What happened

On the 5 August 2018 at about 1545 Western Standard Time, a Boeing 717-200 operating between Perth and Broome, Western Australia, departed from runway 21 at Perth Airport.

Following a normal departure, Air Traffic Control (ATC) advised that the Standard Terminal Arrival Route (STAR)^[1] speed and altitude restrictions were cancelled. The aircraft captain (AC) briefed the first officer that the crew would maintain normal programmed departure speeds. Shortly thereafter, the AC was alerted to a low-speed warning on the primary flight display (PFD). The AC stated that as slat retraction had not been called for, the AC initially thought that the crew were experiencing an unreliable airspeed event. The AC checked the thrust and altitude parameters and identified they were within expected limits. As the airspeed was increasing at a normal rate, and there was no stick shaker or under-speed protection engagement, the AC elected to leave the autopilot engaged and monitor the situation. The AC then identified that the slats had been retracted prior to the AC calling for that action. As all flight parameters appeared normal, the crew continued the flight to Broome. Subsequent discussions identified that the first officer misinterpreted the AC’s instructions to maintain normal departure speeds and prematurely retracted the slats.

Safety action

As a result of this occurrence, the aircraft operator has advised the ATSB that they have issued an Operational Safety Alert, reminding flight crews of the importance of positively identifying and confirming actions prior to selection and taking the time to ensure tasks are done correctly.

Safety message

This incident highlights the importance of inter-crew communication to preventing, trapping and mitigating error. Flight crews should ensure they use procedures such as cross check, or identify and confirm to support effective communications and develop a shared understanding of the aircraft state.

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. STARs are procedural methods to control the flow of traffic within the vicinity of an aerodrome. Flight crews are to comply with published speeds and altitudes unless they are specifically cancelled or amended by ATC

What happened

On 11 September 2018 at approximately 1400 Eastern Standard Time, a Mooney Aircraft Corp, M20C, was on final approach into Bankstown, New South Wales, after completing a private flight.

The pilot of the M20C has lowered the aircraft’s undercarriage whilst on the downwind leg of the circuit in preparation for landing. The pilot reported not feeling confident about the 1,500 ft circuit height they were established in and raised the undercarriage to conduct a go-around^[1].

ATC observed the landing gear being raised and instructed the pilot to conduct a go-around prior to the pilot being able to communicate their intentions.

The flight proceeded without further incident.

Safety message

If a pilot is not completely satisfied that all the requirements are in place for a safe landing, performing a go-around is a way to ensure safety is not compromised.

The ATSB news article, Have an early decision point for an early and proper go-around has more information about the importance of performing an early go-around when a safe landing is in doubt.

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. A go-around is a safe, standard aircraft manoeuvre, which simply discontinues an approach to landing.

What happened

On 22 August 2018, at 1235 Eastern Standard Time, a Bombardier DHC-8 departed Cairns, Queensland (Qld) for a regular public transport flight to Moranbah, Qld.

During initial climb between 600 ft and 1,000 ft, the crew detected severe engine surging. The crew identified the no. 2 engine as the affected engine and shut it down. The crew completed the relevant checklists, declared a PAN PAN^[1] and continued climb to 7,000 ft. The crew then returned the aircraft for landing on runway 33 at Cairns.

Engineers replaced the propeller control unit and the over speed governor and returned the aircraft to service.

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 the afternoon of 30 April 2018, a GippsAero GA8 Airvan was in cruise at 12,000 ft tracking toward Canberra, Australian Capital Territory when the aircraft lost engine power. There was one pilot and one passenger on board.

The pilot declared a MAYDAY to Canberra air traffic control (ATC) and was instructed to activate the emergency locator transmitter.^[1] The pilot elected to land in a cleared paddock and conducted an emergency landing. During landing, the aircraft travelled through a fence (Figure 1) and struck a log and a depression in the ground, before stopping (Figure 2). The aircraft sustained damage to the propeller and landing gear as well as damage to the windscreen and fuselage from contact with the fence.

