What happened

On 16 April 2020 at about 1300 Eastern Standard Time, an ATR 42-300 was taxiing to park on the apron at Pormpuraaw Airport, Queensland (Figure 1). The pilot of the ATR was aware that a de Havilland DHC-8 was due to arrive and with this in mind, was manoeuvring the aircraft to allow sufficient clearance for the parking of both aircraft on the limited apron area available.

During the manoeuvre, the right wingtip contacted a frangible flood light pole situated on the perimeter of the apron. The light pole gave way as designed. Initial contact was with the aircraft’s right navigation light’s perspex cover which cracked and became dislodged. Upon further inspection, a small dent was also identified on the leading edge of the right aileron control horn.

Figure 1: Pormpuraaw Airport, Queensland

Source: Google Earth, annotated by the ATSB

Safety message

This incident reinforces the importance of maintaining situational awareness and a good lookout while taxiing, particularly in circumstances when the manoeuvring area available is restricted or confined by infrastructure or other obstacles.

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 27 March 2020 at around 1822 Eastern Daylight-saving Time, a Diamond DA 40 was being prepared for a training flight. There was a student and instructor on board.

During the pre-flight inspection, while the student was conducting the flight controls free and correct movement check, he observed abnormal elevator movement. The elevator required more force than usual to move, and was unable to be deflected through its full and normal operating range. The student notified the instructor of the issue, the flight was cancelled and the aircraft was deemed unserviceable.

Engineering inspection

The engineers removed the right pilot seat to examine the flight control mechanism. They found a plastic navigation ruler lodged within the elevator push rod mechanism, which was restricting the movement of the elevator. It was determined that the ruler fell between the seat and the centre console in the cockpit.

Figure 1: Navigation ruler lodged in elevator push rod mechanism

Source: Operator’s engineering department

Operator comments

It is important that Diamond DA 40 and DA 42 operators and pilots are alerted to the fact that items and equipment placed on the seat or between the seat and centre console can, in some instances, work their way down through the narrow gap between the inner seat edge and the centre console (Figure 2). This could allow thin items and equipment to find their way into the area under the seat which contains the elevator and aileron control push-rods.

Figure 2: Narrow gap between front seats and centre console

Source: Operator’s engineering department

Safety action

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

• Providing a briefing and the publication of photos to all instructors for awareness.
• Placing a renewed emphasis in pre-flight briefings to solo students on objects taken into and out of the aircraft, to reduce the instances of foreign object debris (FOD) being left in the cockpit.
• Requiring that all navigation equipment and similar items carried in aircraft be labelled with the owner's name. This will increase accountability and source tracing when FOD is located and help to ensure pilots place the aircraft unserviceable for a FOD inspection if an item is missing at the end of a flight.

Safety message

This incident highlights the importance of ensuring that all pre-flight checks and procedures are carried out comprehensively and systematically. It also serves as a reminder for flight crew to ensure that any misplaced or missing items from their flight bag be identified and located. If unable to locate any missing items, this information should be reported promptly so an aircraft inspection can be carried out.

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 2020, a Piper PA-44 Seminole was conducting a circuit assessment flight with a student and instructor on board, using runway 17L at Moorabbin Airport, Victoria. the instructor reported, the student had conducted three normal circuits to the required standard including the normal procedure of turning the fuel pumps off once above 500 ft AGL.

After the circuits, the instructor obtained a clearance from ATC to conduct asymmetric operations and planned to carry out a practice engine failure on the upwind leg of the circuit. As the aircraft climbed through 700 ft AGL, the instructor initiated the practice by announcing it and slowly closing the throttle on the right engine. The student carried out all the required initial actions, identifying that it was the right engine and verbalising the appropriate steps to secure the engine.

As the instructor then attempted to set a zero thrust power setting to complete the circuit, he identified that the aircraft was not performing as it normally would and was still yawing.^[1] Upon identifying the right engine was no longer running the instructor took over, feathered^[2] the right propeller, and continued a slow climb. Air Traffic Control was informed of the situation as the instructor continued in the circuit. Once established on downwind, the instructor found that both right engine magnetos were in the off position. Despite returning the magnetos to on and attempting a restart, it could not be achieved prior to landing. The aircraft subsequently landed without further incident. Once the aircraft was on the ground, the right engine was restarted normally.

