What happened

On 14 August 2019 at approximately 1500 Eastern Standard Time, an Aeroprakt 32 was conducting a training flight from Moorabbin Airport, Victoria, with an instructor and a student on board.

During the take-off run, the crew detected that the airspeed indicator (ASI) was indicating zero and subsequently rejected the take-off. The aircraft then taxied off the runway.

Following the incident, an engineering inspection was carried out. It was determined that the pitot tube was blocked, likely from water. A blocked pitot tube affected the accuracy of the ASI, resulting in fluctuating or zero speed indications.

A test flight was subsequently conducted, and the aircraft was returned to service.

Safety action

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

• ensuring all aircraft are allocated pitot tube covers
• issuing a safety reminder to all pilots to fit pitot tube covers after all flights and report if a pitot tube cover is missing.

Safety message

This occurrence highlights the importance of pre-flight checks, as well as the use of pitot tube covers to minimise the risk of the aircraft departing with an unserviceability. Pitot tube covers are designed to prevent foreign objects from entering the pitot tube while the aircraft is stationary.

It also serves as a reminder to be aware of unreliable or erroneous airspeed indications during the take-off run. If detected and it is safe to do so, abort the take-off.

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 July 2019, the pilot of a Piper PA-28 was conducting a private flight from Jandakot to Meekatharra, Western Australia.

During the flight, the pilot identified that the fuel in the left-hand tank was lower than, and being consumed at, a greater rate than expected. Shortly after, the engine failed and due to the remote location of the aircraft, the pilot advised that he declared a MAYDAY^[1] to air traffic control. The pilot commenced troubleshooting as per the aircraft’s flight manual to attempt to resolve the engine issue. After changing the fuel selector and activating the fuel pump, power was restored to the engine.

Rather than proceed with the planned flight, the pilot diverted and landed the aircraft to Paynes Find Airport for further assessment. There were no reported injuries or damage to the aircraft.

A post-flight inspection revealed that the left-hand fuel drain was not in the fully closed position leading to fuel leaking from the left tank.

Safety message

If an engine fails or runs rough due to fuel starvation, changing the selected tanks should restore power but may take some time to take effect. In this incident, after engine power was restored, the pilot assessed the situation and elected to land the aircraft as soon as possible for inspection, to ensure the safety of the aircraft and its occupants.

Fuel starvation continues to be a common cause of engine failures. More information can be found in the ATSB report, Starved and exhausted: Fuel management aviation accidents, which highlights key messages about accurate fuel management and keeping fuel supplied to the engines.

This incident also highlights the importance of thorough pre-flight inspections to ensure the aircraft is safe for flight. This includes confirming that fuel drains are correctly closed after fuel sampling.

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. MAYDAY: an internationally recognised radio call announcing a distress condition where an aircraft or its occupants are being threatened by serious and/or imminent danger and the flight crew require immediate assistance.

What happened

On the afternoon of 30 July 2019, a local pilot and owner of a DR-107 One Design amateur-built aircraft^[1] commenced flying activities at Narromine Airport, New South Wales. At about 1415 Eastern Standard Time, while conducting aerobatics, the pilot experienced degraded rudder control. The pilot elected to land immediately on runway 22. On landing, the left rudder pedal/cable mechanism collapsed, the aircraft veered to the right of the runway and ground looped,^[2] colliding with a nearby gable marker. The pilot sustained minor injuries, and the aircraft was substantially damaged.

Post-Accident Inspection

Immediately following the accident, the aircraft owner conducted a detailed inspection of the left rudder pedal assembly, including the rudder cable, pedal and the surrounding areas for damage. The pilot discovered that the nut and bolt (with split pin) fastener, connecting the left rudder pedal to the rudder cable, had failed (Figure 1). The left rudder pedal was extended to the maximum forward position (Figure 2). The subsequent walk-around inspection identified additional external damage to the lower side of the forward fuselage, the left-wing tip and the left landing gear.

