What happened

On 15 February 2018 at 1845 Eastern Daylight-saving Time (EDT), the pilot of a Zenith Zodiac 601 was conducting stall recovery training approximately 16 kilometres east of Temora Airport, New South Wales (NSW). At approximately 6,000 feet, during a stall recovery, a bag containing tie down equipment dislodged from its stored position. The bag subsequently broke through the canopy of the aircraft before grazing the rudder and falling to the ground.

The flight continued without further incident and the pilot landed the aircraft safely at Temora Airport. The aircraft operator informed that ATSB that the bag punched a hole, approximately 400 millimetres in diameter, in the canopy of the aircraft causing damage to the leading edge of the rudder.

Safety message

Prior to departure, it is important for pilots to ensure that all passengers, cargo and equipment are secure inside the aircraft. If the pilot is intending to undertake aerobatic flight or stall manoeuvres, they should always apply the HASELL^[1] checklist. The HASELL checklist is a mnemonic designed to ensure that:

• the aircraft has sufficient height for the manoeuvres
• the airframe can be configured correctly
• the cabin is secure with no loose articles that may move, even during violent or negative g manoeuvres
• the engine can be properly configured
• the location is acceptable, not over populated areas
• the pilot should keep a lookout for other traffic during the manoeuvres.

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. CASA Civil Aviation Advisory Publication Issue 155-1(0) Section 8.3

What happened

On 1 February 2018, the helicopter was operating a charter flight with one pilot and five passengers from Gold Coast Airport, Queensland (Qld).

At approximately 1300 Eastern Standard Time (EST), the pilot conducted visual checks of the seatbelts and doors, and the helicopter commenced its take-off, climbing to 500 ft. As the helicopter turned onto crosswind, the pilot detected a popping noise and turned around to see the main door was open. The pilot then slowed the helicopter to 80 knots and conducted a return to Gold Coast, Qld.

Post-flight, the passengers were disembarked, and the helicopter was inspected. The inspection revealed that the rear door window was missing, and the door was unable to be closed. It is suspected that the door was not correctly secured prior to the flight.

Safety message

It is important for flight crew and ground staff to ensure the security of doors during pre-flight checks. The risks of a door opening in-flight can result in pilot distraction, damage to the aircraft and objects falling from 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 10 February 2018, the pilot of an American Champion Aircraft 7GCBC was conducting solo circuit training at Orange, New South Wales (NSW), on the unrated cross runway 04, which has a grassed red clay surface.

At 0930 Eastern Daylight-saving Time (EDT), during a touch-and-go landing in gusty wind conditions, the aircraft landed hard and bounced. After the aircraft bounced a second time, the pilot applied power and attempted to go-around but during the initial climb, struck the airport perimeter fence.

The pilot sustained a minor bump on the head but was otherwise uninjured. The aircraft’s right wheel was torn off and there was damage to the right side of the tail and the right wingtip. The aircraft’s propeller was also bent.

Safety message

This incident highlights the importance of maintaining directional control when landing, particularly in gusty conditions. A Safety Alert produced by the National Transportation Safety Board in the United States, Stay Centred: Preventing Loss of Control During Landing, addresses this issue and directs pilots to other resources which provide guidance in conducting crosswind approaches and landings.

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 17 January 2018, at about 1320 Eastern Daylight-saving Time (EDT), a Hawker Beechcraft Corporation B200C was en-route to Essendon, Victoria (Vic.), with a pilot, flight paramedic and passenger on board. On passing through flight level (FL) 130,^[1] the flight paramedic advised that an oxygen mask had fallen from the stowed position. The cabin altitude indicator showed a positive rate of climb, with the indicator displaying 9,500 ft. Reducing cabin pressure confirmed the loss of pressurisation.

The pilot conducted the non-normal checklist and obtained a clearance from air traffic control to descend to 10,000 ft. As the aircraft levelled at 10,000 ft, the pilot observed that the cabin altitude was stable at 9,500 ft. The pilot followed the appropriate failure management procedures, however, none of these actions restored the pressurisation system to operational. The flight continued at 10,000 ft and landed without further incident at Essendon Airport.

