What happened

On 27 May 2018, a student pilot undertaking their second solo flight in a Piper Aircraft 28-161 aircraft departed Moorabbin Airport, Victoria to conduct three circuits.

During the first touch-and-go landing on runway 35R, the pilot inadvertently missed retracting the landing flap. Immediately upon becoming airborne, the pilot noticed the incorrect flap setting and retracted the flaps resulting in the aircraft sinking onto the runway. The pilot then rejected the take-off, veered off the runway and collided with a sign resulting in minor damage.

Safety action

As a result of this occurrence, the flying school where the student pilot is conducting training has advised the ATSB of the following:

• The pilot will undertake additional training prior to any additional solo flights.
• This incident has been used as an example to educate other student pilots about threat and error management and potential loss of control.

Safety message

After take-off a partial or complete retraction of the flaps at very low airspeed can result in a loss of lift, resulting in the aircraft settling back onto the ground. To avoid such an outcome, it is essential for the pilot to ensure that the flaps are retracted incrementally to allow time for the aircraft to accelerate progressively as they are being raised.

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 May 2018, the pilot of a SOCATA TB-20 was conducting circuits at Cambridge, Tasmania. The pilot was the only occupant on board.

The pilot was conducting his first circuit. Soon after take-off, Air Traffic Control (ATC) advised that another plane was joining the base leg and the SOCATA would be second in the landing sequence. The pilot extended his circuit accordingly. ATC observed that the wheels of the aircraft were extended on the base leg and final approach. The pilot said that he decided to leave the gear down to aid in slowing the aircraft and maintaining separation.

When the pilot turned the aircraft onto final approach, the sun was in his eyes, requiring him to use sunglasses. This impaired his vision of the instrument panel. The pilot then performed the final landing checks, whilst monitoring the preceding traffic and with the sun in his eyes. He inadvertently selected gear up.

The pilot subsequently landed the aircraft with the wheels retracted and was observed to come to a stop half way down the runway. He then reported the incident to ATC and emergency services were called.

The aircraft sustained damage to the propeller.

Safety message

This incident highlights the importance of managing distraction. During times of high workload, distraction can often lead to human error.

External pressures and distractions are sometimes unavoidable, however, there are effective ways to manage them, as discussed in the ATSB research report B2004/0324, ‘Dangerous distraction: An examination of accidents and incidents involving pilot distraction in Australia between 1997 and 2004’.

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. Tip number 3 and 4 are particularly pertinent to this incident. Tip number 4 is about recognising that modified or interrupted traffic patterns frequently contribute to gear-up landings and for the pilot to be extra vigilant in these situations. Tip number 3 is about ensuring that all final approaches have a short, final gear position check.

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 13 June 2018 at 1957 Eastern Standard Time, a Diamond DA 40 was conducting solo night circuit training at Bankstown Airport, New South Wales. Bankstown is a class D metropolitan airport, with fixed wing and rotary pilots. The circuits were conducted on runway 29C, during tower hours with a left circuit direction.  Meteorological conditions were reported as night (bright), visibility greater than 10 km with wind speeds a top of 5 kts.

The DA 40 was on upwind runway 29C and was instructed by air traffic control (ATC) to follow a Fairchild SA227 that was joining downwind. The pilot of the DA 40 sighted the SA227, which was positioned joining the circuit left downwind. The DA 40 pilot conducted a rate one turn^[1] crosswind in front of the SA227. While conducting the turn, the pilot was focused on his instruments and lost visual contact with the SA227. ATC then instructed the DA 40 to conduct a left turn and re-join the circuit upwind.

The pilot continued his rate one turn and once established on the upwind leg for runway 29C, ATC instructed the pilot to follow a Piper PA 28, which had just become airborne off runway 29C. The pilot of the DA 40 reported sighting an aircraft ahead and below of his position and incorrectly assumed that was the PA 28, but it was another aircraft in the circuit.

As the PA 28 was climbing upwind, the crew sighted the DA 40 overhead and in close proximity. The pilot of the PA 28 pitched the aircraft’s nose down to increase separation and informed the tower of the DA 40’s position. ATC issued the DA 40 a safety alert and an immediate climb instruction to 1,500 ft.

The DA 40 had overtaken the PA 28 and had come into close proximity.

Both aircraft continued circuit training without further incident.

