What happened

On 22 March 2018, an Airbus A320-232 was on descent into Cairns, Queensland (Qld) when it encountered severe turbulence. A cabin crew member in the rear of the aircraft sustained a broken ankle as a result.

The aircraft was flying in and out of cloud at the time of the occurrence and the pilot reported that the weather radar only showed green patches, indicating nil significant turbulence. The seat belt signs were therefore not illuminated.

The pilot reported that no turbulence was forecasted or expected. No encounters with turbulence had been reported prior to the occurrence.

Safety message

The ATSB research report Staying safe against in-flight turbulence (AR-2008-034) details that while turbulence is normal and occurs frequently, it can be dangerous. It is rarely a threat to passenger aircraft or to pilot control of the aircraft. In a typical turbulence incident, 99% of people on board receive no injuries. The report discusses what you can do to stay safe.

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 22 May 2018, a SAAB 340B departed from Wagga Wagga, New South Wales (NSW) with 3 crewmembers and 30 passengers on board.

At about 1651 Eastern Standard Time, as the take-off roll commenced on runway 23, the crew observed four galahs rise up from the grass to the left and cross in front of the aircraft. As the aircraft’s speed reached V1^[1], the crew heard the distinct impact of the four galahs coming from the right side of the aircraft. The pilot flying^[2] (PF) proceeded to rotate^[3] at VR^[4]. The crew detected surges, power loss and vibrations from the no. 2 engine and the PF called “Positive rate, gear up, max power” initiating the engine failure at or above V1 procedure.

The crew continued to follow the company departure procedure by flying out to the south-west of the aerodrome on the runway heading. During initial climb, the crew observed the no. 2 engine had reduced torque and subsequently the pilot monitoring (PM) shut down the engine using the engine failure “Memory Items.” Passing 2,000 ft on climb, the crew proceeded to turn the aircraft left to conduct a return to Wagga Wagga via the instrument landing system (ILS)-Z runway 23 approach. The PM made radio calls on the common traffic advisory frequency (CTAF) to advise everyone within the aerodrome vicinity of the crew’s intentions and declared a PAN PAN^[5] on the Melbourne Centre frequency. The aerodrome rescue and firefighting reponse team acknowledged the radio calls offering their assistance if required.

At a safe altitude, the flight crew advised the cabin crew of the birdstrike and briefed them on the intended plan of action. The cabin crew member moved a paxing crew member towards the front of the aircraft to provide assistance if required. The flight crew advised the passengers of the situation and the cabin crew subsequently recited from the precautionary landing card and continued to secure the cabin with the paxing crew.

After the aircraft landed safely, the crew stopped the aircraft on the runway. The PM briefed the passengers and the cabin crew, and made radio calls on the CTAF and Melbourne Centre to advise of their intended actions. The crew then taxied the aircraft back to the bay where the passengers disembarked. During the post-flight inspection, the flight crew and engineers found bird remains in the engine intake and an air scoop on the inboard side of the no. 2 engine.

The engineering inspection revealed a stage one rotor blade bent beyond limits in the no. 2 engine and the engine was subsequently replaced.

Safety message

This incident provides an example of how effective failure management and crew resource management can lead to the safe recovery of an aircraft when an unplanned incident occurs. Occurrences involving aircraft striking wildlife, particularly birds, are the most common aviation occurrence reported to the ATSB. Strikes with birds continue to be a potential safety risk and present a significant economic risk for aerodrome and airline operators.

The ATSB research report AR-2016-063, Australian aviation wildlife strike statistics: 2006–2015, is available from the ATSB website.

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. V1: the critical engine failure speed or decision speed required for take-off. Engine failure below V1 should result in a rejected take off; above this speed the take-off should be continued.
2. Pilot Flying (PF) and Pilot Monitoring (PM): procedurally assigned roles with specifically assigned duties at specific stages of a flight. The PF does most of the flying, except in defined circumstances; such as planning for descent, approach and landing. The PM carries out support duties and monitors the PF’s actions and the aircraft’s flight path.
3. Rotation: the positive, nose-up, movement of an aircraft about the lateral (pitch) axis immediately before becoming airborne.
4. VR: the speed at which the rotation of the aircraft is initiated to take-off attitude. This speed cannot be less than V1 or less than 1.05 times VMCG. With an engine failure, it must also allow for the acceleration to V2 at a height of 35 ft at the end of the runway.
5. 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 10 March 2018 at 0945 Eastern Standard Time, a Piper PA-38-112 Tomahawk aircraft was on a training flight from Toowoomba City Aerodrome, Queensland with a student and an instructor on board.