Crew comments

During the debrief about the incident, I identified that the student had mistakenly turned the right engine’s magnetos off when the practice engine failure was initiated. It appears that the practice emergency had occurred as the student was preoccupied conducting the normal after take-off checks that include turning the fuel pumps off above 500 ft AGL. Under normal circumstances, this would be more readily noticeable as the yaw and noise reduction would immediately alert the crew to the error, however, in a less than zero thrust condition the loss of power from the right engine was not immediately identified. Once the mistake was identified, the propeller had been feathered and a restart in the circuit would have been difficult to achieve.

Figure 1: Cockpit layout of magneto and fuel pump switches

Source: Operator

Safety action

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

• All multi-engine instructors have been directed not to initiate a simulated engine failure while the student is preoccupied with other tasks and particularly when the after take-off checks are being carried out.
• Any simulated failure should be conducted either before or after take-off checks and comply with the minimum height restrictions.
• Fuel pumps are now to be turned off one at a time as a further way of mitigating the possible reoccurrence.

Safety message

This incident highlights the need for instructors to comprehensively pre-brief simulated emergency procedures noting potential errors, and closely monitor the actions of their student pilots when they are reacting in a high workload environment to any simulated 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.
__________

1. Yawing: the motion of an aircraft about its vertical or normal axis.
2. Feathering: the rotation of propeller blades to an edge-on angle to the airflow to minimise aircraft drag following an in-flight engine failure or shutdown.

What happened

On 22 March 2020 at about 1030 Western Standard Time, a privately chartered de Havilland DH-82 Tiger Moth commenced take-off for a local flight. As the aircraft became airborne, the aircraft’s attitude pitched up with the high take-off power setting and the pilot was unable to move the elevator control forward. The pilot performed a precautionary landing on the remaining available runway by adjusting power to control aircraft pitch attitude.

The aircraft was taxied back to the parking bay and secured. Upon examination, the pilot observed a hand-held inspection mirror lodged between the elevator control and the frame of the aircraft.

Figure 1: Hand-held inspection mirror lodged in elevator control

Source: Operator

Operator’s investigation

The mirror was not visible during a normal pilot pre-flight inspection and the elevator had full and free movement during both the pre-flight inspection and the pre-take-off checks. The operator concluded that the mirror was therefore inside the cockpit in a position not easily visible prior to the flight. It appeared to have moved during the take-off run into the position inhibiting elevator control.

The operator held a workshop safety briefing into the incident but was unable to confirm how the mirror got into the aircraft.

Safety message

This incident highlights the importance of effective tool control and ensuring any items that are unaccounted for are located. Loose items must also be secured to prevent interference with aircraft controls.

The presence of foreign object debris can pose a significant threat to aircraft safety and has the potential to result in damage during critical phases of 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.

What happened

On 22 February 2020 at 0900 Eastern Daylight-saving Time, a twin-engine Cessna 404 with three crew commenced its take‑off run on runway 17 at Essendon Airport, Victoria. During rotation^[1] the right engine fire extinguisher discharged without crew command.^[2] The crew reported hearing a loud ‘whoosh’ sound and an alert light in the cockpit illuminated indicating zero pressure in the right engine fire extinguisher. The crew continued the take-off and observed normal engine indications during the climb to 5,000 ft.

The crew discussed their situation and elected to conduct a return to Essendon Airport. To avoid an overweight landing, they decided to enter a holding pattern to burn off sufficient fuel. The crew contacted air traffic control (ATC) advising them of their decision and were directed to hold at a nearby waypoint.

About 20 minutes into the holding pattern, the crew detected a burning odour in the cockpit but no smoke was evident. The crew advised ATC of the smell and requested to cancel the holding pattern and land at Essendon Airport. ATC initiated an uncertainty phase (INCERFA)^[3] and cleared the aircraft for a straight-in approach to runway 26. The crew pulled the fire detection and extinguishing system circuit breakers, and the odour disappeared temporarily before returning during final approach. Shortly afterwards, a safe landing was completed after which ATC cancelled the INCERFA.

Engineering inspection

Engineers inspected the aircraft after landing and found that the fire extinguisher discharge button in the cockpit was faulty but the source of the odour could not be determined. After replacing the button and the discharged fire extinguisher, the aircraft returned to service.

Safety message

The unintended discharge of the engine fire extinguisher occurred during a critical phase of flight and was not covered by an emergency response procedure. However, the crew’s actions and decisions ensured that aircraft safety was maintained at all times.

