What happened

On 5 February 2018, a Boeing 717-200 was being prepared for a commercial passenger flight from Melbourne, Victoria (Vic.), to Hobart, Tasmania (Tas.). This was the third and final sector for this crew on the day. As the flight crew were programming the standard instrument departure (SID) into the flight management system (FMS), an incorrect runway was selected.

Air traffic control cleared the aircraft to take-off between two aircraft which arrived in close succession. During the initial climb, the flight crew identified the error before any deviations from the SID occurred. The flight crew manually selected the track required by the SID on the auto flight system. The flight crew subsequently corrected the error in the secondary flight plan and selected this plan as the primary plan in the FMS.

During the cruise, the performance figures for both runways were compared. It was determined that a longer runway was used for take-off than had been selected in the flight management system so there was no additional risk of a runway overrun.

Safety message

This incident highlights the importance of ensuring that the flight management system is programmed correctly for take-off. Ensuring that independent cross-checks are undertaken can reduce the risk that an aircraft attempts to take-off with incorrect performance data. Further information is available from the ATSB research report AR-2009-052, Take-off performance calculation and entry errors: A global perspective.

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 January 2018, the pilot of a Raytheon Hawker 850XP was conducting a check and training exercise from Bundaberg, Queensland (Qld) with three crew on board.

The aircraft arrived at Gladstone airport, Qld at about 1140 Eastern Standard Time (EST). Part of the exercise involved the practice of a one engine inoperative approach and landing in which the pilot inadvertently applied the right hand (RH) brakes causing both RH tyres to lock up and the anti-skid to cease functioning. The aircraft came to a stop and the pilot slowly taxied the aircraft clear of the runway. The anti-skid on this aeroplane does not have locked wheel protection.

The post-flight inspection revealed both RH main landing gear tyres deflated.

Safety action

As a result of this incident, the operator advises that the pilot was debriefed and has since completed simulator training in the Hawker recurrent simulator.

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 March 2018, at about 2018 Eastern Daylight-saving Time (EDT), a Fairchild SA-227-DC arrived at Essendon airport and taxied clear of the runway. During taxi, the flight crew noticed a smell and observed a smoke haze about halfway down the cabin. The aircraft was shut down and the crew and passengers evacuated the aircraft safely. Fire services were not required. Following exterior safety checks, the aircraft was towed to maintenance for investigation.

Following investigation of the aircraft’s air-conditioning system, it was discovered that the left cooling turbine was seized and unable to be rotated. Evidence of metal fragments were also found around the cooling turbine body. Significant damage to the turbine impeller was also observed due to contact within the cooling turbine housing (Figure 1).

Figure 1: Left cooling turbine impeller damage

Source: Aircraft operator annotated by ATSB

Safety message

Smoke and fumes can originate from any number of aircraft systems during any stage of aircraft operation. This incident highlights the effective flight crew management of maintaining awareness at all times and carrying out the actions required to ensure the situation was handled effectively, including the evacuation of the aircraft.

The joint CASA and ATSB research report AR-2013-213, An analysis of fumes and smoke events in Australian aviation, found that a majority of smoke and fumes events were minor in consequence and that they were generally managed appropriately by the flight crews.

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 30 March 2018, at about 1420 Eastern Daylight-saving Time (EDT), a SAAB 340B was en-route to Moruya, New South Wales (NSW), with three crew members and 10 passengers on board. During final approach, the pilot monitoring^[1] (PM) selected gear down. Immediately following, the crew received a hydraulic system caution indication. The “Hydraulic Light ON” requires the action of “Memory Items” and then the conduct of the “Abnormal Checklist”.

While conducting a holding pattern above Moruya airport, the flight crew carried out failure management procedures. The crew verified that the nose gear was down and locked but did not receive a down and locked indication for the main gear. The crew contacted operations to confirm the manufacturer’s recommended speeds for gear-down flight, and landing distance calculations for a zero-flap landing in Sydney. In consultation with the company emergency response team, they made the decision to divert the aircraft to this airport.

The PM declared a PAN PAN^[2] and advised air traffic control (ATC) that the aircraft required a landing on runway 16 at Sydney due to the crosswind on runway 07 and a long final approach. In addition, the crew advised that the aircraft would need to be shut down on the runway prior to being towed to the parking bay. The flight attendant was advised of the need for a precautionary cabin preparation.

On descent into Sydney, the flight crew extended the landing gear with the hand pump extension and received a down and locked indication. The flight crew subsequently obtained a clearance for a long final to ensure a stable approach, and completed a flapless landing. The aircraft was brought safely to a stop on the runway where it was shut down in accordance with standard operating procedures for a hydraulic malfunction and then towed to the bay.