During approach to land on runway 11, the student was in control of the aircraft. After crossing the threshold, the student initiated the landing flare,^[1] and at this time, the aircraft encountered gusty conditions, which unexpectedly increased the aircraft’s rate of sink. The student immediately applied forward pressure to the control column as the instructor stated “taking over” and attempted to pull back on the control column. However, the student inadvertently maintained some forward pressure on the control column during this time, preventing the instructor applying full back pressure prior to landing.

Subsequently, the aircraft landed on all three wheels with sufficient force to shear off the nose wheel. The instructor was able to apply full back pressure on the control column and steered the aircraft off the runway and onto a grassed area. The instructor then shut down the aircraft and both the student and instructor evacuated the aircraft without injury. The aircraft was later assessed to have sustained substantial damage including to the propeller blades and oleo strut.^[2]

Safety message

While conducting training activities, students are more likely to sustain a higher than normal workload, particularly during landing. This can result in a decreased sensitivity to verbal instructions, including an instructor stating that they have taken over control of the aircraft. (Orlady, H. and Orlady, M, 1999). ^[3] It is also possible that a student may not be aware that they are still applying control inputs. As this is a normal part of human performance, it is not possible to eliminate the likelihood of this occurring altogether, and difficult to limit the consequences of it when there is little time available for instructors to identify the problem. However, it may be possible to reduce the risk by conducting comprehensive pre-flight briefing sessions where the required actions for a student once an instructor states, ‘I have control’, are emphasised regularly, particularly for inexperienced pilots.

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. The final nose-up pitch of a landing aeroplane used to reduce the rate of descent to about zero at touchdown.
2. A hydraulic device used as a shock absorber in the landing gear of aircraft, consisting of an oil-filled cylinder fitted with a hollow, perforated piston into which oil is slowly forced when a compressive force is applied to the landing gear, as in a landing.
3. Orlady, H. and Orlady, M., Human Factors in Multi-Crew Flight Operations, Ashgate Publishing Ltd, Aldershot England

What happened

On 21 April 2018, a Cessna 210M aircraft was conducting low-level survey operations to the south-east of Laverton Aerodrome, Western Australia. The pilot was the sole occupant on board.

After completing survey operations, the aircraft was returning to Laverton when, at about 1315 Western Standard Time (WST), the aircraft engine experienced power loss. Power was regained briefly, before the engine again experienced a loss of power. The pilot conducted procedures to identify the problem; including switching the fuel selector between tanks to rectify the rough running, but this did not improve the engine performance.

By this time, the aircraft altitude had reduced to tree top level, when the pilot prepared for a forced landing into the trees. The pilot activated the aircraft emergency location transmitter^[1] (ELT) and Spidertracks^[2] unit. The aircraft then contacted a number of trees before coming to a stop. A small fire started in the engine bay, which was extinguished. The aircraft received substantial damage to the left wing, empennage, firewall and survey stinger. The pilot was not injured.

The aircraft was fitted with auxiliary fuel tip tanks. The pilot commented that the normal fuel transfer procedure from the tip to the main tanks was changed, to lessen the effects of electrical interference to the survey equipment when running fuel transfer pumps. By focusing on the changed procedure, the pilot was distracted and did not ensure that all fuel had been transferred from the tips to the main tanks. This resulted in the starvation of fuel to the engine.

Safety message

This occurrence is an example of what can happen when procedures are not followed. Pilots are reminded to follow published procedures when operating any aircraft system in accordance with the manufacturer’s recommendations.

Issue number 5 in the ATSB’s Avoidable Accident Series, Avoidable Accidents No. 5 - Starved and exhausted: Fuel management aviation accidents (AR-2011-112), provides more detail on these scenarios. This report is available from the ATSB website.

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.
2. Spidertracks is a satellite based tracking system which includes an SOS function for use in emergency.

What happened

On 24 March 2018 the pilot of a Cessna 340 was on a private flight from Bankstown, New South Wales to Lilydale, Victoria. The aircraft was operating under the instrument flight rules (IFR)^[1]. The aircraft arrived at Lilydale at 1205 Eastern Daylight-saving Time.