Prompt decision making between crewmembers and communication with ATC is critical for timely and effective management of a potential in-flight 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.
__________

1. Rotation: the positive, nose-up, movement of an aircraft about the lateral (pitch) axis immediately before becoming airborne.
2. When the engine fire extinguishers are operating normally, only the crew can discharge them via a button in the cockpit.
3. Uncertainty phase (INCERFA): an emergency phase declared by the air traffic services (ATS) when uncertainty exists as to the safety of an aircraft and its occupants.

What happened

On 24 January 2020, a Cessna 182Q was conducting a private flight operating under visual flight rules from Warwick, Queensland, to Dubbo, New South Wales. The pilot was the only occupant on board. Forecast weather in the area at the time was low cloud and thunderstorms.

During cruise at 4,500 ft AMSL, the aircraft encountered severe turbulence at a speed above the aircraft’s turbulence penetration speed. The pilot conducted a climb and levelled off at 6,500 ft in an attempt to avoid further turbulence.

The pilot reported that the aircraft then encountered a severe updraft, resulting in a climb and change of heading of approximately 180° with little to no control of the aircraft. He began a descent to remain out of cloud. The pilot then descended through cloud to 3,500 ft and tracked away from the area, clear of any further cloud and turbulence. While attempting to turn back onto heading, the aircraft was struck by a severe downdraft followed by an updraft, resulting in another heading reversal of approximately 180°.

During the post-flight inspection at Dubbo, it was identified that both wings near the wing strut were bent and warped with visible deformation.

Safety message

This occurrence provides a reminder that pilots need to be aware of their aircraft’s performance and turbulence penetration speed as turbulence can be unpredictable. Should an aircraft encounter severe turbulence, pilots are reminded to reduce the speed of the aircraft to safely navigate through the turbulence in order to avoid potential damage or loss of control.

Further information can be found in the ATSB research report, Staying safe against in-flight turbulence (AR-2008-034).

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 January 2020, a Boeing 737-800 departed Brisbane, Queensland for a commercial passenger flight to Melbourne, Victoria. There were 6 crew and 178 passengers on board.

Passing FL 250 on climb near Gold Coast Airport, Queensland, a cabin crew member advised the flight crew that a passenger alerted them to a panel hanging off the rear of the aircraft’s left wing. The flight crew requested that the cabin crew further investigate, and discontinued the climb and levelled off at FL 300.

The cabin crew subsequently showed pictures to the flight crew of the dislodged panel on the trailing edge flap area of the left wing. The crew then contacted air traffic control and requested a clearance to descend and return to Brisbane. The aircraft landed without incident and taxied to the gate.

Engineering inspection

Following the incident, the engineering inspection revealed that the inboard trailing edge flap on the left wing had delaminated (Figure 1). The engineers determined that the delamination was due to moisture ingress and excess heat from the engine exhaust.

Figure 1: Delaminated section on the aircraft’s left wing

Source: Operator’s engineering department

Figure 2: Diagram of trailing edge assembly

Source: Operator’s engineering department

Safety action

As a result of this incident, the manufacturer and operator have advised the ATSB that they are taking the following ongoing safety actions:

Manufacturer

• Boeing will be supplying a modified metallic assembly to be installed on aircraft.

Operator

• The operator conducted a fleet inspection of its aircraft aged 10 years old or older and found 7 other aircraft had delamination findings recorded. Due to delamination findings, the inspection program was expanded to flaps on aircraft 6 years old or older, to identify potential early defects on younger aircraft.
• A full damage analysis of the completed inspections and expanded program will support the determination of an effective threshold interval for introducing scheduled inspections via a new aircraft maintenance program task.
• Introduction of a modification program to replace the composite bonded assembly wedge with a new design metallic semi-monolithic assembly (Figure 3).

Figure 3: Diagram of new metallic semi-monolithic assembly for trailing edge flap

Source: Operator’s engineering department

Safety message

This incident provides a reminder that although flight crews conduct extensive pre-flight inspections, unexpected failures may still occur in flight. In this situation, the flight crew took all possible precautions by following the relevant procedures, conducting additional checks to assess the situation, providing clear communications to ATC and returning the aircraft 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 14 January 2020 at 1650 Eastern Daylight-saving Time, a Beech 58 Baron was conducting a community service flight from Inverell Airport, New South Wales to Maitland Airport, New South Wales, with a pilot and two passengers on board.

