take-off from Cairns, the landing gear was selected up. The landing gear did not retract and remained down and locked with all green lights illuminated. The crew conducted a return to Cairns and the aircraft landed without incident.

Engineering Inspection

Following the incident, inspection of the landing gear revealed that the landing gear motor circuit breaker in the undercarriage had been pulled the previous day during maintenance and was not reset before the access panel was re-fitted after maintenance was completed. As a result, when the landing gear was selected up, the undercarriage system could not operate without the circuit breaker being reset.

Safety action

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

• improving prescribed paperwork methods
• providing further human factors training
• conducting Efficiency-Thoroughness Trade-Off (ETTO) training^[1]
• conducting more regular tool box talks
• providing safety and quality awareness training.

Safety message

Where an aircraft has been out of service for maintenance, it is important to verify the functionality of all critical aircraft components before returning it to service. These checks should be conducted in addition to the routine, pre-flight checks.

It is important that pilots remain aware that despite conducting comprehensive pre-flight checks, unanticipated failures can still occur during flight. In this situation, the flight crew 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. Erik Hollnagel, ETTO principles and rules that are applicable to the working environment. They compare the difference between efficiency and safety.

What happened

On the morning of 15 May 2018, the crew of a SAAB 340A were conducting a cargo flight from Rockhampton, Queensland (Qld) to Mackay, Qld. At approximately 0545 Eastern Standard Time, the aircraft was on descent into Mackay passing 10,000 ft.

During descent, the left engine surged from 50 per cent torque to over 70 per cent with an increase in interstage turbine temperature^[1]. The crew retarded the power lever and all other indications appeared normal. The aircraft levelled off at 5,000 ft and failure management was carried out. The crew subsequently conducted a normal approach and landing.

Following the incident, the crew were interviewed and an analysis of the flight data recordings occurred. Engineers were notified of the incident and conducted inspections. No faults were found with the engine or controls. It was determined that the constant torque on take-off (CTOT) was inadvertently not de-selected during the climb phase of the flight, resulting in the abnormal engine surge.

Safety action

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

Refresher training was provided to the crew specific to the use and operation of the CTOT system.

The crew conducted a competency-based training refresher course on operations failure management.

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 interstage turbine temperature (ITT) is the temperature of the exhaust gasses between the high pressure and low-pressure turbines.

What happened

On 2 June 2018 the pilot and a passenger departed a station west of Alice Springs, Northern Territory, in a Robinson R22 helicopter for a routine property inspection.

At approximately 1215 Central Standard Time, the pilot conducted a landing at a bore site and the passenger exited the helicopter. The pilot then also exited the helicopter with the engine still running. Shortly after exiting and moving away from the helicopter, the pilot heard the engine power up and began to run towards the helicopter. The helicopter then began to move and the pilot stopped moving towards it.

The helicopter was observed to move backwards and the tail rotor dug into the ground, flipping the helicopter onto its side resulting in substantial damage.

Pilot comments

The pilot reported that during maintenance the previous day, the collective was adjusted to loosen the friction. Before exiting the helicopter, the pilot tightened the cyclic, ensured the collective was down, and the friction nut tightened. The pilot suspects that the friction has loosened, causing the collective to rise and the helicopter to power up.

Safety message

Leaving engines running without a pilot in a control seat presents a significant hazard to the helicopter and persons on the ground. The aircraft manufacturer includes a warning against such practice in the aircraft flight manual, Safety Notice SN-17, Never exit helicopter with engine running.

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 Jul 2018, at about 1000 Eastern Standard Time, the pilot of a Robinson R44 helicopter took off with one passenger on board to conduct a few circuits^[1] at Lethbridge Airport, Victoria, prior to departing the airport for a private flight.

The pilot conducted two circuits and on the third circuit, set up for an autorotation^[2] to demonstrate to the passenger the rate of descent during the manoeuvre. The pilot selected a landing point 1/3 down the runway and established the helicopter at 70 kt, 600 ft above ground level (AGL). The pilot then partially rolled off the throttle to reduce the motor RPM and lowered the collective^[3] to enter autorotation. The pilot was explaining the autorotation to the passenger when the low rotor RPM horn and light came on followed by a significant wobble and shake of the helicopter. The pilot checked the rotor RPM and it was about 70 per cent. The pilot initiated recovery by increasing collective and winding the throttle back on. This made little difference and at 300 ft, the pilot pitched the nose of the helicopter forward to increase RPM. Just prior to impact with the ground the pilot flared the helicopter and pulled full collective, however there was little rotor RPM left.