Following the incident, the fault was confirmed during a ground run and the safety valve solenoid switch was replaced.

Safety message

This incident highlights the importance of flight crews maintaining awareness of all system states and being prepared to act. Quality training in failure management procedures assists in equipping crew members with the required knowledge to effectively respond to a time critical emergency.

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. 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 130 equates to 13,000 ft.

What happened

On 11 February 2018, at 1227 Eastern Daylight-saving Time (EDT), the crew of a Robinson R22 Beta helicopter were conducting flight training on the western grass area of Bankstown Airport, New South Wales (NSW). There were an instructor and a student on board. The weather at the time was fine with 15 knots of wind from the south-east gusting to 25 knots.

While practicing hover drills at 2–3 m above the ground, with the student at the controls, the helicopter commenced a yaw and started to spin anti-clockwise. The rate of rotation increased and the instructor took control of the helicopter, but was unable to arrest the spin. The helicopter impacted the ground, the tail boom separated and the skids were flattened. The instructor shut down the helicopter, and both crew members walked to the flight school. Both crew members sustained minor injuries.

Figure 1: Accident scene, indicating direction of rotation at time of impact.

Source: NSW Police Force

Safety message

Instructing ab-initio students in rotary wing flight is a complex task. The instructor must allow the student the experience of controlling the helicopter while moderating the student’s inputs in order to ensure controllability of the aircraft. Flight in gusty conditions increases difficulty for both the instructor and the student.

Wind gusting between 15 and 25 knots places the helicopter in and out of effective translational lift.^[1] Students may have trouble reconciling the effect of their inputs against movement created by the wind. Instructor workload increases as the student’s control inputs are likely to be larger and less predictable than those used in calm conditions.

CASA Australia and CAA New Zealand produced a Helicopter Flight Instructor Manual which describes hovering as requiring a high degree of coordination. It advises that hovering should not be taught until the student is competent in manipulation of flight controls in forward flight, climbing, descending and turning. The manual also advises to ‘keep a close watch on temperatures, pressures and wind velocity during prolonged hovering’.

While conducting flight training instructors should consider meteorological conditions and the limits of the student’s ability to manage them. Safety Notice SN-42 in the Robinson R22 Pilot’s Operating Handbook advises that ‘…pilots should be aware of conditions (a left crosswind, for example) that may require large or rapid pedal inputs’. To assist instructors, flying schools should publish policies to limit flight in unfavourable conditions and accommodate the competence of their students in varying weather conditions.

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. Effective Translational Lift (ETL) increases the efficiency of the rotor system and is achieved between 16 and 24 knots of wind. FAA Helicopter Flying Handbook Chapter 2

What happened

On 18 February 2018, an Airbus A320-232 departed Melbourne, Victoria (Vic.) on a scheduled passenger flight to Sydney, New South Wales (NSW). At about 0915 Eastern Daylight-saving Time (EDT), cabin crew were alerted to a fire in the cabin.

The cabin crew traced the source of the fire to three smartphone devices located in a passenger bag at row five. The crew subsequently discharged a fire extinguisher and followed the operator’s procedure for the management of a lithium battery fire. The fire was successfully extinguished, and the devices isolated in a container until the end of the flight.

Safety message

Personal electronic devices (PEDs) such as smartphones contain lithium batteries, which are classed as dangerous goods. The incidence of passenger smartphones resulting in fire on board aircraft has increased. The Civil Aviation Safety Authority (CASA) has published advice on the ‘Least wanted dangerous goods’ carried by passengers. Lost or damaged smartphones were identified as the number one hazardous item on passenger aircraft in 2017. Previous Australian Transport Safety Bureau (ATSB) investigations AO-2016-051 and AO-2016-066 provide further examples of incidents of passenger smartphones causing in-flight fires and smoke events.

This incident highlights the need for passengers to become familiar with the hazards associated with the carriage of personal electronic devices, in particular, the potential for fire if a device is damaged or overheated.

