What happened

On 15 May 2018, at about 1500 Western Standard Time (WST), a Fokker F100 was on a scheduled passenger flight from Perth, Western Australia (WA) to Kununurra, WA. The flight crew was comprised of the captain and the first officer (FO).

Passing through 10,000 ft on descent, the crew received a “LG Not Down”, triple chime alert. The flight crew identified that that the Radio Altimeter 1 (RA1) was erroneously indicating ‘zero feet’, which triggered the gear unsafe alert. The flight crew discussed the situation and decided to configure the aircraft for landing early, with the view to extend the gear as soon as practicable, in order to silence the triple chime alert.

Shortly after, the crew observed the autopilot disconnect and a ‘STAB TRIM 1 and 2’ fault alert. The captain took over flying the aircraft manually, commenced speed reductions and called for ‘Flaps 8’. Immediately following, RA1 appeared to return to normal operation and all alerts ceased.

Descending through 7,000 ft, RA1 returned to a reading of ‘zero feet’. The flight crew observed all of the previous alerts, in addition to a “TOO LOW GEAR” GPWS alert. The crew reviewed the situation and agreed to continue with the plan to configure the aircraft early for landing. The remainder of the approach and landing were conducted without further incident.

Once on the ground, the captain contacted Maintenance Watch and the Manager Flight Technical for guidance. In preparation for the return flight to Perth that afternoon, the team made the decision to dispatch the aircraft under the Minimum Equipment List (MEL).

At about 1630 WST, after a lengthy turnaround, the flight crew began the performance calculations for take-off on runway 12. The take-off flap position of ‘Flaps 15’ was correctly identified and circled on the Take-Off and Landing Data (TOLD) Card, to highlight the infrequently used setting.

After start, the flight crew became aware of an inbound aircraft on long final. The flight crew initiated a radio call to the crew on board the approaching aircraft to confirm their intended surface movements. As the departing aircraft approached the runway, the other aircraft made a radio transmission expressing confusion regarding the use of the taxiways. The confusion was resolved and the captain of the departing aircraft began the pre-take off sequences.

Distracted by the earlier confusion and eager to depart, the captain called for ‘Flaps 8’, the more commonly used take-off configuration. The captain then glanced at the TOLD card to cross check the numbers and continued with the take-off.

The aircraft’s speed had climbed above 100 kts before the FO and captain identified the incorrect flap setting. The captain called continue and the take-off was completed without further incident.

Safety message

This incident highlights the importance of managing operational pressures and distraction. The traffic on the taxiway, the events of the previous flight and the extended turnaround time had distracted the crew from completing the pre-flight sequences in a conscious manner. During times of high workload, distraction and perceived time pressures 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 7 July 2018 at 0915 Eastern Standard Time, a Victa Airtourer with two crew was on a private flight from Kilcoy, Queensland (Qld) to a private grass airstrip near Somerset Dam, Qld. Weather conditions were reported as cloud at 2,500 ft with a slight crosswind.

During landing, the pilot landed long on the airstrip which was made up of wet grass. The pilot considered conducting a go-around or conducting a controlled ground-loop^[1]. The pilot briefly opened the throttle to attempt the go-around, but quickly closed it as the aircraft was reaching the end of the strip.

The aircraft overran the strip and collided with a barbed wire fence. After shutting down the aircraft, both occupants evacuated uninjured.

The aircraft was assessed to have sustained extensive damage including to the left-wing leading edge, right aileron, bent propeller blades and a torn off landing gear and nose wheel.

Contributing factors to the overrun include:

• wet grass runway
• minimal wind conditions
• a long touchdown on the strip
• opening the throttle late.

Safety message

When conducting flights into unfamiliar locations, pilots should attempt to research the airstrip or field prior to departure. For private or undocumented strips, conducting a pass over the strip first before landing will aid in determining runway length and characteristics.

In some cases, a wet runway may not be evident prior to landing. Utilising the full length of the strip allows pilots extra time to execute recovery manoeuvres (such as conducting a go-around) from compromising situations such as a wet runway, which can limit an aircraft’s braking abilities.

Additionally, pilots should familiarise themselves with their aircraft operating handbook to build confidence on their decision making in time-critical situations.

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. A ground loop is an ‘involuntary uncontrolled turn while moving on the ground, especially during take-off or landing’ (Bill Gunston, The Cambridge Aerospace Dictionary, New York, New York; Cambridge University Press, 2004, p.275).

What happened

On 13 May 2018, a remotely piloted Da-Jiang Innovations (DJI) Phantom 4 aircraft was launched from a lookout near Hope Downs 4 Mine, with the pilot and observer intending to conduct an aerial berm^[1] inspection within one of the mining pits. At about 0735 Western Standard Time, the aircraft lost power and fell to the pit floor, resulting in the aircraft being destroyed.

