What happened

At about 0945 Eastern Standard Time on 20 September 2020, the pilot of a Robinson Helicopter Company R44 was conducting a 15-minute scenic flight from Archerfield Airport, Queensland with two passengers on board. The route flown departed Archerfield to the east, then headed north past the Brisbane CBD (B in Figure 1) before tracking south via Mount Coot-tha (A in Figure 1). The departure used a helicopter-only procedure known as a ‘University departure’ via the ‘Univat VFR Route’ (Figure 1) to remain clear of surrounding controlled airspace.

The R44 departed Archerfield at 1,000 ft and after passing the Brisbane CBD, climbed to 1,500 ft until reaching Mount Coot-tha. At Mount Coot-tha, the pilot conducted a descent to 1,000 ft as required by the Univat VFR route to remain clear of controlled airspace, and broadcast on the area frequency.

At about 1000, an Aerospatiale Industries AS350 departed Archerfield Airport for Mount Coot-tha via the published northern departure procedure. This procedure required aircraft to maintain 1,000 ft until reaching a VFR tracking point with the radio selected to the Archerfield Tower frequency until the control zone boundary. On reaching the boundary, the AS350 pilot conducted a slow climb and gentle turn towards Mount Coot-tha. Shortly after the AS350 commenced the turn, pilot of both helicopters reported seeing the other helicopter in close proximity on a converging track and immediately manoeuvred to avoid a collision.

The AS350 pilot reported, as the aircraft passed each other, Brisbane Centre made a broadcast on area frequency advising of a collision risk between two aircraft at Mount Coot-tha to which the pilot replied, confirming they were clear. Both pilots reported not hearing any calls from the other helicopter pilot and were probably on different frequencies prior to the proximity event.

Both helicopters were fitted with ADS-B traffic warning systems reported as serviceable and switched on, but neither pilot received a traffic alert. The pilots estimated the helicopters passed 50 m apart.

Figure 1: Archerfield arrivals and departures

Source: Google Earth, annotated by ATSB

Guidance material

The Civil Aviation Safety Authority (CASA) Visual Pilot Guides and online program, OnTrack, which provided recommended procedures for pilots operating in busy metropolitan airspace, are no longer available. However, CASA is developing large wall charts designed for flying schools in metropolitan areas, including Brisbane.

Airservices Australia safety publication Tips for flying at Archerfield details operating procedures and considerations when planning a flight. This supplements information provided in the Aeronautical Information Publication – En Route Supplement Australia section Archerfield – Flight procedures.

Safety action

As a result of this occurrence, the R44 operator has advised the ATSB that it has commenced a trial to make additional calls approaching outbound waypoints and to reverse the flight path flown on the scenic flights. This will keep their helicopters to the east of traffic tracking north to Mount Coot-tha.

Safety message

Archerfield is a busy control zone between Brisbane civil class C and Amberley military class C airspace. Published flight procedures facilitate aircraft movements and assist air traffic control co-ordinate local traffic.

Following a national review of class D airspace in 2010, aircraft operating under visual flight rules no longer need to use published inbound reporting points, provided two-way communication is established with the Tower prior to entry to the control zone. This allows aircraft to approach from any direction, which may result in conflict with traffic adhering to the recommended procedures. When there are multiple frequencies in use and traffic are operating close to control zone boundaries, this increases the likelihood of pilots being unaware of conflicting traffic.

The ATSB recommends pilots operate in accordance with published procedures wherever possible.

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 1 October 2020, an instructor and student pilot in a Robinson R22 helicopter were conducting exercises in the helicopter training area at Jandakot Airport, Western Australia. In the pre-flight brief, the plan for the flight was to conduct some revision circuits and then cover flight control emergency recovery procedures. Having completed the circuit revision portion of the flight, the instructor demonstrated and monitored the student successfully completing the first of the practice emergency procedures.

At about 1145 Western Standard Time, the instructor assessed that the wind had increased to about 20 kt and the conditions were therefore unsuitable to continue the lesson. The instructor informed the student that they would conclude the training at that point. The student lifted the helicopter into the hover in preparation to return to the parking area.

While hovering 3 ft above the ground, there was a momentary uncommanded yaw to the right and the instructor questioned the student as to the cause. The aircraft then commenced a further uncommanded and uncontrolled right yaw and the instructor took over the controls. The yaw continued and the helicopter rapidly went through 2 to 3 rotations. The instructor assessed that the situation was unrecoverable, closed the throttle and raised the collective^[1] to cushion the helicopter onto the ground. This resulted in a heavy landing and substantial damage to the airframe, however, no injuries to the student or instructor (Figure 1).