Figure 1: Left rudder pedal assembly – looking forward

Source: Aircraft owner & pilot

Figure 2: Expanded view – underneath left-hand side heel/foot rest

Source: Aircraft owner & pilot

Safety message

In this incident, the pilot recognised a potential flight control failure while inflight, and successfully recovered the aircraft to the ground as soon as he was able. Aerobatic flying can produce significant stress to flight control mechanisms. This occurrence reinforces the need to complete a diligent pre-flight inspection of all visible flight control components/attachment points, and to act promptly, yet conservatively in the event of any flight control malfunction.

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. Amateur-built aircraft: an aircraft, the major portion of which; has been fabricated and assembled by a person, or persons who undertook the construction project solely for their own education or recreation.
2. Ground-loop: a violent, uncontrolled horizontal rotation of an aircraft while landing, taking off, or taxiing.

What happened

On the morning of 18 June 2019, the pilot of a de Havilland DHC-2 aircraft was conducting a charter flight with three passengers on board. The flight departed from Proserpine, Queensland and planned to land near the Great Barrier Reef before returning to Proserpine. During cruise, the pilot observed a thick, clear substance coating the windscreen but at the time believed it to be cleaning fluid.

As the aircraft approached the landing point, the pilot had trouble seeing the buoys in the water due to the substance and conducted a go-around. At this point, the pilot realised the substance was in fact engine oil and began conducting checks to ensure performance was not compromised, climbing the aircraft to 4,500 ft. The pilot checked the oil dipstick, noting the aircraft was losing oil at a low to moderate rate. Knowing that he had three litres of additional oil carried in the aircraft, he conducted a diversion to Shute Harbour, observing the engine gauges at all times. Once closer to the mainland, he added the remaining oil to the engine and landed without further incident at Shute Harbour.

Engineering Inspection

The engineering inspection revealed that two studs holding the no. 9 cylinder to the engine case were missing and multiple others were loose, resulting in oil spilling from the bottom of the cylinder. The operator advised that an engineering inspection was conducted four days prior to the incident, with no issues identified.

About this report

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

What happened

On 11 June 2019, a Cessna 150M departed Lismore, New South Wales to conduct a training flight. There was an instructor and a student on board.

The student was conducting a practice glide approach to runway 15 at Lismore when the aircraft’s approach profile became too low. The instructor took over control of the aircraft to correct the profile, however, was unable to do so in time resulting in the wheel spat colliding with the airport’s perimeter fence. The aircraft sustained minor damage.

Safety message

During training flights, instructors need to be vigilant and prepared to take over control of the aircraft at short notice. When conducting practice glide approaches, correct speed and approach profile need to be maintained, as power is not used. If the approach is too low and intervention is delayed, there is an increased risk of the aircraft colliding with 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 8 July 2019, at about 1800 Eastern Standard Time, a Fairchild Industries SA227-AC departed Coffs Harbour, New South Wales (NSW) to conduct a charter freight flight to Port Macquarie, NSW. The pilot was the only occupant on board.

During cruise at 9,000 ft, approximately 37 km south of Coffs Harbour, the pilot noticed the right engine fire warning lights had illuminated on the warning panel and immediately commenced the memory items required for an engine fire warning. The pilot shut down the right engine, feathered^[1] the propeller to reduce drag and shortly after, the engine fire warning lights extinguished. The pilot then conducted a return to Coffs Harbour.

After landing, the aircraft was taxied to the parking bay and shut down. Fire services attended and conducted a heat test on the right engine using heat-sensing cameras. No excessive heat was recorded. The pilot then opened up the engine nacelle^[2] to visually inspect the engine. The inspection did not detect any heat damage.

Engineering inspection

The engineering inspection did not reveal any faults with the engine. The fire detector was repositioned with better clearance from surrounding assemblies. The operator has advised that they will be undertaking a feasibility assessment of an enhanced engine wiring harness replacement program.

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. Although there was no in-flight fire in this incident, the crew followed procedures and commenced memory items for the fire warning ensuring 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. 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.
2. Nacelle: a housing, separate from the fuselage that holds engines, fuel, or equipment on an aircraft.