Figure 1: Bankstown runway layout with standard circuit arrows as guide only 

Source: Airservices, annotated by ATSB

Safety message

Pilots and ATC have a dual responsibility in maintaining situational awareness of other traffic. When conducting flight in class D airspace, pilots must sight and maintain separation from other aircraft. If pilots lose situational awareness, ATC are available to pass traffic, however ATC must be notified immediately if aircraft crew cannot sight and maintain their own separation.

In this instance, the crew reported ATC had given them instructions to follow a Piper that had just become airborne, leading the crew to follow the incorrect aircraft. If any doubt exists as to the instruction given, whether it be a phrase used or the inability to comply with an instruction, crew are reminded to seek clarification from ATC immediately.

Pilots should always:

• sight and maintain separation from other aircraft
• comply with ATC instructions whilst ensuring separation is maintained from other aircraft
• notify ATC if a change in clearance is required
• immediately advise ATC if unable to comply with an instruction.

Below are some tips to remember when flying in class D airspace:

• Develop an easy, repeatable scanning technique. Be aware of your relative position and the movement of other traffic.
• Communicate clearly and listen for key words that indicate other aircraft’s position and intentions.
• Recognise the symptoms of losing situational awareness (distractions, fixation).
• Think ahead. Anticipate what will happen several minutes into the future.

For more information about flight tips at Bankstown, visit www.airservicesaustralia.com/publications/safety-publications/ and follow the links under the heading Runway Safety for Tips for flying at Bankstown and Operating in Class D airspace.

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. In turning flight, the number of degrees of heading change per unit of time (usually measured in seconds) is referred to as the rate of turn. A rate one or standard rate turn is accomplished at 3° / second resulting in a course reversal (180°) in one minute or a 360° turn in two minutes.

What happened

On 10 May 2018, at 1110 Western Standard Time, a student pilot took-off from runway 06L at Jandakot Airport for a solo flight to the training area to the south. The flight was in a Cessna A152. Shortly after take-off, the engine failed to produce adequate power. The student was able to maintain 500 ft yet unable to climb further. The student declared an emergency to Jandakot Tower, conducted a low-level left-hand circuit, and landed safely.

The engine powering the Cessna A152 is a four cylinder Lycoming O-235 producing up to 82 kW in normal operation. Lycoming supplied the engine directly to the operator and it had a 2,400 hour time between overhauls (TBO) limit. The power loss occurred 2,146 hours into the engine’s life.

The engineering inspection showed that a burnt valve with a 2 mm hole on the edge of the face at the point of failure caused the power loss. A valve can sustain burning when it no longer turns in operation, exposing the face to a hot spot. Wear was evident on the associated exhaust lobe on camshaft, which could contribute directly to such an event.

Safety message

The student carried out all actions as taught and completed a successful low-level circuit and safe landing. Announcing the emergency to Air Traffic Control allowed them to put emergency services on standby to respond. The successful management of the situation demonstrates the value of solid instruction in the basics of flight.

There are currently 120 Cessna 152s on the Australian Register. Many of them in flight schools, and operated by new pilots. Reduction of camshaft wear and other engine problems can be achieved by ensuring all pilots accurately follow the manufacturer’s recommendations and observe the procedures and limitations in the Pilot’s Operating Handbook. Additionally, owners should ensure regular operation of their aircraft to avoid build-up of contamination on engine components, which can prematurely age the engine.

About this report

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

What happened

On the afternoon of 19 May 2018, a Cessna Aircraft 425 departed Archerfield Aerodrome, Queensland. There was one pilot and four passengers on board. Shortly after take-off, at about 1525 Eastern Standard Time, the pilot received an annunciator warning, indicating the right engine starter generator was engaged in its starting function. The annunciator in this instance is illuminated when the starter is in the ‘start’ function and not acting as a generator and is normally illuminated during the start sequence only.

After identifying the problem, the pilot conducted the actions required to shut down and secure the right engine as detailed in the aircraft checklist procedures. The pilot declared a PAN PAN^[1] and informed Archerfield tower that the aircraft would require an immediate return to the runway.

With clearance from the tower received, the crew then conducted a non-standard right circuit to runway 10L and landed safely. A subsequent engineering inspection found the starter annunciation to be a false indication, due to a chafed wire in the engine electrical system.

Safety message

Although this occurrence was an indication issue, not an actual fault, it demonstrates the importance of identifying system failures as presented to the pilot and carrying out the corrective actions required. It also demonstrates the knowledge required by the pilot, having to conduct non-standard operations and to state their intentions to the controllers, to enable a safe return to the airfield.