The aircraft overflew the airport and joined the circuit for runway 23. The pilot reported that there were no kangaroos observed during the overfly.

While flaring to land, a mob of kangaroos was sighted by the pilot to the left of the runway with one kangaroo subsequently entering the runway and contacting the aircraft’s nose landing gear. The nose gear collapsed, and the aircraft skidded along the runway for approximately 150 metres. While the aircraft continued down the runway, the pilot shut down the engines and selected fuel to off. The aircraft came to a stop and the pilot secured the aircraft before evacuating all occupants via the rear doors.

The pilot and passengers were uninjured, and the aircraft sustained damage to the nose landing gear, propellers and lower fuselage.

Figure 1: The aircraft post kangaroo strike

Source: NSW Police, digitally altered by the ATSB to remove the aircraft registration as occurrence briefs are de-identified.

Safety message

Airservices Australia’s En Route Supplement Australia (ERSA) entry for Maitland specifies that significant animal (kangaroo) hazard exists at this airport.

Kangaroos are among the ground-based animals that are most frequently struck by aircraft, as found in the ATSB report, Australian aviation wildlife strike statistics (AR-2018-035). Due to their size and unpredictable behaviour, they pose a serious safety risk for aircraft. Pilots should mitigate this risk as best they can by maintaining adequate situational awareness, particularly when operating at regional strips known for significant wildlife 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.

What happened

On 4 February 2020 at 0945 Eastern Daylight-saving Time, a Bombardier DHC-8 was conducting a precision runway monitor (PRM) approach^[1] to runway 16L at Sydney Airport, New South Wales. The scheduled passenger service comprised of a training captain as pilot monitoring, a first officer undergoing line training as the pilot flying, and a safety pilot. The aircraft was operating in visual meteorological conditions.

During the approach, with another aircraft also on approach to the parallel runway, the aircraft deviated from the runway centreline and the training captain instructed the first officer to re-establish the approach path. At this time, the safety pilot alerted the captain to select the additional PRM frequency to be monitored, as dual VHF is required during PRM operations.

ATC observed the DHC-8 to be within the no transgression zone (NTZ), which is a 610 m-wide safety buffer between the parallel approaches. The controller issued the aircraft with break-out instructions, in order to abort the approach. However, the aircraft continued the approach. It was later determined that the crew had inadvertently delayed selecting the additional PRM frequency and therefore did not hear the break-out instructions issued by ATC.

Safety message

This incident highlights the importance of effective crew resource management and adherence to standard operating procedures, particularly during phases of high workload when vulnerability to error is increased.

Further information on PRM operations can be found on the Airservices Australia 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. During periods of the day with peak arrival demand and inclement weather, capacity at Sydney Airport can be maintained with the use of PRM operations. A highly accurate surveillance system allows ATC to precisely monitor aircraft tracking on their approach paths and permit independent visual approaches.

What happened

On 3 January 2020, a Cessna 501 Citation was conducting a private flight with a single pilot and seven passengers from Merimbula, New South Wales to Moorabbin, Victoria. During the instrument approach to runway 35 at Moorabbin in low visibility conditions due to smoke, the pilot became visual with the runway environment at approximately 500 ft. The pilot reported that the aircraft was slightly high and fast compared to the normal landing profile but decided to continue with the landing.

The aircraft touched down past the normal landing point and at a higher than normal speed. Despite the application of maximum braking, the aircraft overran the end of the runway by approximately 20 metres. There were no injuries to the pilot or passengers. The aircraft sustained minor damage.

Pilot comments

In hindsight, my decision should have been to conduct a missed approach and proceed to my planned alternate where the weather was better.

Figure 1: Skid marks on the runway end leading to where the aircraft came to a stop.

Source: Supplied

Figure 2: Skid marks on the runway end into the grass.

Source: Supplied

Safety action

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

• conducting a comprehensive debrief and review of the occurrence with their instructor
• undertaking further briefing and remedial training, concentrating on decision-making.

Safety message

This incident highlights the need for pilots to have a personal approach minimums checklist including clearly defined unstable approach criteria. If the approach does not meet these criteria or if there is any doubt, pilots should conduct a go-around.

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. One of the safety concerns is inflight decision making.

About this report

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