Figure 1: The helicopter in situ after the heavy landing

Source: Airport operator

Safety action

As a result of this occurrence, the operator has advised the ATSB that a staff safety meeting was conducted following the heavy landing incident and prior to resumption of flight training activities, with the focus on mitigating future risks during hovering operations. The instructor and student also completed additional training.

Safety message

This incident is a reminder for instructors to be aware of, and respond quickly to, situations that develop during training. These may be due to the student’s limited experience, decision-making, aircraft performance limitations or changing weather conditions, which pose risks to the safe conduct of the flight.

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. Collective: a primary helicopter flight control that simultaneously affects the pitch of all blades of a lifting rotor. Collective input is the main control for vertical velocity.

What happened

On 4 September 2020, the crew of a Diamond Industries DA 40 were on a dual training exercise and conducted a stop-and-go landing at Adelaide, South Australia. After landing, air traffic control (ATC) cleared the aircraft to taxi to reposition for take-off advising there was a Boeing 737 on the holding bay ahead of them. As the DA 40 approached the taxiway adjacent to the holding bay, the instructor noted the grass moving but continued as instructed.

The taxi clearance required the aircraft to make a left turn and as the crew initiated the turn, the aircraft entered the jet blast^[1] of the 737 (Figure 1). The instructor was unable to manoeuvre as required with differential braking^[2] and made the decision to attempt a turn to the right to exit the jet blast. Upon releasing the brakes and applying right rudder, the pilot reported the DA 40 abruptly turned to the right and the pilot then taxied back towards the runway.

The crew notified the controller they had lost rudder control and ATC responded that the jet was conducting 50 per cent power ground runs.

Figure 1: Location of jet blast

Source: Aerodrome diagram excerpt provided by operator and annotated by the ATSB

Jet blast and effect on controls

Many manufacturers provide information on predicted velocities and safe distances from jet engine exhausts. Figure 2 shows the predicted exhaust gas velocity using breakaway thrust power settings behind a 737-400 similar to the aircraft in the occurrence. It should, however, be noted that breakaway thrust is approximately 35 per cent power under normal circumstances and this aircraft was conducting maintenance ground runs using 50 per cent, meaning the exhaust velocity would be significantly greater than those indicated in this diagram. The DA 40 passed approximately 80 m behind the 737. At breakaway thrust, the DA 40 would be expected to encounter winds in excess of 30 kt, which is beyond the DA 40 maximum demonstrated crosswind limit of 20 kt. This contributed to the handling difficulties experienced while taxiing.

A review by the airside manager of Adelaide Airport found that the 737 maintenance ground runs were conducted in the appropriate location. The controller believed the level of power being used would not affect the DA 40 given the distance from the 737 and therefore there was no requirement to issue a caution to the DA 40 crew.

Figure 2: Predicted exhaust gas velocity for 737-400 aircraft

Source: Boeing annotated by the ATSB

Operator’s investigation

The operator conducted an investigation that included a review of radio transmission transcripts. Their investigation found that there was no advice or warning given to the DA 40 crew by ATC that the 737 was performing ground runs, or that these were being conducted at 50 per cent power. This was despite the controller being aware of the power setting be used. Although the pilot observed the grass moving along the taxiway, they took no action and it was determined that the crew were unfamiliar with the hazards associated with jet blast. The aircraft was exposed to the jet blast for approximately 1 minute.

Safety action

Airservices Australia advised the ATSB that the unit tower supervisor issued a ‘lessons learned’ to raise awareness of the event.

This was the first jet blast occurrence for the operator and as a result of this occurrence, the operator has advised the ATSB that it is taking the following safety actions:

• a review of theoretical training relating to identifying and managing jet blast
• a review of actions to be taken in the event of a jet blast occurrence including initial actions and inspections to be carried out by crew and maintenance personnel.

Safety message

This incident highlights the importance of situational awareness for pilots of smaller aircraft operating around larger aircraft. Jet blast is a hazard at all airports where high performance or transport category aircraft operate. While the risks are generally recognised within the ramp environment, jet blast can be encountered anywhere greater than idle power settings are used.

Avoiding a jet blast hazard requires pilots of light aircraft to be aware of the following:

• the potential danger area behind large jets
• the increased risk potential when aircraft may be about to move or use higher than idle power settings
• being attentive to, and taking cues from, indicators in the operational environment, such as wind socks and grass at the edge of a taxiway.