Fire on board aircraft is potentially catastrophic if not managed quickly and appropriately. It is important for operators to ensure crew receive training and are periodically tested in the management of lithium battery fires on board 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 18 January 2018, an Aero Commander 500-U departed Cobar, New South Wales (NSW), for Charleville, Queensland (Qld). Another aircraft, Mooney M20J, was also airborne at the same time, flying from Broken Hill, NSW, to Archerfield, Qld.

During cruise at 8,500 ft, the pilot of the 500-U observed traffic on their electronic flight bag (EFB) application in their 10 o’clock position at 10 NM. The EFB application indicated the traffic was within 200 ft of the 500-U’s altitude. The pilot of the 500-U reported that the application displayed the relative positions of the two aircraft remained constant and the distance between them was reducing.

The pilot of the 500-U initiated contact with the crew of the M20J, resulting in the M20J descending to 7,500 ft. Two minutes later, the 500-U pilot observed the M20J passing directly underneath, crossing their track at almost 90 degrees.

Airspace

The aircraft passed each other in Class G airspace. Class G airspace is non-controlled airspace in which IFR^[1] and VFR^[2] aircraft are permitted to operate without a clearance. There is no air traffic control separation service in Class G airspace.

Weather

The pilot of the 500-U reported that a grey haze prevented sighting the M20J until it passed directly underneath.

Safety message

This occurrence highlights the importance of following the altitude requirements for VFR flight (see Figure 1) in uncontrolled airspace. This is especially significant when considering the limitations discussed in the ATSB research report Limitations of the See-and-Avoid Principle.

Figure 1: Table of VFR cruising levels

Source: Aeronautical Information Publication Australia

It also highlights the importance of monitoring area frequency for potential traffic and that electronic aids can be used as a supplementary tool that may enhance maintaining situational awareness.

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. 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. Visual flight rules (VFR): a set of regulations that permit a pilot to operate an aircraft only in weather conditions generally clear enough to allow the pilot to see where the aircraft is going.

What happened

On 7 January 2018, at about 1327 Eastern Daylight-saving Time (EDT), a Fairchild Industries Inc. SA227-DC was conducting training exercises in the circuit area at Ballina, New South Wales, with two crew on board. While on the downwind leg of the circuit, the crew noticed the right engine fire warning light had illuminated on the warning panel. The warning light went out as the crew were about to commence the memory items required for an engine fire warning, and the approach and landing were completed normally.

After parking and shutting the aircraft down, the crew identified smoke stains on the cowls of the right engine. Further inspection revealed evidence of a fire on the upper rear section of the engine. The aircraft was subsequently grounded pending a maintenance inspection.

Maintenance engineers identified a fuel leak from the manifold had ignited resulting in damage to the fuel lines and associated fittings and controls in the immediate vicinity (Figure 1). All damaged parts were replaced and tested prior to the aircraft being returned to service.

Figure 1: Pictures of fire damaged components within the right engine bay

Safety action

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

Inspections have been completed on all aircraft in the fleet with no other potential fuel system faults identified.

Safety message

This incident highlights the importance of flight crews maintaining awareness of all system states and being prepared to act at the first sign of trouble. A fire during flight has the potential to rapidly propagate unless it is quickly identified and managed, and the aircraft landed at the earliest opportunity.

About this report

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

What happened

On 22 February 2018, a Piper PA-28R departed from a local aerodrome to travel to Sunshine Coast Airport, Queensland (Qld). The weather at the time included rain showers, low cloud and reduced visibility. Approaching the airport, the pilot progressively descended the aircraft to remain clear of cloud.

Air traffic control (ATC) advised the pilot that further adverse weather was approaching the airport and provided options to divert to a suitable landing area. The pilot elected to continue, arriving into the circuit at low level in deteriorating weather conditions.

ATC issued a ‘check gear down’ warning to the aircraft shortly before being unable to maintain visual contact with the aircraft in the circuit.^[1] Air traffic controllers further issued a ‘Safety Alert, Terrain’^[2] call as the aircraft manoeuvred to the north of the airport in the proximity of Mt Coolum (682ft). Air traffic control regained visual contact with the aircraft on short final.