Following the incident, engineering fault isolation identified a faulty relay in the hydraulic system. The relay was replaced in accordance with the aircraft maintenance manual, functional checks were carried out and the aircraft was returned to service.

Safety message

This incident highlights the importance of having experienced flight operations and engineering support staff to assist well-trained flight crew with making decisions in the event of a technical failure in-flight. Clear communication with ATC also resulted in a safe outcome.

About this report

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

__________

1. 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.
2. 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 1 March 2018, at about 0730 Eastern Daylight-saving Time (EDT), the flight crew of a Bombardier DHC-8-402 aircraft reported to engineering staff at Sydney, New South Wales (NSW), that a torch was missing from the flight deck. The engineering staff subsequently inspected the flight deck and found the torch behind the left-side rudder pedals. It was unknown as to how or when the torch moved from its usual position.

Safety message

This incident highlights the importance of not only ensuring unaccounted items are located, but loose items are secured to prevent interference with the aircraft’s controls.

ATSB investigation report AO-2017-108 (Foreign object damage involving Airbus A320) notes that the presence of foreign object debris poses a significant threat to aircraft safety and demonstrates the effect that foreign object debris can have on aircraft operations. Similarly, the National Aeronautics and Space Administration aviation safety reporting system provided an example of where a foreign object jammed the rudder pedals during a critical phase of flight (aviation safety reporting system report number 736444). While taking off, the left rudder pedal became jammed on a Regional Jet CRJ700 aircraft and the take-off was successfully rejected. The pilot reported that directional control was difficult, but maintained during the rejected take-off. The pilot subsequently found a small tissue box under the rudder pedal.

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 evening of 18 January 2018, a Diamond DA42 aircraft departed from Parafield Airport, South Australia (SA) on an IFR^[1] dual training flight.

At about 2104 Central Daylight-saving Time (CDT), the aircraft was maintaining 3,200 ft, 5 NM north-west of Parafield Airport when the crew received a DOOR OPEN annunciator on the primary flight display. The crew checked and secured the front canopy and observed the rear door to be in the unlocked position. With the student pilot flying, the instructor attempted to latch the rear door. During the attempt, the rear door opened abruptly and detached from the aircraft. The instructor took over control and conducted a return to Parafield Airport, SA.

It was determined that the crew omitted to check and secure the door in the pre-flight inspection, the before-start checks and the hold point checks. The door was observed to be closed and down; however, it was unlatched and therefore not secured.

The aircraft flight manual (AFM) (Figure 1) in-flight emergency procedure when a door opens, advises to reduce speed and land at the nearest aerodrome. The crew did not reference the AFM and attempted to shut the door in-flight resulting in the door opening and subsequently detaching from the aircraft.

The operator conducted a search, but was unable to locate the door.

Figure 1: Diamond DA42 Emergency Procedure for an open door

Source: Diamond Aircraft Industries Inc.

Related occurrences

A search of the ATSB database revealed a similar occurrence:

AO-2014-164

On the afternoon of 14 October 2014, the pilot/owner of an amateur-built Van’s Aircraft Inc. RV-6A aircraft, registered VH-JON and operated in the ‘experimental’ category, departed Moorabbin Airport, Victoria on a local flight.

Shortly after reaching a cruise altitude of 2,900 ft, the aircraft descended to 2,500 ft. After that time, no further air traffic control radar returns were received from the aircraft. The aircraft descended rapidly, and a witness reported observing objects falling from the aircraft. The aircraft subsequently collided with the ground next to a house in the suburb of Chelsea, 8 km south of Moorabbin. The pilot was fatally injured, and the aircraft was destroyed.

Following the accident, members of the public found a number of aviation-related items away from the accident site that belonged to the pilot.

The liberation of the items from the aircraft’s interior indicated that the canopy likely opened in‑flight. However, this was based on the assumption that the items were initially inside the cabin.

It was possible that the pilot was startled and distracted after the canopy opened due to the severe cockpit wind, noise and debris flying about. Though, the extent to which this contributed to the occurrence was unknown.

Also, while the ATSB was unable to determine how the canopy opening would have affected aircraft control, there were indications that the pilot was attempting to respond to the situation. However, for reasons undetermined, recovery did not occur.

Safety action

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

The Head of Operations issued an email reminding crew of the correct procedures of obtaining a visual confirmation of the door being latched and secured, and when a door becomes open in flight.

Safety message

This occurrence serves as a reminder for pilots to check the security of their aircraft’s doors prior to departure. When a door opens mid-flight the risks can result in distraction, damage to the aircraft, personal injury, and if it becomes detached; damage or injury on the ground. The incident also highlights the importance of referencing the flight manual during emergency procedures.