During descent into Lilydale the pilot reported passing through broken cloud and becoming visual with the airfield. The pilot then cancelled IFR and proceeded to overfly the airfield to inspect the runway and windsock. The windsock indicated little wind. There was rain forecast in the area and showers in the vicinity, however there was no rain reported over the airfield at the time of arrival.

The pilot conducted a normal approach and touched down 250-300 m down the 850 m grass runway. After touchdown, the pilot applied moderate braking force. After realising that the aircraft was not slowing, the pilot applied further braking. The aircraft failed to slow and the pilot confirmed the throttles were at idle and pumped the brakes. The aircraft continued to slide down the runway. As the aircraft approached the end of the runway, the pilot applied full left rudder to turn the aircraft which resulted in a slight veer to the left. The aircraft collided with an embankment at the end of the runway, passed over a road and coming to rest against a fence (Figure 1). The aircraft was substantially damaged, and the pilot was not injured.

Post-flight it was determined that the airfield had received significant rain within around 1 hour before the landing which may have resulted in aquaplaning^[2]. The pilot reported that flap was set at 30 degrees for landing, less than the maximum available of 40 degrees. Contributing factors to the overrun include;

• wet grass runway (with possible standing water)
• nil wind conditions
• selection of less than full flap
• touchdown one third down the runway.

Figure 1: Final resting position of the aircraft 

Source: Victoria Police

Safety message

Wet runways present a hazard as the braking ability of the aircraft may be limited, particularly if there is standing water. Pilots should familiarise themselves with the pilots operating handbook for their aircraft and make allowances for runway length, size, slope, construction and condition.

__________

1. Instrument flight rules (IFR): a set of regulations that permit the pilot to operate an aircraft 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.
2. Aquaplaning: occurs when a layer of water builds up between the tyres and the runway. This results in loss of traction, preventing effective braking and aircraft control.

What happened

On 18 May 2018, test flights were being conducted on an experimental category aircraft Spacewalker II at Denmark, Western Australia (WA). The first five flights were completed with a test pilot, to fine-tune details of the aircraft and to make engine adjustments.

At about 1300 Western Standard Time (WST), having previously completed two successful landings, on the third landing, the aircraft bounced and landed hard resulting in the landing gear collapsing and the aircraft veering off the runway. The aircraft sustained substantial damage to the propellers, landing gear, engine, engine mount and firewall (Figure 1).

The pilot advised that he typically had flown aircraft with the side stick on the left and the throttle in the right hand. The Spacewalker II aircraft has the side stick on the right and the throttle in the left hand. While he was aware of this issue, in the moment of the bounce, the pilot inadvertently pulled the throttle back and pushed the side stick forward. This resulted in the aircraft moving towards the ground rather than the intended action of conducting a missed approach.

Figure 1: The Spacewalker II post-accident 

Source: Owner

Safety action

As a result of this occurrence, the pilot has advised the ATSB that he is taking the following safety actions:

The pilot will conduct further training in similarly configured aircraft and will spend more ground time in the Spacewalker II aircraft cockpit simulating flight to build more control familiarity.

Safety message

This accident serves as a reminder for all pilots that aircraft have different flight characteristics and systems. Pilots may have many hours experience, but that experience may be specific to one aircraft type or configuration.  The ATSB research report AR-2012-035: Avoidable Accidents No. 6: Experience won't always save you highlights that good training, focussed preparation and a readiness for the unexpected has a significant part to play in preventing an accident.

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 6 March 2018, a Cessna 206 was being operated on a training flight from Mareeba, Queensland (Qld) to Dimbulah, Qld (Figure 1) with a student and instructor on board.

Figure 1: Map showing locality

At about 1045 Eastern Standard Time, as the aircraft was on approach to Dimbulah, with flaps selected to 20 degrees and at 80 knots, the flight crew heard a loud clunk. The flight crew thought that they may have struck a bird and discontinued the approach. They commenced climbing and found that they required significant right aileron to remain tracking straight. Once at a safe altitude, the crew raised the flaps in stages.

The crew diverted the aircraft to Mareeba to conduct a flapless straight-in approach. As the aircraft slowed during the landing roll, the flaps extended towards 20 degrees.

The operator inspected the aircraft and found several issues, including:

• failure of the synchronising rod at the rod-end
• disconnection of the transmission worm drive between the actuating tube and the collar
• damage to the preselect cable clamp
• damage to the right flap track
• failure of the right centre aft roller. 