The ATSB has published a research report, Power plant failures in turboprop-powered aircraft (AR-2017-017), which is available from the ATSB website. It highlights the importance of reporting all power plant-related occurrences. By doing so, the ATSB hopes that the wider aviation industry will be able to learn from the experience of others.

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. PAN PAN: an internationally recognised radio call announcing an urgency condition which concerns the safety of an aircraft or its occupants but where the flight crew does not require immediate assistance.

What happened

On 9 September 2018 at approximately 0845 Eastern Standard Time, a Textron Aviation Inc. 172S departed Moorabbin, Victoria (Vic.), to conduct a Flight Instructor’s rating flight to Tooradin, Vic. There were two crew on-board, the flight instructor as pilot monitoring (PM) and a student as the pilot flying (PF).

The aircraft was configured for a short-field take-off. On line-up, the crew reported the engine was run-up to full, showing 2,350 RPM and nil issues. The crew reported a normal take-off run, however on rotation, engine RPM and performance was observed to degrade. The RPM had dropped to approximately 2,000 RPM and minor engine vibrations were detected. The PF confirmed that the throttle was still fully open.

The crew determined that a landing back at Moorabbin was necessary and the PM took over as PF. Following this, multiple severe engine vibrations began to occur. An assessment to land on the remaining runway was made from approximately 100-150 ft from above the runway. The landing was reported as normal; however, the crew observed engine vibrations while taxiing and determined the vibrations did not occur between 700-800 RPM. The remaining taxi was completed with minimal braking and throttle adjustment, to roll the aircraft back to the apron.

While standing, the crew opened the throttle to 1,000 RPM and did not observe any vibrations. They also completed a magneto check with nil further issues.

The company maintenance inspection revealed the number 2 cylinder exhaust valve was partially stuck open contributing to the engine abnormalities. The cylinder was subsequently replaced. The inspection also found scorching on the exhaust valve with carbon deposits inside the guide.

At the time of the incident, the aircraft was at a flight switch of 98.2 from the last 100-hour service and 46.6 from the last 50-hour service.

Safety message

When emergencies present themselves, pilots need to be familiar with how to handle their aircraft as per their aircraft’s pilot operating handbook (POH).

If any aircraft malfunctions or abnormalities are detected, pilots should discontinue the flight and conduct a precautionary landing if it is safe to do so. In this instance, the crew followed their standard operating procedures and a safe outcome was achieved. Decisive actions by the crew meant that this situation was handled safely before the issue could escalate.

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 August 2018 at about 1400 Eastern Standard Time, an Airbus A380 departed Sydney, New South Wales for a regular public transport flight to Dallas, US.

Passing FL 250 on climb, a loud noise was detected coming from a door on the upper deck. The door was locked correctly and not at risk of opening, however due to the passenger discomfort and the unknown nature of the issue the decision was made to return the aircraft to Sydney. The crew conducted a fuel dump and an uneventful approach and landing into Sydney.

The post-flight engineering inspection revealed damage to the door, caused by contact with a catering truck while the aircraft was loaded. The door seal retainer and seal on the underside of the door was damaged. Due to distraction of the non-normal operation of the catering truck, the damage to the door seal and seal retainer was not observed by the catering crew and therefore not reported to the flight crew or engineering. This resulted in the aircraft departing with the damaged door.

Figure 1: Damage to the door seal and door seal retainer

Source: Operator

Safety action

The operator launched an investigation into the ground handling incident.

Safety message

All persons working in and around aircraft have a responsibility to notify the operating crew about any damage to the aircraft. Ground crew should always be on the lookout for damage or anything abnormal. If any doubt exists, it is imperative to notify flight and/or ground crew for an engineering inspection.

About this report

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

What happened

On 7 August 2018, at about 1120 Central Standard Time, a Cessna 210M was departing Mount Ive, South Australia, for aerial work with only the pilot on board.

During initial climb from runway 04 after retracting the landing gear and turning onto a left crosswind leg, the pilot detected an abnormal engine noise described as popping and a reduction in engine power. The pilot adjusted the throttle that did not result in any improvement. The pilot then turned the aircraft toward runway 17 and slowed the aircraft sufficiently to extend full flap. During landing, the pilot flared, and the aircraft skidded down the runway. The landing gear was left in the retracted position. The cause of the abnormal engine indications was not able to be determined.

