What happened

On 13 July 2018, at 1119 Eastern Standard Time, the pilot of a Piper PA-28 aircraft was conducting a touch-and-go^[1] at Warrnambool Airport, Victoria.

During the flight, the pilot noticed that although the engine was idling within the green arc it was running slightly rougher than normal. After completing a circuit and landing on the runway, the engine idled to a halt. The pilot subsequently tried to restart the engine and noticed that the pump sounded sluggish and had lost volume. The mixture was set to full rich at all times.

During the second attempt to restart the engine, fumes and smoke were detected emanating from the engine compartment and liquid could be seen draining onto the runway. The pilot immediately shutdown the engine, switched off the aircraft electrical system and vacated the aircraft.

A fire started in the front section of the engine compartment and spread to the aft of the aircraft. As a result of the fire, the aircraft was destroyed.

Safety message

This incident provides a reminder that priming a hot engine can result in an engine fire. Most aircraft manuals will have a checklist to follow for engine fires on start-up. It is important for pilots to memorise this procedure specific to the aircraft they are flying.

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. Touch-and-go: The combination of a landing and take-off, performed as one fluid operation through touchdown, rolling reconfiguration, and lift-off.

What happened

On 9 May 2018, around 1150 Central Standard Time, the pilot of a Diamond DA 40 departed from Parafield South Australia (SA) on a solo-training visual flight rules (VFR) navigation exercise. The pilot planned to fly from South Para Reserve to Tori Hills, SA. As the flight progressed, the pilot lost directional awareness and subsequently conducted the 1 in 60-correction tracking ^[1] in the wrong direction taking the aircraft off course. The pilot then followed the operator’s lost procedure and contacted Air Traffic Control (ATC) for assistance. ATC directed the aircraft to Lameroo Aerodrome and from there the pilot was able to continue on the rest of the navigation without assistance.

Figure 1: Map of Area

Source: Airservices Australia

Safety action

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

• The trainee pilot conducted a dual sortie involving a more complex lost procedure.
• The operator held discussions on the use of the Global Navigation Satellite System (GNSS) as an aid in visual flying.

Safety message

This incident highlights the importance of requesting assistance from ATC when flight crew are unsure of the aircraft’s position. ATC are able to assist crew in locating positions using transponder codes, prominent landmarks and radio navigation. It is better to ask for assistance before fuel reserves are compromised.

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1. A basic rule of thumb, which states that if a pilot has travelled sixty miles then an error in track of one mile is approximately a 1° error in heading. Utilised by single pilots with many other tasks to perform, often in a basic aircraft without the aid of an autopilot.

What happened

On 1 August 2018 at 1530 Western Standard Time, the crew of a Fokker F28 aircraft was conducting a revenue passenger transport flight between Perth and Kalgoorlie, Western Australia. The flight crew comprised a captain and a first officer. The first officer was on his second day of training.

During approach, the captain briefed the first officer for a flap 25 configuration for the landing.

Later in the approach, the captain inadvertently called for the flaps to be extended to 42. The first officer questioned this call, and the captain confirmed the call for a flap 42 configuration. The first officer did not further question the captain’s call, and flap 42 was selected.

The captain reported that he was responding to other demands during this approach. There was a crosswind at 40 knots, and conditions were turbulent. The captain reported that during the approach he was focussed on monitoring the flight instruments.

The captain subsequently identified the incorrect flap configuration, and conducted a go-around. A second approach was conducted successfully.

Safety message

This incident highlights the importance of inter-crew communication. There was a breakdown of communication between the first officer and the captain. The flap configuration was not effectively communicated within the cockpit, resulting in an incorrect configuration being set. Although the first officer did query the captain’s initial instruction for a flap 42 configuration, he did not further challenge this call. Flight crews are reminded that active and effective communication, including clarification of unclear instructions, plays an important role in ensuring safe flight.

This incident also highlights the importance of managing operational pressures and 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’.

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 April 2018, an Airbus Industrie A320-232 operated as a commercial passenger flight from Melbourne, Victoria to Hobart, Tasmania. The flight crew conducted the area navigation approach (RNAV) for runway 30 at Hobart. Approaching 1,000 ft, the pilot in command (PIC), being the pilot flying (PF) identified that the aircraft glidepath appeared low with reference to the Precision Approach Path Indicator (PAPI)^[1], which was showing four red lights. The PIC disconnected the autopilot, regained the glidepath manually and landed the aircraft without any further issue.

After landing, the first officer, as pilot monitoring (PM) noticed his altimeter QNH setting was incorrect and adjusted it accordingly. This resulted in a NAV ALTI discrepancy ECAM alert. The flight crew realised that both pilots had the same, but incorrect altimeter QNH setting during the RNAV approach resulting in the aircraft being lower than it should have been during the approach.

Safety message

This occurrence reminds pilots that continuously monitoring aircraft and approach parameters and the external environment can assist to ensure they maintain a stable approach profile and make appropriate decisions for a safe landing.