Figure 2: Diagram showing position of synchronizing rod assembly on aircraft

The operator replaced the damaged parts. The operator then carried out a return to service flight. The flaps system cable tension was found to be low. Maintenance subsequently readjusted the cable tension.

Safety message

This incident highlights the importance of conducting a go-around if something unexpected occurs during an approach to land. The flight crew immediately conducted a go-around, which allowed them time to consider the implications of the technical failure and the opportunity to conduct a diversion to an airport where appropriate emergency response facilities were available if required.

About this report

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

What happened

On 28 March 2018, a Boeing 787-8 departed Bali, Indonesia on a scheduled passenger flight to Melbourne, Victoria (Vic.). After arrival in Melbourne, at about 0230 Eastern Standard Time, maintenance engineers were investigating a right engine anti-ice fault indication, when they discovered a cabin passenger blanket within the engine cowling (Figure 1).

Investigation by the operator found that maintenance had been performed in Bali prior to the aircraft returning to Australia, and five blankets from the passenger cabin had been used in place of correct personal protective equipment to prevent burn injuries to the engineers while maintenance was conducted. One of these blankets was inadvertently left on the engine after maintenance. The area in which the blanket was discovered was protected by fire suppressant, should it have been required.

Figure 1: Passenger blanket as found on engine

Safety message

This incident highlights the importance of maintenance personnel remaining vigilant in the conduct of their duties. There are a number of factors that can lead to errors occurring. The ATSB research report AR-2008-055, An Overview of Human Factors in Aviation Maintenance is available from the ATSB website.

Utilising an independent inspector may also minimise the possibility of items being missed upon the completion of maintenance.

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 May 2018, a Gippsland Aeronautics GA-8 Airvan departed Bundaberg, Queensland (Qld) for Hervey Bay, Qld. The pilot was the only occupant.

During cruise at 2,500 feet, the pilot recalled hearing a loud noise from the engine area and immediately after experienced airframe vibration. The pilot observed the engine instruments fluctuating and the engine running rough.

The aircraft lost airspeed and was unable to maintain altitude. The pilot elected to conduct a forced landing on Woodgate beach approximately 40 km SE of Bundaberg. The pilot completed a successful forced landing and was uninjured.

Engineering inspection

The post-flight inspection revealed the engine crankcase to be cracked adjacent to the number six cylinder. The operator replaced the engine and the aircraft returned to service.

Safety message

Following a complete engine failure, a forced landing is inevitable. For a partial power loss, pilots are faced with the decision as to whether to continue the flight or land immediately.

Pilots should:

• Conduct a thorough pre-flight and engine ground run to reduce the risk of a partial power loss occurring
• Plan their decision making for emergencies and abnormal situations prior to flight. ATSB investigations Engine failure involving Gippsland Aeronautics GA-8, VH-AJZ (AO-2011-125) and Partial engine failure involving a Gippsland Aeronautics GA-8, VH-FGN (AO-2015-123) highlight the importance of having thoroughly rehearsed emergency procedures.
• Constantly monitor engine instruments as they can provide early indication of a problem
• Take positive action and maintain aircraft control when conducting a forced landing until on the ground, while being aware of flare energy and aircraft stall speeds.

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 1250 Eastern Standard Time (EST), the pilot of a Piper PA-31 aircraft was preparing for departure on a freight charter flight from Moorabbin, Victoria (Vic.), to Wynyard, Tasmania (Tas.). Once lined up on the runway and cleared for take-off, the pilot advanced the throttle to the required settings, to stabilise the engines and check the temperatures and pressures, which were all in the normal operating range. The pilot released the brakes and commenced the take-off run. During the take-off, the aircraft yawed to the left and the pilot immediately closed the throttles and a rejected take-off was conducted. The pilot observed that the left propeller was stationary and therefore completed the shutdown procedure for the left engine. The pilot notified air traffic control and taxied to the parking area where the aircraft was shut down. The pilot observed fuel draining from the left engine for 5 to 10 minutes after both engines had been shut down. The engineers and the chief pilot were notified of the sequence of events.

Engineering inspections, ground and flight tests were carried out. No maintenance or mechanical issues could be identified which may have contributed to the power loss or fuel venting.

Safety message

This incident reinforces the importance of conducting a rejected take-off if any aircraft malfunctions or abnormalities are detected. In this instance, the pilot followed standard operating procedures to ensure a safe outcome was achieved. Decisive actions by the pilot ensured this emergency situation was contained safely before it could develop further.

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.