Pilot comments

The pilot stated that he did hear a noise during the approach, however, was not familiar with the sound of the landing gear warning horn. This in addition to the high workload and pressure of landing the aircraft contributed to the landing gear not extended prior to landing.

Safety message

During times of high workload, simple tasks such as selecting the landing gear could be unintentionally omitted. Pilots should be mindful that during an abnormal situation that all normal pre landing checks are completed. Pilots should also be familiar with all aircraft systems and warning devices.

For more information about managing partial engine failures after take-off, see ATSB research report, Avoidable Accidents No. 3 - Managing partial power loss after take-off in single-engine 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 the morning of 28 August 2018, the crew of a Cessna 172S departed Tamworth, New South Wales (NSW) to conduct a training flight. There was an instructor and a student on board.

During cruise, while the student was flying and tracking towards Wakefield, NSW, the instructor noticed uncommanded control movement and pitching^[1] of the aircraft. The instructor decided to observe the elevator^[2] movement and saw that it was moving abnormally. The instructor took control of the aircraft to ascertain the integrity of the elevator and found that the aircraft was pitching without any pilot input.

Although the degree of movement was minor, the aircraft was not operating within prescribed performance parameters. The instructor performed further elevator control and trim checks and decided the best course of action was to conduct a return to Tamworth, NSW. The instructor contacted Air Traffic Control (ATC) to notify them of the control issues, and the aircraft was cleared to track direct to Tamworth. The instructor decided to land without flaps^[3] to avoid exacerbating the control issues. The aircraft landed without incident.

Engineering inspection

Following the incident, the engineering inspection revealed that the elevator trim inspection panel had been partially installed causing an airflow disturbance over the right-hand elevator and trim.

Safety action

As a result of this incident, the maintenance organisation has advised the ATSB that they are taking the following ongoing safety actions:

• handover procedures to be reviewed and improved
• refresher training regarding the maintenance organisation exposition (MOE) procedures
• MOE procedures to be reviewed and updated
• more regular maintenance audits.

Safety message

This incident highlights the importance of ensuring that all pre-flight checks and procedures are carried out comprehensively and systematically. It also highlights the importance of ensuring that while the aircraft is in maintenance, all aircraft components are refitted and reinstalled in accordance with the aircraft’s maintenance manual and to verify the functionality of all critical aircraft components before returning it to service. The flight crew, in this instance, took all appropriate actions in-flight by assessing the situation, notifying ATC and conducting a return to the aerodrome resulting in a safe outcome.

About this report

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

__________

1. Pitching: the motion of an aircraft about its lateral (wingtip-to-wingtip) axis.
2. Elevator: Elevators are flight control surfaces, usually at the rear of an aircraft, which control the aircraft's pitch, and therefore the angle of attack and the lift of the wing.
3. Flaps: Flaps are a type of high-lift device used to increase the lift of an aircraft wing at a given airspeed. Flaps are usually mounted on the wing trailing edges of a fixed-wing aircraft. Flaps are used for extra lift on take-off. Flaps also cause an increase in drag, which can be beneficial during approach and landing, because it slows the aircraft.

What happened

On 28 August 2018, the pilot of the American Aircraft Corp. AA-5B departed Lilydale, Victoria to conduct a private flight. The pilot was the only occupant.

During initial climb, at about 300 ft above ground level, the engine failed. The pilot lowered the nose of the aircraft and searched for a suitable landing area, finding a nearby paddock to be suitable. The pilot conducted a successful forced landing on the surface of the paddock. The aircraft did not sustain any damage as a result of the landing.

Following the incident, the engineer suspects the likely cause of the engine failure was an unserviceable air filter, parts of which were missing. The air filter had not been replaced in accordance with the manufacturer’s recommendation. Metal contamination was also detected in the residual fuel in the carburettor. The source of the contaminants were rusty metal fragments traced back to the electric fuel pump which was found to have an incorrectly installed filter.

Safety message

Simulated total loss of power and a subsequent practice forced landing is at the core of a pilot’s emergency training. Following the engine failure, the pilot involved in this incident had to make important decisions in a short space of time, including where to land and how to manage the remaining altitude.

Pre-flight self-briefing is an important tool in reinforcing planned emergency actions, including in circumstances of unfavourable terrain immediately past the aerodrome. It is also important that aircraft are maintained in accordance with the aircraft’s maintenance manual, to ensure aircraft performance is maintained.

About this report

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