What happened

On 3 February 2019 at 2245 Central Standard Time, a Gates Learjet Corp 35A was operating a medevac^[1] flight with two crew and four passengers on board from Darwin, Northern Territory to Adelaide, South Australia.

During the take-off run, the crew noticed a moderate shimmy in the right hand main wheel resulting in the aircraft slightly veering to the right of the runway. The crew suspected a blown tyre; however, as there were no abnormal indications they elected to continue to Adelaide.

While en route to Adelaide, the crew were notified by Air Traffic Control that rubber tyre and metal fragments had been recovered from the runway in Darwin. The crew then requested a local standby^[2] for their arrival into Adelaide.

At 0150 Central Daylight-saving Time, the aircraft landed safely at Adelaide Airport with aviation rescue and firefighting teams in attendance.

Upon landing it was found that both the right hand tyres had blown and damage was sustained to the aircraft’s right wheel and brake assemblies (Figure 1) and to the right flap (Figure 2).

The operator suspects that the cause of the blown tyres was due to foreign object debris (FOD) on the runway at Darwin. However, Darwin Airport did not find any FOD apart from tyre debris.

Figure 1: Damage to the right main landing gear and fuselage

Source: Adelaide Airport

Figure 2: Damage to the right flap

Source: Adelaide Airport

Safety message

This occurrence highlights the importance of communicating any suspected FOD, including a blown tyre, to airport authorities to ensure that a runway inspection is carried out in a timely matter. Boeing, in Foreign Object Debris and Damage Prevention, estimate that FOD damage costs the aviation industry $4 billion per year.

All aerodromes are encouraged to have an active FOD management program in place. Aerodrome staff and pilots are reminded to keep an active lookout and retrieve any identified FOD before it becomes a hazard.

Further information about FOD management at aerodromes can be found on the Australian Airports Association website, Foreign object debris.

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. Medevac by ambulance aircraft. Medical evacuation, or medevac, is the transportation of seriously ill patients by air.
2. Local standby: declared when only airport-based agencies are required in the AEP (e.g. the on-airport Rescue and Fire Fighting Service and the Aerodrome Safety Officer). A Local Standby will be the normal response when an aircraft approaching an airport is known or is suspected to have developed some defect, but the trouble would not normally involve any serious difficulty in effecting a safe landing (This generally equates to a PAN PAN).

What happened

On 3 June 2019, an Avro RJ100 departed for a commercial passenger flight from Port Augusta to Adelaide, South Australia. During approach into Adelaide, performance data and speeds were entered into the flight management system (FMS). The configuration selected for this particular approach was a flap 24 landing, due to the aircraft’s low landing weight. While conducting the approach, the crew observed that the speed was too low for a flap 24 approach and received an amber speed indication. The crew subsequently adjusted the speed setting.

After landing, the crew identified that incorrect data was entered into the FMS. Specifically, a flap 33 landing was selected, resulting in a lower approach speed. When entering the data into the FMS, standard operating procedures dictated that both crewmembers needed to crosscheck the performance data to ensure that it is correct prior to executing. In this instance, neither crew member crosschecked the data that was entered. The crew reported multiple contributing factors relating to this incident, including fatigue at the end of a long duty day, low arousal levels due to benign conditions and expectation bias as a flap 33 landing was used for all previous sectors that day.

Safety message

This incident highlights the importance of ensuring that the FMS is programmed correctly for all phases of flight, in particular critical phases, to reduce the risk of an aircraft approaching and landing with incorrect performance data. It also provides a reminder for crewmembers to monitor with each other during the flight to identify any potential decline in performance levels or alertness.

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 April 2019 at 1300 Central Standard Time, the pilot of a Cessna 210L aircraft was conducting a chartered passenger flight between Tindal and Hodgson Downs, Northern Territory.

Once established in the circuit area at Hodgson Downs, the landing gear was selected down as the aircraft manoeuvred to land. The pilot confirmed that the gear was down by visually checking the undercarriage was extending, hearing that the gear pump had stopped and identifying three green lights indicating gear down. The pilot continued the approach and completed the pre-landing checks, which included checking the landing gear again on final.