The pilot called for the passenger to brace and the helicopter landed somewhat level. As it skidded forward, the helicopter rolled to the left side and came to a stop. The helicopter was destroyed and the passenger sustained serious injuries.

Figure 1: R44 wreckage at Lethbridge Airport, Victoria 

Source: Owner

Safety message

Practice of emergency recovery techniques such as autorotations should not be conducted with passengers on board. These carry an inherently elevated degree of risk. Additionally, passengers increase a pilot’s workload and can cause distractions. When conducting an autorotation; attitude, airspeed and rotor RPM should be the focus of the pilot’s attention. Practice autorotations are a dynamic manoeuver, increasing the potential to mishandle the helicopter. Two serious conditions associated with a mishandled autorotation are low rotor RPM stall and vortex ring state.

Safety Notice SN-10 on the Robinson Helicopter Company website states that, ‘No matter what causes the low rotor RPM, the pilot must first roll on throttle and lower the collective simultaneously to recover the RPM before investigating the problem.’

Safety Notice SN-24 Low RPM Rotor Stall can be Fatal and Safety Notice SN-22 Vortex Ring State Catches Many Pilots by Surprise, both detail recovery actions that require the collective to be lowered as part of the initial recovery actions.

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. Circuit: The circuit is an orderly pattern that involves the pilot making approaches to a landing area, touching down and then applying power to take off again.
2. Autorotation: Autorotation is a condition of descending flight where, following engine failure or deliberate disengagement, the rotor blades are driven solely by aerodynamic forces resulting from rate of descent airflow through the rotor. The rate of descent is determined mainly by airspeed.
3. 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.

What happened

On 30 May 2018, a Cessna 206 departed Oenpelli, Northern Territory (NT), for Croker Island, NT with a pilot and four passengers on board. After unloading the passengers at Croker Island, the pilot departed for the return flight to Oenpelli.

During the return leg at approximately 1705 Central Standard Time while the aircraft was cruising at 1,500 ft, the engine lost power and failed. The pilot noted that the airspeed had dropped back to 70 knots and was unable to maintain height. The pilot turned towards a mud flat, checked the fuel, mixture, and magnetos however the engine failed to respond. The pilot made a MAYDAY^[1] call and set up the aircraft for landing. The aircraft landed on a mud flat with no damage.

The post-flight engineering inspection did not reveal any faults with the engine and there was sufficient fuel and oil. The aircraft was later flown out from the mud flat.

Pilot comments

The pilot commented that the low altitude of the aircraft resulted in limited time to troubleshoot the cause of the engine failure. As a result, the engine failure checks and forced landing was required to be done quickly, with increased possibility of error.

Safety message

Although the cause of the engine failure could not be identified, the quick response by the pilot resulted in landing the aircraft in a suitable area without damage. Engine failures can happen at any time. If an engine fails at low level, the time to troubleshoot failures and glide to a suitable area is limited.

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: an internationally recognised radio call announcing a distress condition where an aircraft or its occupants are being threatened by serious and/or imminent danger and the flight crew require immediate assistance.

What happened

On 16 May 2018, at about 0700 Eastern Standard Time (EST), an Airbus A330-303 was beginning its descent into Melbourne, Victoria (Vic.). The aircraft was on a scheduled passenger flight from Tokyo, Japan with 12 crew members and 297 passengers on board.

The flight crew received clearance from air traffic control (ATC) to conduct a descent to 9,000 ft. Shortly after commencing a managed descent,^[1] the first officer (FO) observed the aircraft was slow of its commanded speed. The FO selected OP DES^[2] and the aircraft accelerated towards a managed speed of 310 kt. The aircraft’s maximum allowable operating speed (VMO) was 330 kt.

Passing through flight level (FL) 320^[3], the wind direction shifted from a crosswind to a headwind and consequently the aircraft rate of descent increased. The flight crew deployed the speed brakes and levelled the aircraft, by selecting ‘PUSH TO LEVEL OFF’ on the flight control unit, to reduce speed. Despite these actions, the aircraft continued to accelerate. During the descent, the aircraft reached a maximum speed of 336 kt for 6 seconds.

The aircraft landed at Melbourne without further incident. There was no damage to the aircraft or injuries sustained to crew or passengers.

Engineering Inspection

Following the incident, the operator’s engineering team examined the details of the occurrence and determined that the maximum speed obtained was within the permissible limits of the aircraft maintenance manual. No inspections of the airframe were required, and the aircraft was returned to service.