There were no injuries and the pilot contacted Canberra ATC, with the assistance of another aircraft flying in the vicinity, to advise of their safe landing.

Figure 1: Aircraft path across paddock 

Source: Copyright owner annotated by ATSB

Figure 2: Final position of aircraft including ground depression struck 

Source: Copyright owner annotated by ATSB

Engineering inspection

The engine was removed and sent to an approved engine facility where it was disassembled and inspected. The inspection revealed that the engine crankshaft had separated between crank cheek number 8 and the number 5 connecting rod journal. A defect report for the crankshaft has subsequently been submitted to the Civil Aviation Safety Authority. The engine had completed approximately 1,055 hours since overhaul.

Safety message

Following a complete engine failure, a forced landing is inevitable. In this instance, the pilot followed standard emergency procedures to ensure a safe outcome was achieved.

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. Emergency locator transmitter (ELT): a radio beacon that transmits an emergency signal that may include the position of a crashed aircraft, activated either manually or in the crash.

What happened

On 30 April 2018, at about 1114 Eastern Standard Time, a Beech Aircraft Corporation BE76 was on a dual flying training flight under instrument flight rules^[1], returning to Gold Coast, Queensland (Qld). There were an instructor and student pilot on board the aircraft.

During the cruise, Brisbane air traffic control (ATC) issued a heading vector to the flight crew. The student pilot set the autopilot’s heading bug to the assigned heading but did not change the autopilot from navigation mode to heading mode resulting in the aircraft continuing on the original heading. The instructor did not detect that the student pilot had not selected heading mode and as the autopilot is positioned to the left of the instrument panel, it is difficult for them to see the selected control mode.

The instructor was troubleshooting why the aircraft had not turned onto the required heading when the crew received an instruction from ATC to descend. The student pilot entered the assigned altitude into the assigned altitude indicator and disconnected the autopilot. The aircraft subsequently climbed 100 ft above the assigned altitude. This generated an alert to ATC.

The crew then regained positive control of the aircraft and descended in accordance with the clearance.

Safety message

This incident highlights the importance of all flight crewmembers being aware of the selected autopilot modes during all stages of flight. When changes are made to the selected mode, these should be verbalised and where possible verified by the second crewmember.

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. Instrument flight rules (IFR): a set of regulations that permit the pilot to operate an aircraft to operate in instrument meteorological conditions (IMC), which have much lower weather minimums than visual flight rules (VFR). Procedures and training are significantly more complex as a pilot must demonstrate competency in IMC conditions while controlling the aircraft solely by reference to instruments. IFR-capable aircraft have greater equipment and maintenance requirements.

What happened

On 1 May 2018, a solo training flight was conducted in a Diamond DA 40 at Coffs Harbour Airport, New South Wales. On returning to Coffs Harbour, air traffic control (ATC) cleared the aircraft for a visual approach to join the final leg of the circuit for runway 21. ATC also instructed the pilot to follow a Piper PA-28, which at that time was on a left base leg for runway 21. The pilot of the DA 40 confirmed that they had sighted the PA-28, and ATC instructed the pilot to follow the PA-28 and report when they joined the final approach leg of the circuit.

As the DA 40 joined the final approach, the pilot advised ATC that they were on a 3 NM final, however the aircraft was unable to be sighted. ATC subsequently observed the DA 40 on final approach to taxiway E5. The controller advised the pilot that the aircraft appeared to be on final for taxiway E5, and that runway 21 location was to their left. The pilot turned left and reported runway 21 in sight. The aircraft landed without further incident.

Figure 1: Coffs Harbour Airport Chart

Source: Airservices Australia DAP155 Aerodrome & Procedure Charts

Safety message

Pilots should be aware of the layout of aerodromes and runways they are using. At Coffs Harbour aerodrome, warnings exist in the aerodrome charts regarding the potential confusion of taxiway E5 and runway 21, including a notice on how to avoid this confusion by confirming the presence of a Precision Approach Path Indicator at the end of the runway.