Notwithstanding the need for pilots’ situational awareness, ATC also needs to be aware of the effects of jet blast on light aircraft. When there is a specific hazard, the requirement for controllers regarding jet blast is detailed in the Manual of Air Traffic Services section 12.1.1.2. Airservices Australia Aeronautical Information Publication stated that ATC should provide a caution to the aircraft. Additionally, taxi clearances should facilitate movement of light aircraft away from jet blast hazards.

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. Jet blast: the hazard associated with the blast force generated behind a jet engine, especially at high engine power settings when taxiing, before and during take-off, and during engine maintenance activity.
2. Differential braking: The use of independent braking systems installed on the left and right wheels of an aircraft to assist in steering.

What happened

On 6 August 2020, the pilot of a Cessna 172RG was conducting a private flight under visual flight rules from Noosa Airport to Thangool Airport, Queensland.

The pilot had not previously landed at Thangool Airport and chose to overfly the airfield in order to observe the windsock and assess the crosswind for a landing on runway 28.^[1] The pilot perceived the windsock to indicate a steady but manageable crosswind that was consistent with the Thangool Airport aerodrome weather information service.^[2]

The aircraft then joined the circuit for a landing on runway 28. The pilot elected to cross the runway threshold slightly faster and higher than normal, to gauge the effect of the crosswind and conduct a go-around if necessary. During the flare, just prior to touching down, the pilot felt the aircraft encounter a strong gust of wind from the right. The pilot was unable to maintain control of the aircraft and it touched down heavily, veered left, and exited the left side of runway 28 (Figure 1). The pilot was the only occupant on board and was uninjured in the occurrence. The aircraft sustained substantial damage (Figure 2).

The recorded automatic weather for Thangool Airport, for the period 15 minutes before and after the occurrence, indicated a wind direction between 020–060° true, a wind speed between 7–11 kt, and wind gusts between 8–14 kt.

Based on the recorded wind direction, when landing on runway 28 with a 14 kt wind gust, the aircraft would have encountered a crosswind of 10–14 kt and a tailwind component of 0–9 kt. The aircraft’s maximum demonstrated crosswind was 15 kt.

The pilot had 46.5 hours of experience on the aircraft type and a total aeronautical experience of 141.2 hours.

Figure 1: Marks on the runway and grass leading to the aircraft’s final position

Source: Provided to the ATSB

Figure 2: Aircraft damage

Source: Provided to the ATSB

Safety action

As a result of this occurrence, the pilot advised the ATSB that they will pursue additional crosswind landing training.

Safety message

This occurrence highlights the importance of exercising caution when operating in conditions that have the potential to exceed the maximum demonstrated crosswind speed of an aircraft. It also illustrates the need for pilots to establish a personal minimums checklist that is commensurate with the flying experience of the individual. If the conditions do not meet these criteria, or if there is any doubt, pilots should not attempt the activity.

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]     Runway number: the number represents the magnetic heading of the runway. The magnetic variation at Thangool was 10° east.

[2]     Aerodrome weather information service (AWIS): actual weather conditions, provided via telephone or radio broadcast, from Bureau of Meteorology (BoM) automatic weather stations, or weather stations approved for that purpose by the BoM.

What happened

On 21 September 2020, two Cessna 208Bs departed Proserpine, Queensland, for scenic charter flights. The lead Cessna had one pilot and 12 passengers on board and the trailing Cessna had a pilot and 13 passengers on board.

After departing Proserpine, both aircraft climbed to 1,000 ft and began to track towards Hamilton Island. The pilots reported that they would normally transit the area between 1,500 ft and 2,000 ft, but elected to maintain 1,000 ft as the cloud base was at 1,500 ft. When 10 NM west-south-west of Hamilton Island Airport, the pilot of the lead Cessna broadcast on the Hamilton Island common traffic advisory frequency (CTAF) to advise their intentions to track via the northern tip of Dent Island and Hamilton Island at 1,000 ft for Whitehaven Beach (Figure 1). No replies were heard from any other aircraft in the area.

At approximately 0800 Eastern Standard Time, the lead Cessna was approaching the northern tip of Dent Island and a Eurocopter EC130 departed Hamilton Island Airport climbing to 1,000 ft for a ferry flight to Shute Harbour. The EC130 then turned left to track towards Shute Harbour. The pilot of the helicopter reported making entering runway, take-off and departure radio calls on the Hamilton Island CTAF but did not hear any replies. The helicopter pilot then sighted the lead Cessna on a crossing track at the same height. The pilot of the lead Cessna also sighted the helicopter.