The landing roll felt normal until the aircraft slowed and more weight was applied to the landing gear, at which point the aircraft began to yaw to the right. The yaw was countered with rudder input, however the aircraft continued to yaw right and veered off the runway, coming to rest inside the flight strip.

Once the aircraft was shut down and secured, the pilot evacuated the passengers safely. No one was injured, however the aircraft sustained substantial damage.

Figure 1: Damage sustained to the aircraft after landing

Source: Operator

Engineering Inspection

The engineering inspection revealed one of the gear down indication switches was jammed in the closed position. On L-model Cessna 210 aircraft, when all three switches (left main, right main and nose) are closed, the gear down light is illuminated and the gear pump will stop. Upon further inspection, it appeared the switch was jamming intermittently.

During this incident, the pilot reported that he had lowered the landing gear, completed all checks as appropriate and received three green undercarriage lights. It appeared from the visual check at the time of lowering that the gear was down and locked. It is likely that the left main gear and the nose gear locked before the right main gear, however due to the right main gear switch being stuck in the closed position, the light illuminated and the pump stopped before the right main gear had fully locked in the down position.

Safety action

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

The incident has been examined and debriefed with the pilot and company’s training captains.

A company-wide memo was released regarding the importance of the visual undercarriage checks on final approach. As part of ongoing updates to the company flight crew operating manual, a revised final approach procedure has been included to clearly specify that visual gear checks must be conducted on final approach as part of the ‘UNDERCARRIAGE’ item on the checklist.

Safety message

This incident highlights the importance of pilots being familiar with all aircraft systems. This allows them to be aware of the possible effects of the failure of an interacting or interrelated component in those systems and provides them with a greater understanding of the aircraft’s operation in both normal and emergency situations.

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 3 May 2019, a Cirrus SR20 departed Moorabbin, Victoria (Vic.) with one pilot and two passengers on board. The pilot hired the aircraft from an operator for a private scenic flight that was planned to orbit Melbourne city before landing at Tooradin, Vic. During the initial stages of landing, the pilot observed the aircraft to be slightly high before it sank heavily onto the runway and bounced. After the second bounce, the pilot applied full power and retracted the flaps to conduct a go-around.

The aircraft yawed to the left and the pilot observed the indicated airspeed to be at 65 kt. The pilot received a stall warning annunciation and assessed that the aircraft had become airborne, and she therefore elected to pitch the nose of the aircraft down to land on the remaining runway. However, the aircraft rolled abruptly to the left and the wing struck the ground. The aircraft then collided with a drainage ditch to the left of the runway and was subsequently destroyed (Figure 1). The pilot and passengers exited without injury.

Operator’s investigation

The operator retrieved and reviewed the data from this private-hire flight and confirmed from the position of the flap transmission worm drive that, during the go-around procedure when full power was applied, the flaps were fully retracted. The pilot operating handbook recommends 50 per cent and indicates approximately 10 kt increase in stall speed from flaps 100 to zero per cent.

The data revealed that upon application of full power, a change of track of 15 degrees to the left of the runway resulting in the aircraft exiting the runway onto soft ground. The aircraft continued to diverge from the runway until it contacted the drainage ditch where it came to rest. The main landing gear tyre tracks were evident in the grass from the runway edge to the accident site, therefore confirming that contrary to the pilot’s recollection of events, the aircraft did not become airborne following execution of the go-around.

The operator advised that upon reviewing the data, it became apparent that during final approach, the pilot was pitching to control airspeed. The pilot reported that she used both power and elevator to land the aircraft.

Figure 1: Aircraft damage

Source: Operator

Safety action

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

• teaching pilots the correct go-around technique in this aircraft type from a low airspeed situation, such as after a significant bounce or a series of bounces, which requires right rudder pressure to counteract torque roll and p-factor^[1]
• highlighting this situation to pilots during conversion training, in line with recommendations from the manufacturer.

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. P-factor, also known as asymmetric blade effect and asymmetric disc effect, is an aerodynamic phenomenon experienced by a moving propeller that is responsible for the asymmetrical relocation of the propeller’s centre of thrust when an aircraft is at a high angle of attack.