The pilot reported that approaching the airport in the reduced visibility, he relied upon vertical visual contact with the ground to maintain his situational awareness when the horizontal visibility deteriorated. The pilot also stated that he was familiar with the local area and carried two Garmin GPS^[3] and two iPads with planning and navigation software.

Figure 1: Sunshine Coast Airport proximity to Mt Coolum, Qld

Source: Google Earth Pro Image 31 October 2017 with ATSB annotations

Visual Meteorological Conditions (VMC) requirements

Table 1: VMC criteria for aeroplanes below 3,000ft above mean sea level

Source: Aeronautical Information Publication (AIP) Australia: ENR 1.2-4 10 November 2016

Safety message

Pilots are encouraged to make conservative decisions when considering how forecast weather may affect their flight. If poor weather is encountered en-route, timely and conservative decision making may be critical to a safe outcome.

VFR^[4] pilots are also encouraged to familiarise themselves with the definition of VMC criteria, and carefully consider available options where forecast or actual conditions are such that continued flight in VMC cannot be assured.

The ATSB SafetyWatch highlights the broad safety concerns that come out of our investigation findings and from the occurrence data reported to us by industry.

Flying with reduced visual cues and Inflight decision making such as in this occurrence remains one of the ATSB’s major safety concerns.

Number 4 in the Avoidable Accident series published by the ATSB titled ‘Accidents involving pilots in Instrument Meteorological Conditions’ lists three key messages for pilots:

• Avoiding deteriorating weather or IMC^[5] requires thorough pre-flight planning, having alternate plans in case of an unexpected deterioration in the weather, and making timely decisions to turn back or divert.
• Pressing on into IMC conditions with no instrument rating carries a significant risk of severe spatial disorientation due to powerful and misleading orientation sensations in the absence of visual cues. Disorientation can affect any pilot, no matter what their level of experience.
• VFR pilots are encouraged to use a ‘personal minimums’ checklist to help control and manage flight risks through identifying risk factors that include marginal weather conditions.

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 standard path normally flown within 3nm (5.5 km) by aircraft when taking off and landing at an airport
2. Air traffic control will issue a ‘Safety Alert, Terrain’ to aircraft, when they become aware that an aircraft is in a situation that is considered to place it in an unsafe proximity to terrain along its intended flight path
3. Global Positioning System
4. Visual Flight Rules
5. Instrument meteorological conditions (IMC): weather conditions that require pilots to fly primarily by reference to instruments, and therefore under Instrument Flight Rules (IFR), rather than by outside visual reference. Typically, this means flying in cloud or limited visibility.

What happened

On 7 January 2018, the pilot of the Cessna 152 departed Jandakot, Western Australia (WA) to conduct aerobatics. The pilot was the only occupant.

At approximately 1412 Western Standard Time (WST) following an aerobatic-loop, the pilot applied power and the engine failed to accelerate. The pilot completed the emergency checklist, but the engine would not accelerate beyond 1900 RPM. The pilot searched for a suitable landing area, finding Lake Walyungup to be suitable. The pilot then made a PAN-PAN and later a MAYDAY radio transmission. The pilot conducted a successful forced landing on the dry surface of the lake.

The aircraft did not sustain any damage as a result of the landing. The post-flight inspection revealed the carburettor to be the cause of the failure. Metal contamination was detected in the carburettor which was likely disturbed during the aerobatics resulting in the partial engine failure. The source of the contaminants could not be identified.

Safety message

Simulated total loss of power and a subsequent practice forced landing is at the core of a pilot’s emergency training. However, data shows that for light single-engine aircraft a partial power loss is three times more likely to occur than a complete engine failure.

Following the partial engine failure, the pilot in this occurrence had to make important decisions in a short space of time, where to land and how to manage the remaining altitude. The ATSB’s publication and YouTube video ‘Managing partial power loss after take-off in single-engine aircraft’ is available on 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.