Both pilots manoeuvred to avoid a collision. The two aircraft came into close proximity, with the lead Cessna passing under the EC130, resulting in an estimated separation of 50 ft vertically and 100 m horizontally.

Figure 1: Extract of Google Earth showing relevant positions

Source: Google Earth – annotated by ATSB

Safety message

Research for the ATSB report Safety in the vicinity of non-towered aerodromes (AR-2008-044) found that insufficient communication between pilots and breakdown of situational awareness were the most common causes of safety incidents near non-controlled aerodromes. The report advises pilots to avoid transiting circuit areas where possible and highlights the importance of transiting circuit areas at least 500 ft above circuit height to maintain vertical separation with departing aircraft.

Further information can be found at:

• A pilot's guide to staying safe in the vicinity of non-controlled aerodromes
• See and Avoid
• Limitations of the See-and-Avoid Principle
• Operations at non-controlled aerodromes

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 1 October 2020, at about 0800 Eastern Standard Time, the crew of a Jetstream 32 were preparing to depart from Canberra, Australian Capital Territory, on a scheduled passenger flight to Ballina, New South Wales. As the luggage was being loaded onto the aircraft, the captain observed smoke and fire emanating from a piece of baggage. The captain removed the baggage and aerodrome fire services were called to extinguish the fire. The source of the fire was determined to be an e-cigarette and battery pack, which had subsequently ignited.

Safety message

This incident highlights the importance of ensuring that all items taken on board an aircraft do not pose a safety risk to the flight. E-cigarettes can be taken in a passenger’s carry-on luggage, however, cannot be checked in. Spare batteries must also be taken as carry-on luggage only and be individually protected so as to prevent short circuits or by placing each battery in a separate plastic bag or protective pouch. More information regarding dangerous goods can be found on the CASA website, including the Can I pack that? dangerous goods app for passengers.

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 16 August 2020, at about 2145 Central Standard Time, a Bell 412 helicopter was conducting a medical retrieval from a farm in Lower Light, South Australia. The helicopter was to land at an unprepared helicopter landing site in an open paddock to the east of the house. As the approach was being conducted in near dark night conditions (8 per cent celestial illumination), the crew of the helicopter were in contact with the Country Fire Service (CFS) crew including a helicopter landing officer, who were at the site identifying any potential obstacles. The CFS crew identified wires running alongside the road next to the paddock, but no wires were observed in the paddock.

The helicopter crew were using night vision goggles and searchlights to assist with visibility. Additionally, the CFS vehicles  illuminated the landing spot. The pilot conducted two orbits of the area to allow the crew to identify possible obstacles around the landing site. The crew did not detect any obstacles and the pilot commenced descent. Passing approximately 50 ft above ground level, the pilot identified a single-wire earth return (SWER) wire running perpendicular to the approach path. After identifying the wire, the pilot announced ‘wires’ and conducted a right turn, subsequent approach and entered a hover to clear any obstacles. The crew used an appropriate approach profile that allowed an effective go-around procedure to be conducted.

Upon landing, it was identified the CFS crew had inadvertently set their vehicles and the lights directly below the SWER line. The power poles were obscured in trees and located approximately 350 m from the paddock’s border.

Safety action

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

• Highlighted the incident to company aircrew, noting the wire was detected on short finals at a profile that allowed for evasive action to take place.
• Highlighted to company aircrew that any helicopter landing site advice provided by external agencies is to be considered as ‘for information only’.
• Reviewed the crew flight safety training video and recency requirements for helicopter landing officers.

Safety message

Wires are difficult to sight and often in the most unexpected places in rural areas. The ATSB research report Avoidable Accidents No. 1 – Low level flying (AR-2009-041) provides information on wire hazards associated with flight below 500 ft.

Although extensive obstacle identification had taken place by both the crew of the helicopter and the CFS crew on the ground, this wire was unable to be sighted until the helicopter was on final approach. This occurrence highlights the importance of maintaining an awareness and lookout for powerlines during low-level operations. Property owners are also reminded that they can contact power companies to have wires marked if they present a hazard to low-level 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.

What happened

On 6 September 2020, a Beechcraft G36 departed Colina for a private flight to Lake Keepit, New South Wales. There was one pilot and five passengers on board.

On arrival at Lake Keepit, ground personnel advised the pilot that there was a glider and tow vehicle on the threshold of runway 14. They had been towed into place to prepare for departure in 30 minutes.