Safety message

This occurrence highlights that unexpected changes in weather can occur at any time. Sudden shifts in wind direction can have a significant impact to aircraft speed. Flight crews should pay particular attention to monitoring the aircraft’s speed during descent when operating with a reduced margin to VMO as the impact of a wind gradient can result in an airframe overspeed. In particular, when flying close to the wind direction or in turbulent conditions, flight crew should adjust the speed target to allow adequate margin below VMO.

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. In the managed descent mode, the aircraft follows a pre-computed descent profile that allows for aircraft deceleration and airspace restrictions along the active flight planned route.
2. OP DES: allows the aircraft to climb or descend uninterrupted toward flight control unit selected altitude, maintaining a target speed (managed or selected) with a fixed given thrust.
3. Flight level: at altitudes above 10,000 ft in Australia, an aircraft’s height above mean sea level is referred to as a flight level (FL). FL 320 equates to 32,000 ft.

What happened

On 31 March 2018 at 0745 Eastern Daylight-saving Time, the pilot of a Kavanagh E-300 balloon was on final approach to land near Billinudgel, New South Wales with a pilot and 11 passengers on board.

As it was a new landing area, the pilot had asked the ground crew following the balloon to check the landing site and adjacent road and report any powerlines. The ground crew reported none and the pilot directed his attention to managing the landing. Neither the pilot nor passengers had identified any powerlines on the approach path to the landing site.

Just before landing, at 3-4 kt and 10 ft above ground level, the pilot saw two wires in front of the balloon, about a third of the way up the envelope. The pilot immediately pulled the red rip line to deflate the balloon, but the envelope struck the powerlines, which snapped and fell to the ground. The powerlines short-circuited five times and then stopped sparking.

No one was injured, and a subsequent inspection found no tears, burns or abrasion marks on the balloon envelope. The owner of the property was advised, and the ground crew contacted the power supplier to report the incident.

Pilot comment

The powerlines had only become visible when seen against the sky. On approach, against the dark green surface of the landing site, neither the pilot nor passengers had seen the wires.

Once the ground crew had advised there were no powerlines on the approach path to the landing site the pilot had concentrated on landing the balloon, rather than looking for wires.

Safety action

As a result of this occurrence, the balloon’s operator has advised the ATSB that they have spoken to the ground crew about the importance of identifying powerlines adjacent to landing sites and communicating that information to the pilot. The operator’s other pilots and ground crew received a comprehensive briefing on the incident.

Safety message

The Australian Ballooning Federation’s Pilot Circular No 18, dated February 2012, emphasised the importance of avoidance and made the following points:

• Pre-flight planning: Critical for ballooning, maps, charts and information must be current. Consult council staff, locals and farmers, topographic map in hand, for precise location of powerlines and those not on the maps.
• Complacency: Familiarity and repetition regarding operation and location can lead to complacency. Be aware of this and hence be vigilant. Data shows the worst accidents are often made by the most experienced and skilled operators.
• Crew/passenger briefing: Stress to crew and passengers pre-take-off and before approach: (1) you are only human and may not see threatening powerlines, and (2) to feel free to point them out to you.
• Reduced visibility: Sun, mist, haze, contrast. Be vigilant and conservative under these conditions.
• See and Avoid scanning technique: Avoid focusing too long on close objects or scanning quickly left and right. Focus at a distance and move attention slowly over small arcs pausing briefly for a few seconds each time to closely examine the area.
• Country flying: Expect lines to be along roads with feed offs to farmhouses. Often, single wires can be identified only by first locating their poles, so look for them first and assume lines run between them. They also cross paddocks to connect to other facilities. In this case be aware poles are often placed among trees making them difficult to see.
• Minimum safety altitude: Most power line strikes involve wires which are usually no more than 15 metres (50 feet) above ground level. Except for take-off and landing, staying above this height when flying in unfamiliar or risky areas is great insurance against hitting a wire.
• Distraction on approach: Checks, fuel, pilot lights, passengers, stock, obstacles, stress, tunnelling. All are Human Factors aspects that must be recognised and managed early such that full attention is then available for approach and landing.

The Civil Aviation Safety Authority web site includes a list of wire strike resources that specifically address this hazard.

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 11 April 2018, at about 0643 Eastern Standard Time, an Airbus A320 (A321-231) took-off from Melbourne Airport, Victoria bound for Hobart Airport, Tasmania. During initial climb, after retracting the landing gear, the flight crew received an ECAM^[1] alert indicating low fluid pressure in the green hydraulic system. The green hydraulic system is one of three independent operating hydraulic systems on the Airbus A320 aircraft.

Upon receipt of the warning, the flight crew contacted air traffic control (ATC) on the departures frequency to notify them of the alert and requested to maintain flight at 5,000 ft in order to further asses the issue. The flight crew then completed checks in the ECAM system and identified that they had lost fluid from the green hydraulic system.