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 27 April 2018, a BRM Aero Bristell was conducting flight training at Bathurst Airport, New South Wales. During final approach to runway 17 at, the crew observed a Van's RV-8 on short final approach to runway 35. The crew of the Bristell conducted a go-around^[1] and manoeuvred to the dead side^[2] of runway 17 to maintain separation and visibility of the RV-8 on final for runway 35 while trying to contact the RV-8 by radio with no response. The Bristell re-joined the circuit and both aircraft landed without further incident.

It was later established that the pilot of the RV-8 had not selected the appropriate radio frequency for Bathurst and was distracted by glider operations on runway 08 and had not seen the Bristell until after landing.

Figure 1: Separation sequence of events at Bathurst Aerodrome 

Source: Google Earth image annotated by ATSB

Safety action

As a result of this occurrence, the RV-8 pilot advised the ATSB that they will in future write the relevant frequencies of the destination aerodrome on the flight plan in the pilot notes area, to have them readily available in flight.

Safety message

Maintaining situational awareness of your surroundings is a key element of safe operations in the vicinity of non-towered aerodromes. Pilots should:

• maintain effective lookout
• use radio to supplement un-alerted see and avoid
• be aware that other aircraft may not be on the correct frequency or broadcasting.

Appropriate radio broadcasts made on the correct frequency within 10 NM of non-towered aerodromes whilst maintaining good visual scanning is eight times more effective than normal lookout in detecting and avoiding other traffic.

The ATSB booklet A pilot’s guide to staying safe in the vicinity of non-controlled aerodromes outlines many of the common problems that occur at non-controlled aerodromes, and offers useful strategies to keep yourself and other pilots safe.

The Civil Aviation Safety Authority (CASA) has produced several publications and resources that provide important safety advice for operations at, or in the vicinity of non-towered 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.

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1. To abandon the landing and make a fresh approach [Cambridge Aerospace Dictionary]
2. Side of airfield or active runway away from that of the circuit pattern in use. [Cambridge Aerospace Dictionary]

What happened

On 27 April 2018 at approximately 0905 Eastern Standard Time, a Glaser-Dirks DG-1000S glider aircraft (the glider) was conducting solo training in the left-hand circuit of runway 08 at Bathurst Airport, New South Wales. As the glider made its downwind radio call, a Cessna aircraft broadcast that it was taxiing for runway 35. The pilot of the Cessna acknowledged a further call made by the glider ground controller that there was a glider training in the circuit area.

Several seconds later the glider turned onto the left base of the circuit and broadcast, “turning left base, runway 08”.

Later, as the glider was turning final for runway 08, the Cessna broadcast its rolling call on runway 35. Recognising the potential separation issue at the intersection points of runways 08 and 35, the glider ground controller called “ABORT, ABORT, ABORT, glider on final runway 08”.

The Cessna pilot brought the aircraft to a full stop prior to the intersection and the glider landed on runway 08 without incident. The Cessna pilot then backtracked and departed from runway 35.

Figure1: Diagram of Bathurst Airport showing indicative aircraft position 

Related occurrences

A search of the ATSB database revealed a similar occurrence that took place at Bathurst Airport in 2016:

AO-2016-034

On 13 April 2016, an instructor and student of a Jabiru J170-D aeroplane, registered 24-7750 (7750), conducted a local training flight from Bathurst Airport, New South Wales. At about 1446 Eastern Standard Time, the aircraft arrived in the circuit, and the instructor broadcast that they were joining the circuit on an early downwind for runway 17, for a full-stop landing.

Powered aircraft were operating on runway 17 and gliders (and towing aircraft) were operating on runway 08.

Meanwhile, a student pilot of a Glaser-Dirks DG-1000S glider, registered VH-NDQ (NDQ) was conducting a solo flight at Bathurst. At about 1449, about 90 seconds after the pilot of 7750 had communicated with Glider Ground regarding glider traffic in the air, the pilot of NDQ broadcast on the Bathurst CTAF that they were on left downwind for runway 08.