The aircraft then joined midfield crosswind for runway 14. During approach, the pilot became distracted by the glider and tow vehicle on the runway and forgot to complete the approach and landing checklist. As a result, the landing gear was not extended and the aircraft landed with the wheels retracted. The aircraft sustained minor damage to the underbelly and propeller (Figure 1).

Figure 1: Aircraft after landing

Source: The Gliding Federation of Australia

Safety message

This incident highlights the importance of managing distractions and being vigilant during critical phases of flight. Distractions can result in critical tasks being omitted and not being detected until it is too late.

Wheels-up landings are not uncommon; the Flight Safety Australia article, Those who won’t: avoiding gear-up landings includes valuable information to assist pilots in avoiding these incidents.

In addition to landing wheels up, the aircraft landed on an occupied runway. Pilots need to ensure the runway is clear before conducting an approach to land.

About this report

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

What happened

On 12 September 2020, the pilot of a Cessna 188 was conducting aerial application operations on a crop near Urana township, New South Wales. The pilot had just completed the final planned spray pass and, after observing a small amount of chemical remaining in the hopper, decided to spray the remainder in an extra pass. The selected run included two sets of known powerlines from the previous operation with a T-intersection running across the planned spray run (Figure 1). Another company aircraft was operating nearby and the pilot contacted them by radio to advise them of the change of plans and to organise separation. Approaching the run, the pilot identified the powerlines, and turned their attention to the other company aircraft to ensure separation for the run.

With their focus momentarily diverted, the pilot commenced an unplanned descent prior to the T-intersection in the wires. The pilot reported being aware of the crossing wire but did not observe the powerline prior to contact, striking the lines with the undercarriage gear legs. The wire-cutters fitted to the gear legs cut the first wire but were ineffective on the second wire with the aircraft decelerating rapidly and pitching towards the ground.

The aircraft collided with terrain in a level attitude, coming to rest in the paddock 70 m from the strike location and the pilot exited the aircraft uninjured. The aircraft was substantially damaged.

Figure 1: Flight path and powerline location

Source: Look up and live web application. Annotated by the ATSB.

Safety message

Wirestrikes pose an on-going hazard to aerial agricultural operations. Between 1 January 2015 and 12 September 2020, 154 wirestrike occurrences were reported to the Australian Transport Safety Bureau (ATSB). Of these, 102 strikes were recorded during aerial agricultural operations with 21 of the occurrences resulting in an accident. Previous research by the ATSB has shown that 63 per cent of pilots involved in a wirestrike accident were aware of the location of the wire before they struck it. (Aviation Research and Analysis Report – B2005/0055)

This accident highlights the dangers of distractions and last-minute change of plans, especially those made inflight during low-level operations. The ATSB has released, in association with the Aerial Agriculture Association of Australia, an educational booklet, Wirestrikes involving known wires: A manageable aerial agriculture hazard (AR-2011-028). This booklet contains numerous wirestrike accidents, the lessons learnt from them and suggestions to safely manage low-level flying Inflight decision making is one of the ATSB’s major safety concerns.

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 4 September 2020 at 1300 Eastern Standard Time, a pilot and instructor were conducting training in a Piper PA-31-325, 9 NM south of Cambridge, Tasmania. The instructor was training the pilot with a simulated engine fire, including engine shutdown, feathering of the propeller and cross feeding of fuel.

Once the simulated exercise began, the pilot worked through the checklist for securing an inoperative engine. The pilot completed the checklist, which included closing the firewall shut-off lever, closing the throttle and feathering the propeller. The pilot then began going through the stages of returning the aircraft to normal flight operations. While they were unfeathering the propeller, the revolutions per minute of the propeller unexpectedly accelerated and the pilot returned it back to the feathered stage. Engine power could not be restored, and the instructor made the decision to shut down the no.1 engine. The pilot suggested diverting the aircraft to Hobart. The instructor agreed and contacted air traffic control, declaring a PAN PAN^[1] before diverting the aircraft to Hobart. The aircraft landed safely and was met by engineers from the instructor’s company.

During the post-flight inspection, engineers discovered that the no.1 engine firewall shut-off lever was still in the closed position. When the training exercise was over, the firewall shut-off lever should have been in the open position. Because of this, the no.1 engine was unable to return to full power during the unfeathering procedure, which subsequently led to the in-flight engine shutdown.

Safety message

This incident highlights the importance of pilots having a good working knowledge of aircraft systems and checklists prior to practicing emergency procedures. In this instance, the checklist for unfeathering the engine did not include a check of the firewall shut-off lever. As a result, the firewall shut-off lever was left in the closed position, resulting in the loss of engine power.

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. 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.