During the flight, witnesses observed the battery separate from the body of the aircraft and fall to the ground. An inspection revealed hairline fractures around the catch, which locks the battery in place. The recovered battery was also fractured in this area.

Later, it was determined that a post-flight check had not been completed on the previous flight. In addition, the pre-flight inspection of the aircraft just prior to the accident flight had not included a check of the battery connection and locking mechanism.

Safety action

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

• modifying their procedures to include the recording of all maintenance activities to their sub 2 kg remotely piloted aircraft
• including in their pre-flight checklist that the observer or a secondary person will check the installation of the battery.

In addition, the operator has emphasised the importance of pre and post-flight checks of the aircraft.

Safety message

This accident highlights the importance of pre and post-flight inspection of remotely piloted aircraft. Aircraft manufacturer user manuals, which are generally accessible online, provide specific guidance in relation to each model of aircraft, including information in relation to the correct fitment of the battery. Additionally, the Civil Aviation Safety Authority provides generic guidance in relation to the operation of remotely piloted aircraft and the training requirements of operators on their Flying drones/remotely piloted aircraft in Australia web page.

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. Berm is a term used to describe a barrier, such as a wall.

What happened

On 1 August 2018 at approximately 1200 Eastern Standard Time, the pilot of a Lancair 360 commenced his pre-flight inspection at Roma Airport, Queensland (Qld). The sequence of the pre-flight inspection was altered due to the need to refuel prior to departure. During the inspection, the pilot was also interrupted on multiple occasions where he was required to leave the aircraft. When he returned, he approached the aircraft from behind and inadvertently omitted to inspect the front.

The pilot completed pre-flight checks and believed that the aircraft was ready for flight. During the climb, the pilot noticed a slight vibration, which discontinued once in cruise configuration. The pilot also noted that the oil temperature was one to two degrees lower than normal during the flight. No further unusual events were observed throughout the flight and the aircraft landed safely at Gold Coast Airport, Qld.

Upon unloading the aircraft, the pilot noticed that he had not removed the tow bar from the aircraft prior to departure. He contacted Roma Airport ground staff and advised that the tow bar handle may have fallen off on the taxiway; they were unable to locate it. The next day the pilot received a phone call from Gold Coast Airport staff advising him that they had located and removed his tow bar handle from the runway. No damage was sustained to the aircraft. The tow bar handle was slightly bent and scratched.

Safety message

The incident highlights the importance of ensuring that all pre-flights checks are carried out systematically and with minimal interruption. If interrupted, it is best practice to start again from the beginning to ensure that nothing is missed.

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 2 April 2018, a student pilot was conducting solo circuit training in a Piper PA-28 from Bankstown Airport, New South Wales.

At 1114 Eastern Standard Time, the aircraft was passing through 700 ft on climb to circuit height on the crosswind leg runway 29L, when the engine failed. The pilot immediately turned the aircraft towards the airport and conducted a forced landing, omitting the required checks. During landing, the aircraft contacted trees resulting in substantial damage. The pilot was not injured.

Post-flight it was determined that fuel starvation was the cause of the engine failure. The pilot stated they thought the right fuel tank was full and the left fuel tank was just under full before the flight. After the accident, fuel on board prior to the flight was calculated to be 24 litres in the left tank and 43 litres in the right tank. After the engine failed, the pilot did not switch fuel tanks.

The operator has an arrangement with a local refueller whereby they fill up the aircraft to full tanks and leave a chalk mark on a tyre. When an aircraft has been moved, the refueller can see this and tops up the tanks to full capacity. This did not occur on this occasion and may have led to complacency with the expectation that the tanks would be full.

Safety message

Accurate fuel management starts with knowing exactly how much fuel is being carried at the commencement of a flight. This is easy to know if the aircraft tanks are full, or filled to tabs. If the tanks are not filled to a known setting, then a different approach is needed to determine an accurate quantity of usable fuel.

Fuel starvation continues to be a common cause of engine failure. Effective fuel management in flight and the checking of fuel quantities reduces the risks of a fuel starvation event. Once an engine has failed or runs rough due to fuel starvation, changing the selected tanks should restore power but may take some time to take effect. Fuel tank changes should be done in conjunction with any other checks as recommended by the aircraft flight manual. For more information on fuel management, see ATSB research report, Starved and Exhausted: Fuel management aviation accidents (AR-2011-112).

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 15 June 2018, at about 1420 Eastern Standard Time, a Piper Aircraft PA-38-112 was departing Amberley Airport, Queensland (Qld) for Archerfield Airport, Qld with one pilot and one passenger on board.

Shortly after the aircraft became airborne, the pilot observed a drop in engine power. Over the next few seconds, the pilot observed the engine power fluctuate between normal power and a reduced power output. Because of the fluctuating engine power, the pilot elected to land the aircraft on the remaining runway.