After 7750 touched down on runway 17, about 100 m before the intersection with runway 08, the pilot sighted a glider (NDQ) on short final for runway 08, at an estimated 100 feet above ground level. The pilot applied full power to cross runway 08 as quickly as possible.

As 7750 landed, the pilot of NDQ assessed that there was the potential for a collision, closed the glider’s airbrakes and initiated a climb to pass over 7750. The glider then landed ahead on runway 08.

The instructor in 7750 lost sight of NDQ as it passed overhead. As 7750 accelerated with a high power setting, the instructor elected to continue a take-off and conducted a circuit before landing safely.

Safety message

While in this case, the incident did not result in a near collision, the safety message remains the same between the two occurrences.

Simultaneous operations on crossing runways can be problematic, particularly where the operation types are different (such as powered flight and gliding operations). Organisations responsible for the coordination and conduct of such activities are encouraged to carefully assess and manage the risks involved. This is particularly important when operations are likely to involve instructional flights and less experienced pilots, where workload and the potential for pilot distraction may be elevated.

This incident highlights the importance of effective communication. The primary purpose of communications on the CTAF is to ensure the maintenance of appropriate separation through mutual understanding by pilots of each other’s position and intentions. Where a pilot identifies a risk of collision, that pilot should alert others as soon as possible to allow a coordinated and effective response.

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 26 March 2018, a Raytheon Aircraft Company B200 aircraft was flying from Kowanyama, Queensland (Qld) to Cairns, Qld. At 2000 Eastern Standard Time, passing 3,700 ft on approach to runway 15 using the instrument landing system (ILS), the pilot reported that the ILS flagged intermittently and then permanently. The co-pilot side had a glideslope flag. The pilot subsequently elected to conduct a missed approach.

The pilot turned left onto the missed approach heading of 030 earlier than detailed in the published missed approach procedure. The air traffic control tower expected the aircraft to continue to overhead the middle marker before making the turn. The pilot reported that he chose to turn early to remain well clear of the hills on his right side and because of the lack of lateral guidance. He also took into consideration that there was a 28 kt westerly wind.

During the missed approach circuit, the pilot hand flew the aircraft on the co-pilot’s instruments. He communicated further with the air traffic control tower, who confirmed the correct operation of the ILS. The aircraft landed without further incident.

Figure 1: ILS Approach for Cairns 

Source: Airservices Australia, annotated by the ATSB

Safety action

As a result of this occurrence, the aircraft operator has advised the ATSB that they contacted the equipment vendor who advised a range of tests to carry out. The operator conducted the tests and narrowed the problem down to small green particles on the cannon plugs on the rear of the instrument. These plugs were replaced, and no further fault could be found with the instrument. The aircraft has subsequently flown the ILS into Cairns several times without fault.

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 June 2018, a Jabiru J160-C was conducting a training flight. The crew consisted of a student (the pilot flying) and an instructor (the pilot monitoring).

Approximately 90 minutes into a planned two hour flight, the student attempted a touch and go. The engine failed on the runway and the aircraft rolled to a stop. The instructor advised Air Traffic Control and attempted unsuccessfully to restart the engine.

The instructor and student pushed the aircraft onto an adjacent grass taxiway. The crew were able to restart the engine and taxi to the apron area.

Post-flight, the right wing fuel cap was found to be loose. After refitting the cap, the aircraft returned to service.

Safety message

ATSB publication Avoidable Accidents No. 5 - Starved and exhausted: Fuel management aviation accidents found from 2001 to 2011, accidents involving fuel starvation resulted in 10 fatalities and 18 serious injuries.

Fuel starvation happens when the fuel supply to the engine(s) is interrupted although there is adequate fuel on board.

This incident reinforces the need to:

• conduct a thorough pre-flight inspection
• determine prior to flight the expected rate of fuel consumption
• monitor fuel consumption during flight
• be fully familiar with the fuel systems operation.

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.