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. Precision Approach Path Indicator (PAPI): a ground based system that uses a system of coloured lights used by pilots to identify the correct glide path to the runway when conducting a visual approach.

What happened

On the morning of 8 September 2018, a Bell 206B helicopter departed a caravan park on a private flight with a pilot and three passengers on board. Approximately 30 minutes into the flight, the pilot conducted an orbit around a cleared area intended for landing and completed his landing checks. During late downwind, the pilot reports that the helicopter experienced an uncommanded yaw to the right. To counteract the yaw, the pilot applied left pedal, however the helicopter continued to yaw to the right and subsequently began an uncontrolled descent into trees. As the helicopter entered the trees, the pilot rolled off the throttle and pulled on the collective^[1] and the helicopter contacted the ground, resulting in the tail rotor severing. The main rotor also sustained damage from contact with the trees. The pilot and passengers exited the helicopter without injury.

At the time of the accident, the pilot reports that gusty, variable winds were encountered which may have caused a loss of tail rotor effectiveness (LTE),^[2] contributing to the accident.

Safety message

There are various factors that can contribute to a loss of tail rotor effectiveness. The NTSB Safety Alert, Loss of Tail Rotor Effectiveness in Helicopters identifies these factors and the subsequent risks associated with LTE.

About this report

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

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1. Collective: a primary helicopter flight control that simultaneously affects the pitch of all blades of a lifting rotor. Collective input is the main control for vertical velocity.
2. In helicopters, loss of tail rotor effectiveness (LTE), or unanticipated yaw, is an uncommanded rapid yaw that does not subside on its own accord.

What happened

On 7 October 2018 at 1130 Western Standard Time, the pilot of a Mooney M20J aircraft was conducting a private flight from Bunbury to Jandakot, Western Australia.

En route to Jandakot, the pilot observed indications of mechanical problems with the aircraft. The pilot assessed that the engine performance was erratic.

Rather than proceed with the planned flight, the pilot elected to divert to Murray Field Airport, to perform a precautionary landing. The pilot determined that, were he to continue toward Jandakot airport, his options to perform a forced landing closer to his destination would become more constrained. The pilot also assessed that his current location afforded a number of suitable sites for forced landing if necessary, and was away from built-up areas.

The pilot landed the aircraft at Murray Field Airport, approximately 60 km south of Jandakot. There was no reported damage, and no injuries.

A post-flight inspection revealed that a flexible fuel line under the cowl had come loose. This lead to reduced fuel flow to the engine and fuel leakage. The cause of the fuel line becoming loose was not determined.

Safety message

This incident highlights the importance of maintaining awareness of aircraft systems performance. Because the pilot noted indications of erratic engine performance, he was able to take the positive action of diverting the aircraft. Flight crews are reminded that mechanical issues can emerge at any stage, and they must remain vigilant to warning signs.

This incident also highlights the importance of effective pilot decision making to ensuring safe flight. The pilot’s decision to divert when he observed erratic engine performance reduced the risk of injury or equipment damage. If the pilot had elected to continue with the flight, he would have had reduced options to manage those risks. Flight crew are encouraged to identify the hazards and risks they encounter during flight, and to make control decisions to minimise those risks where possible. The FAA provides decision making guidance to pilots in their Aeronautical Decision Making (ADM) training package.

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 2018, at about 0620 Eastern Standard Time, a Beech Aircraft Corp B1900D was conducting a charter flight from Cairns Airport, Queensland (Qld) to Skardon River Airport, Qld with two crew and 16 passengers on board.

Just after take-off from Cairns, the landing gear was selected up. The landing gear did not retract and remained down and locked with all green lights illuminated. The crew conducted a return to Cairns and the aircraft landed without incident.

Engineering Inspection

Following the incident, inspection of the landing gear revealed that the landing gear motor circuit breaker in the undercarriage had been pulled the previous day during maintenance and was not reset before the access panel was re-fitted after maintenance was completed. As a result, when the landing gear was selected up, the undercarriage system could not operate without the circuit breaker being reset.

Safety action

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

• improving prescribed paperwork methods
• providing further human factors training
• conducting Efficiency-Thoroughness Trade-Off (ETTO) training^[1]
• conducting more regular tool box talks
• providing safety and quality awareness training.

Safety message

Where an aircraft has been out of service for maintenance, it is important to verify the functionality of all critical aircraft components before returning it to service. These checks should be conducted in addition to the routine, pre-flight checks.

It is important that pilots remain aware that despite conducting comprehensive pre-flight checks, unanticipated failures can still occur during flight. In this situation, the flight crew took all possible precautions by following non-normal 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.

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1. Erik Hollnagel, ETTO principles and rules that are applicable to the working environment. They compare the difference between efficiency and safety.

What happened

On the morning of 15 May 2018, the crew of a SAAB 340A were conducting a cargo flight from Rockhampton, Queensland (Qld) to Mackay, Qld. At approximately 0545 Eastern Standard Time, the aircraft was on descent into Mackay passing 10,000 ft.