After landing, fluid was found to be dripping from the aircraft. Emergency services were called to clean the contaminant from the runway.

Following the incident, the operator removed the aircraft from service, placing it in quarantine until engineering inspections were completed.

Operator’s investigation

A post-incident inspection of the fuel system revealed a faulty fuel gascolator (filter) and a cracked fuel primer line. The maintenance provider replaced the fuel gascolator assembly and primer line to rectify the defect and returned the aircraft to service.

The operator identified the cause of the incident to be a fuel leak in the fuel gascolator assembly. The leak resulted in reduced fuel flow to the engine carburettor, which subsequently caused the power fluctuations on take-off. The operator’s investigation report noted that the fuel leak only became evident after the aircraft was exposed to the vibrations associated with high power settings and becoming airborne.

Safety action

The aircraft operator in conjunction with the maintenance provider has identified a more robust fuel gascolator that can be fitted under the authority of a Supplemental Type Certificate.

The operator is progressively replacing these units on their fleet of aircraft to reduce the probability of a similar incident in future.

Safety message

This incident highlights the importance of being able to act quickly and decisively in-flight to ensure an effective response in time critical situations. In this instance, proper monitoring of flight instruments and decisive action by the pilot ensured 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.

What happened

On 9 April 2018 at 0700 Eastern Standard Time (EST), the pilot of a Kavanagh G-450 balloon was on final approach to land near Mareeba, Queensland (Qld) with a pilot and 11 passengers on board.

Having received advice by radio from the pilot of a balloon that had already landed, the pilot anticipated a fast landing at approximately 6 kt, descending rapidly after passing over tall trees and stopping before reaching a barbed-wire fence on the downwind side of the paddock.

Before descending, the pilot contacted the ground crew by radio and asked them to provide “weight on” during the landing, to reduce the distance the basket may be dragged before stopping. This is a commonly used strategy in confined landing areas, overcoming the buoyancy of the balloon by adding the weight of the ground crew to that of the balloon and its occupants.

The ground crew moved to the anticipated landing site and waited for the balloon, but rather than remaining at the edge of the paddock, monitoring the balloon’s progress and only moving in once it had passed, one of the ground crew entered the paddock before the balloon arrived.

The ground crew member was walking across the paddock, away from the rapidly descending balloon, but directly in its path, when the pilot shouted a warning. The crew member immediately dropped to the ground and the balloon’s basket passed overhead. The balloon landed safely, and the ground crew member, pilot and passengers were not injured. The other two members of the ground crew remained behind the basket and were not at risk.

If the ground crew member had not heard the shouted warning and responded immediately, the consequences may have been significant. The ground crew member could have been struck by the loaded basket.

The operator’s training manual did not specifically prohibit ground crew members from placing themselves beneath the path of the balloon during landing and the ground crew member, although experienced in performing operational support tasks, was focussed on walking through the long grass and weeds in the paddock, rather than watching the approaching balloon.

Safety action

As a result of this occurrence, the balloon’s operator has advised the ATSB that they have spoken to the ground crew member about the lack of situational awareness and poor risk assessment. The operator intends to amend the company’s training manuals and ensure incidents of this type are covered in the initial and annual emergency procedure checks for all ground personnel.

The company’s Chief Pilot advised all flight and ground crew members of the incident, outlined the expectations when working or walking near balloons in low-level flight, and made the following recommendations:

• Never position yourself in a location where the basket will pass directly overhead. Balloons can be subject to low-level turbulence or last-minute inputs by the pilot (such as venting) and can descend rapidly and unexpectedly.
• When you are close to a balloon in flight, even if it is still attached to the quick release, keep your eyes on the balloon at all times to ensure you know where it is going. Ensure that the balloon does not pass overhead. If it does, react immediately and move to a safe area away from the basket.
• Do not make assumptions on the pilot’s intentions. These may vary from day to day, depending on the circumstances.
• When asked to put weight on during a landing remain off to the side of the basket until it has passed and then move in from behind.

Safety message

The Australian Ballooning Federation's Pilot Training Manual Part 5 "Aerostatics and Airmanship" describes the responsibilities and duties of the pilot and ground crew in detail.

The U.S. Department of Transportation Federal Aviation Administration’s Balloon Flying Handbook is another detailed and valuable resource. In its section on Human Resources, the handbook notes that balloons differ from aircraft in their reliance on unlicensed, non-certified and even first-time volunteers to support ground handling of the balloon.

The handbook goes on to make the point that “while all final decisions and the responsibility for safety still rest with the pilot, this broader than usual safety resource management model recognizes the human resources upon which every pilot relies for safe flight planning and decision-making”.