About this report

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

__________

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

What happened

On 18 January 2018, at 1400 Eastern Daylight-saving Time (EDT), a DJI Matrice 600 Pro hexacopter remotely piloted aircraft (RPA) was conducting a flight above Roseville Chase oval, New South Wales (NSW). During the return-to-home procedure, at a height of 20-25 m, the RPA contacted a pole and subsequently collided with terrain. It sustained damage beyond repair.

The pilot speculated that it is possible that the return-to-home height was not checked after the application was started. This caused the RPA to return to home at an unsafe height.

Safety message

This incident highlights the importance of following pre-flight procedures for remotely piloted aircraft to ensure that all flight parameters are set correctly.

Further information about flying a drone (RPA) safely can be found on the ATSB website, under the news item: Know your drone and the rules to fly safely.

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 February 2018, at 0917 Central Standard Time (CST), a Cessna 210M commenced its take-off run on runway 34 at Port Keats, Northern Territory (NT) for departure to Bathurst Island, NT. At this time, a Cessna 404 was also at Port Keats, taxiing to depart for Darwin, NT, from the same runway.

The 404 entered runway 34 while the 210 was in the take-off run resulting in the pilot of the 210 rejecting their take-off, stopping approximately 50 m from the 404. The 404 taxied clear of the runway and the 210 repositioned and departed without further incident.

The pilot of the 404 reported that while the 210 was taxiing for runway 34, they were awaiting traffic information from air traffic control (ATC). The pilot of the 404 made a taxi call on the Port Keats common traffic advisory frequency (CTAF) which the pilot of the 210 reported hearing prior to broadcasting that they were rolling for take-off. It was during this rolling broadcast that ATC contacted the pilot of the 404. This radio call required repeating of information twice due to transmission difficulties. As a result, the pilot of the 404 did not hear the pilot of the 210 making the rolling call.

Prior to entering runway 34, the pilot of the 404 reported scanning the circuit area, presuming the 210 had already departed. They reported that they had not focused on the runway environment during the scan.

Safety message

According to ATSB publication A pilot's guide to staying safe in the vicinity of non-controlled aerodromes (AR-2008-044(1)) and the associated research report Safety in the vicinity of non-towered aerodromes (AR-2008-044(2)), runway incursions are amongst the most common occurrences at non-towered aerodromes.

Both publications highlight common errors leading to conflicts in operations at or near non-towered aerodromes and strategies are discussed to assist pilots to ensure that safe operations are always maintained.

About this report

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

What happened

On 10 March 2018, at about 1600 Eastern Standard Time (EST), an Agusta AW139 helicopter was ground-taxiing to its parking area when it struck a maintenance work stand with the main rotor blades. At the time of the impact, the helicopter was being positioned short of the refuelling area to allow another aircraft to utilise it.

The helicopter was travelling at a slow walking pace when the impact occurred. The impact was felt as a vibration through the rotor system and had no effect on the fuselage or forward movement. The crew conducted a normal shutdown.

Post-flight, engineers inspected numerous components of the helicopter. Damage was isolated to the tip cap assemblies of the main rotor blades (Figure 1).

Figure 1: Damage to main rotor blades

Source: Owner

Safety message

Even when operating in familiar environments, flight crew need to remain vigilant for potential hazards in the area and maintain a good look out to ensure distances from obstacles are maintained.

About this report

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

What happened

On 19 March 2018, a Boeing 737-8 departed Brisbane, Queensland (Qld) on a scheduled passenger flight to Townsville, Qld. On descent, at about 2130 Eastern Standard Time (EST), cabin crew became aware of smoke emanating from a point of sale (POS) machine.

The cabin supervisor contacted the flight crew and relayed guidance obtained from the flight crew to the cabin crew member managing the event. The cabin crew subsequently removed, isolated and submerged the battery and the device in water. However, communication difficulties between the cabin supervisor and the cabin crew were experienced during the event.

Safety message

Fire and smoke on an aircraft can eventuate from a range of sources. As such, crew members must remain vigilant during all stages of flight to ensure that any situation that arises is handled effectively.

In addition to operational procedures, non-technical skills for cabin crew, such as crew communication and coordination are imperative in any abnormal or emergency situation. An example of effective crew coordination between flight and cabin crew can be found in previous ATSB investigation; Tailstrike involving Airbus A320, VH-VGF, at Melbourne Airport, Victoria on 11 May 2016. Operators are therefore reminded of the benefits of providing cabin crew with the opportunity to practice these skills. The International Civil Aviation Organization (ICAO) and the Civil Aviation Safety Authority (CASA) provide guidance in the Cabin Crew Safety Training Manual as well as Civil Aviation Advisory Publication (CAAP) SMS-3(1) Non-Technical Skills Training and Assessment for Regular Public Transport Operations.

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.