During descent, the left engine surged from 50 per cent torque to over 70 per cent with an increase in interstage turbine temperature^[1]. The crew retarded the power lever and all other indications appeared normal. The aircraft levelled off at 5,000 ft and failure management was carried out. The crew subsequently conducted a normal approach and landing.

Following the incident, the crew were interviewed and an analysis of the flight data recordings occurred. Engineers were notified of the incident and conducted inspections. No faults were found with the engine or controls. It was determined that the constant torque on take-off (CTOT) was inadvertently not de-selected during the climb phase of the flight, resulting in the abnormal engine surge.

Safety action

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

Refresher training was provided to the crew specific to the use and operation of the CTOT system.

The crew conducted a competency-based training refresher course on operations failure management.

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. The interstage turbine temperature (ITT) is the temperature of the exhaust gasses between the high pressure and low-pressure turbines.

What happened

On 2 June 2018 the pilot and a passenger departed a station west of Alice Springs, Northern Territory, in a Robinson R22 helicopter for a routine property inspection.

At approximately 1215 Central Standard Time, the pilot conducted a landing at a bore site and the passenger exited the helicopter. The pilot then also exited the helicopter with the engine still running. Shortly after exiting and moving away from the helicopter, the pilot heard the engine power up and began to run towards the helicopter. The helicopter then began to move and the pilot stopped moving towards it.

The helicopter was observed to move backwards and the tail rotor dug into the ground, flipping the helicopter onto its side resulting in substantial damage.

Pilot comments

The pilot reported that during maintenance the previous day, the collective was adjusted to loosen the friction. Before exiting the helicopter, the pilot tightened the cyclic, ensured the collective was down, and the friction nut tightened. The pilot suspects that the friction has loosened, causing the collective to rise and the helicopter to power up.

Safety message

Leaving engines running without a pilot in a control seat presents a significant hazard to the helicopter and persons on the ground. The aircraft manufacturer includes a warning against such practice in the aircraft flight manual, Safety Notice SN-17, Never exit helicopter with engine running.

About this report

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

What happened

On 12 Jul 2018, at about 1000 Eastern Standard Time, the pilot of a Robinson R44 helicopter took off with one passenger on board to conduct a few circuits^[1] at Lethbridge Airport, Victoria, prior to departing the airport for a private flight.

The pilot conducted two circuits and on the third circuit, set up for an autorotation^[2] to demonstrate to the passenger the rate of descent during the manoeuvre. The pilot selected a landing point 1/3 down the runway and established the helicopter at 70 kt, 600 ft above ground level (AGL). The pilot then partially rolled off the throttle to reduce the motor RPM and lowered the collective^[3] to enter autorotation. The pilot was explaining the autorotation to the passenger when the low rotor RPM horn and light came on followed by a significant wobble and shake of the helicopter. The pilot checked the rotor RPM and it was about 70 per cent. The pilot initiated recovery by increasing collective and winding the throttle back on. This made little difference and at 300 ft, the pilot pitched the nose of the helicopter forward to increase RPM. Just prior to impact with the ground the pilot flared the helicopter and pulled full collective, however there was little rotor RPM left.

The pilot called for the passenger to brace and the helicopter landed somewhat level. As it skidded forward, the helicopter rolled to the left side and came to a stop. The helicopter was destroyed and the passenger sustained serious injuries.

Figure 1: R44 wreckage at Lethbridge Airport, Victoria 

Source: Owner

Safety message

Practice of emergency recovery techniques such as autorotations should not be conducted with passengers on board. These carry an inherently elevated degree of risk. Additionally, passengers increase a pilot’s workload and can cause distractions. When conducting an autorotation; attitude, airspeed and rotor RPM should be the focus of the pilot’s attention. Practice autorotations are a dynamic manoeuver, increasing the potential to mishandle the helicopter. Two serious conditions associated with a mishandled autorotation are low rotor RPM stall and vortex ring state.

Safety Notice SN-10 on the Robinson Helicopter Company website states that, ‘No matter what causes the low rotor RPM, the pilot must first roll on throttle and lower the collective simultaneously to recover the RPM before investigating the problem.’

Safety Notice SN-24 Low RPM Rotor Stall can be Fatal and Safety Notice SN-22 Vortex Ring State Catches Many Pilots by Surprise, both detail recovery actions that require the collective to be lowered as part of the initial recovery actions.

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. Circuit: The circuit is an orderly pattern that involves the pilot making approaches to a landing area, touching down and then applying power to take off again.
2. Autorotation: Autorotation is a condition of descending flight where, following engine failure or deliberate disengagement, the rotor blades are driven solely by aerodynamic forces resulting from rate of descent airflow through the rotor. The rate of descent is determined mainly by airspeed.
3. Collective: a primary helicopter flight control that simultaneously affects the pitch of all blades of a lifting rotor. Collective input is the main control for vertical velocity.