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 March 2018 at approximately 0700 Central Standard Time (CST), the pilot of a Pilatus PC-12/47E commenced his pre-flight inspection at Darwin Airport, Northern Territory. During the inspection, the pilot was interrupted on several occasions to attend to matters pertaining to the aircraft’s passengers and crew.

At approximately 0800 CST, the pilot had completed pre-flight checks and believed the aircraft was ready for flight. The aircraft taxied and took off from runway 29. During the initial climb, the pilot noted that the co-pilot’s airspeed indicator was not functioning correctly. The pilot then contacted Air Traffic Control (ATC) and requested a return to Darwin. While still in the circuit for runway 29, the pilot, thinking that the problem may be with the computer, requested clearance to taxi off the runway after landing and restart the aircraft. Clearance was granted and the landing, taxi and restart were conducted without incident. The pilot then requested a clearance from ATC for take-off, noting that if the issue with the airspeed indicator continued that the take-off would be aborted, and the aircraft would return to the parking area. Clearance was granted and the aircraft taxied and commenced the take-off roll. During the roll, the pilot noted that the airspeed indicator was still not functioning correctly and subsequently aborted the take-off and returned the aircraft to the parking area.

Upon exiting the aircraft, the pilot noted that the cover was still on one of the aircraft’s pitot tubes. The pilot removed the cover and inspected the tube. Once he was satisfied that there was no damage, he restarted the aircraft and proceeded with the flight with no further issues.

Safety message

This incident highlights two key safety elements. Firstly, it highlights the importance of ensuring that all pre-flight checks and procedures are carried out systematically, efficiently and with minimal interruption. Secondly, its shows the necessity of assessing a situation quickly and being prepared to conduct a diversion or return if there is an issue with the 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 29 April 2018, at 1330 Eastern Standard Time (EST), a Cessna 172N commenced taxiing on the southern apron at Archerfield, Queensland, in preparation for take-off. At the same time, a fuel truck was fuelling a Cessna 172S to the left side of the taxiway. As the Cessna 172N taxied past, the leading edge of the left wing contacted the fuel truck. The Cessna 172N was immediately stopped and the engine was shut down. Damage to the windscreen of the truck and leading edge of the Cessna 172N’s left wing was identified upon inspection. The Cessna 172N was then pushed clear of the taxiway.

A flying competition and social event was in progress, resulting in higher than normal air and foot traffic in the aerodrome vicinity. Visibility was good, with scattered cloud and a light southerly breeze.

Figure 1: Damage post incident, to the Cessna 172N and fuel truck

Source: Pilot in Command

Safety message

A number of taxiing collisions have been investigated by the ATSB, including Taxiing collision involving a Cessna 172S, VH-EOT and a Cessna 172S, VH-EOP at Moorabbin Airport, VIC on 29 January 2015 (AO-2015-011), which is available from the ATSB website. These incidents reinforce the importance of maintaining situational awareness^[1] and a good lookout during taxiing, particularly in instances of higher than normal activity and distraction.

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. Situational awareness: being aware of what is happening around you, where you are, where you are supposed to be, and whether anyone or anything around you is a threat to your health and safety. Source: Health and Safety Executive (HSE)

What happened

On 31 March 2018, at 1545 Central Daylight-saving Time (CDT), a Diamond DA40 departed from runway 26 at Port Pirie, South Australia for navigation training purposes. The pilot was the only occupant.

During initial climb, between 100 ft and 400 ft, the engine commenced rough running combined with reduced performance and a high cylinder head temperature indication. A low level circuit was completed to enable an immediate return to Port Pirie, where the aircraft landed safely. An observer noted smoke emanating from the engine cowling during return taxi. An inspection found that the pilot had inadvertently fuelled the aircraft with Jet A-1 (AVTUR),^[1] instead of AVGAS^[2] immediately prior to flight. The aircraft was recovered by road vehicle, to enable engine replacement.

Operator’s investigation

The operator found the student had undertaken one of three allocated briefing and monitoring sessions in refuelling operations, prior to assessment for competency, due to time constraints.

Figure 1: Refuelling point at Port Pirie, SA

Source: Operator

Safety action

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

A reinforcement to their instructors of the importance in ensuring student competence in unassisted refuelling, after previous instruction and monitoring, prior to solo refuelling operations.

Safety message

Pilots are reminded of the importance of checking fuel for the correct grade in addition to contaminants after refuelling operations are complete. The higher density of AVTUR in comparison to AVGAS, will cause it to settle to the bottom of fuel tanks, enabling distinction by colour and smell.

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. AVTUR: Aviation turbine fuel, designed for use in aircraft gas turbine engines. Either straw coloured or colourless. Source: Chevron Products Company
2. AVGAS: Aviation gasoline, designed for use in aircraft piston engines. Dyed green or blue for identification. Source: Chevron Products Company