Having identified the issue, the crew advised ATC that they intended to return to Melbourne and required 20 minutes holding time before commencing approach in order to complete necessary checks and preparations. ATC approved the request to hold at current position and declared an INCERFA^[2] and Local Standby services^[3].

During the hold, the flight crew established that due to the green hydraulic system failure, they would not have normal brakes or nose wheel steering available on landing. The crew subsequently briefed the cabin manager of the situation and made a public address call to the passengers. The public address notified the passengers of the technical fault and the intention to return to Melbourne, advising that the landing would be normal but that the aircraft would need to be towed back to the gate due to brake and steering issues. The crew also notified their ground services of this requirement and a tug was made available for use.

Before commencing approach to land, the crew completed a landing gear gravity extension procedure using the checklist and then conducted an instrument landing system approach to land on runway 16. The aircraft vacated the runway on the roll onto high speed taxiway G and came to a stop clear of the runway. The aircraft was then towed back to the terminal where passengers and crew were disembarked.

An engineering inspection was subsequently conducted which identified that a ruptured steel hydraulic pipe in the left wing was the cause of the fluid loss. Removal and inspection of the failed pipe occurred and the maintainer reported that the failure was the result of fretting wear to the outer surface of the pipe due to repeated rubbing from a bolt over a long period of time. Pictures of the failure surface of the hydraulic line and its location relative to the bolt head are shown in Figures 1 and 2.

The engineering inspection also identified that there was insufficient clearance between the line and bolt though it was not known how this had occurred.

Figure 1: Failure surface of the green system hydraulic line showing fretting wear

Source: Aircraft maintainer

Figure 2: Location of the failed hydraulic pipe (blue outline) relative to a flap guide fixation bolt (red outline)

Source: Aircraft maintainer, annotated by ATSB.

Safety action

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

Inspection of hydraulic lines on similar aircraft within the fleet, no additional instances of damage have been noted.

Safety message

The actions of all parties in response to this event reaffirms the importance of having and utilising correct event response procedures when experiencing technical failures in-flight. The actions of the flight crew, ATC and ground staff in coordinating and dealing with the event resulted in a safe outcome.

In the past 12 months (to June 2018), the ATSB has received more than 30 occurrence reports where the flight crew of air transport high-capacity aircraft received hydraulic system fault warnings during operation including an occurrence that is currently being investigated (AO-2018-014). A similar hydraulic failure event, on landing in an air transport low-capacity aircraft, was reported to the ATSB on 30 March 2018 and published as an occurrence brief (AB-2018-046). In these cases, the flight crew successfully identified and managed the failure.

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. Airbus Electronic Centralised Aircraft Monitor (ECAM): A system that monitors aircraft functions and relays them to the pilots. The specific alert displayed by ECAM in this occurrence was HYD G SYS LO PR indicating a loss of hydraulic pressure in the Green hydraulic system.
2. Uncertainty phase (INCERFA): emergency phase declared by the air traffic services when uncertainty exists as to the safety of an aircraft and its occupants. it is the lowest of the three possible alert levels.
3. Local Standby: a nationally recognised level of aerodrome emergency response that notifies airport based rescue and firefighting services and the aerodrome safety officer of the event. A local standby is the normal response when an aircraft approaching the airport is known, or suspected to have developed some defect but it would not normally involve serious difficulty in effecting a safe landing.

What happened

On the morning of 23 June 2018, a Cirrus SR20 returned to Archerfield, Queensland from a private flight with one pilot and one passenger on board.

During the final approach to runway 28R, the pilot observed an aircraft ahead commencing its take-off as well as an aircraft holding at the taxiway intersection. Passing 300 ft on final approach, the preceding aircraft became airborne and the pilot then realised that he may be approaching the incorrect runway. The pilot elected to continue the approach as the runway was clear and he believed a go-around may cause more issues. On the landing roll, ATC advised the pilot to contact the Tower. The ground controller confirmed that the aircraft had landed on the incorrect runway.

Post-incident, the pilot advised that due to the increased workload of ATC transmissions, having a passenger on board and losing some situational awareness, he became tunnel-visioned leading to the error. The pilot plans to fly with his instructor to further practice joining the circuit.

Safety message

This incident highlights the need for pilots to anticipate, plan and execute early and correctly performed go-arounds if a safe landing is in doubt.

The ATSB newsroom report, News: Know when to go-around, is available from the ATSB website. More information on when and how to execute a go-around can be found at the FAA’s

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.