What happened

On 15 June 2018, at about 1420 Eastern Standard Time, a Piper Aircraft PA-38-112 was departing Amberley Airport, Queensland (Qld) for Archerfield Airport, Qld with one pilot and one passenger on board.

Shortly after the aircraft became airborne, the pilot observed a drop in engine power. Over the next few seconds, the pilot observed the engine power fluctuate between normal power and a reduced power output. Because of the fluctuating engine power, the pilot elected to land the aircraft on the remaining runway.

After landing, fluid was found to be dripping from the aircraft. Emergency services were called to clean the contaminant from the runway.

Following the incident, the operator removed the aircraft from service, placing it in quarantine until engineering inspections were completed.

Operator’s investigation

A post-incident inspection of the fuel system revealed a faulty fuel gascolator (filter) and a cracked fuel primer line. The maintenance provider replaced the fuel gascolator assembly and primer line to rectify the defect and returned the aircraft to service.

The operator identified the cause of the incident to be a fuel leak in the fuel gascolator assembly. The leak resulted in reduced fuel flow to the engine carburettor, which subsequently caused the power fluctuations on take-off. The operator’s investigation report noted that the fuel leak only became evident after the aircraft was exposed to the vibrations associated with high power settings and becoming airborne.

Safety action

The aircraft operator in conjunction with the maintenance provider has identified a more robust fuel gascolator that can be fitted under the authority of a Supplemental Type Certificate.

The operator is progressively replacing these units on their fleet of aircraft to reduce the probability of a similar incident in future.

Safety message

This incident highlights the importance of being able to act quickly and decisively in-flight to ensure an effective response in time critical situations. In this instance, proper monitoring of flight instruments and decisive action by the pilot ensured 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.

What happened

On 9 April 2018 at 0700 Eastern Standard Time (EST), the pilot of a Kavanagh G-450 balloon was on final approach to land near Mareeba, Queensland (Qld) with a pilot and 11 passengers on board.

Having received advice by radio from the pilot of a balloon that had already landed, the pilot anticipated a fast landing at approximately 6 kt, descending rapidly after passing over tall trees and stopping before reaching a barbed-wire fence on the downwind side of the paddock.

Before descending, the pilot contacted the ground crew by radio and asked them to provide “weight on” during the landing, to reduce the distance the basket may be dragged before stopping. This is a commonly used strategy in confined landing areas, overcoming the buoyancy of the balloon by adding the weight of the ground crew to that of the balloon and its occupants.

The ground crew moved to the anticipated landing site and waited for the balloon, but rather than remaining at the edge of the paddock, monitoring the balloon’s progress and only moving in once it had passed, one of the ground crew entered the paddock before the balloon arrived.

The ground crew member was walking across the paddock, away from the rapidly descending balloon, but directly in its path, when the pilot shouted a warning. The crew member immediately dropped to the ground and the balloon’s basket passed overhead. The balloon landed safely, and the ground crew member, pilot and passengers were not injured. The other two members of the ground crew remained behind the basket and were not at risk.

If the ground crew member had not heard the shouted warning and responded immediately, the consequences may have been significant. The ground crew member could have been struck by the loaded basket.

The operator’s training manual did not specifically prohibit ground crew members from placing themselves beneath the path of the balloon during landing and the ground crew member, although experienced in performing operational support tasks, was focussed on walking through the long grass and weeds in the paddock, rather than watching the approaching balloon.

Safety action

As a result of this occurrence, the balloon’s operator has advised the ATSB that they have spoken to the ground crew member about the lack of situational awareness and poor risk assessment. The operator intends to amend the company’s training manuals and ensure incidents of this type are covered in the initial and annual emergency procedure checks for all ground personnel.

The company’s Chief Pilot advised all flight and ground crew members of the incident, outlined the expectations when working or walking near balloons in low-level flight, and made the following recommendations:

• Never position yourself in a location where the basket will pass directly overhead. Balloons can be subject to low-level turbulence or last-minute inputs by the pilot (such as venting) and can descend rapidly and unexpectedly.
• When you are close to a balloon in flight, even if it is still attached to the quick release, keep your eyes on the balloon at all times to ensure you know where it is going. Ensure that the balloon does not pass overhead. If it does, react immediately and move to a safe area away from the basket.
• Do not make assumptions on the pilot’s intentions. These may vary from day to day, depending on the circumstances.
• When asked to put weight on during a landing remain off to the side of the basket until it has passed and then move in from behind.

Safety message

The Australian Ballooning Federation's Pilot Training Manual Part 5 "Aerostatics and Airmanship" describes the responsibilities and duties of the pilot and ground crew in detail.

The U.S. Department of Transportation Federal Aviation Administration’s Balloon Flying Handbook is another detailed and valuable resource. In its section on Human Resources, the handbook notes that balloons differ from aircraft in their reliance on unlicensed, non-certified and even first-time volunteers to support ground handling of the balloon.

The handbook goes on to make the point that “while all final decisions and the responsibility for safety still rest with the pilot, this broader than usual safety resource management model recognizes the human resources upon which every pilot relies for safe flight planning and decision-making”.

About this report

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

What happened

On 28 March 2018 at approximately 0700 Central Standard Time (CST), the pilot of a Pilatus PC-12/47E commenced his pre-flight inspection at Darwin Airport, Northern Territory. During the inspection, the pilot was interrupted on several occasions to attend to matters pertaining to the aircraft’s passengers and crew.

At approximately 0800 CST, the pilot had completed pre-flight checks and believed the aircraft was ready for flight. The aircraft taxied and took off from runway 29. During the initial climb, the pilot noted that the co-pilot’s airspeed indicator was not functioning correctly. The pilot then contacted Air Traffic Control (ATC) and requested a return to Darwin. While still in the circuit for runway 29, the pilot, thinking that the problem may be with the computer, requested clearance to taxi off the runway after landing and restart the aircraft. Clearance was granted and the landing, taxi and restart were conducted without incident. The pilot then requested a clearance from ATC for take-off, noting that if the issue with the airspeed indicator continued that the take-off would be aborted, and the aircraft would return to the parking area. Clearance was granted and the aircraft taxied and commenced the take-off roll. During the roll, the pilot noted that the airspeed indicator was still not functioning correctly and subsequently aborted the take-off and returned the aircraft to the parking area.

Upon exiting the aircraft, the pilot noted that the cover was still on one of the aircraft’s pitot tubes. The pilot removed the cover and inspected the tube. Once he was satisfied that there was no damage, he restarted the aircraft and proceeded with the flight with no further issues.

Safety message

This incident highlights two key safety elements. Firstly, it highlights the importance of ensuring that all pre-flight checks and procedures are carried out systematically, efficiently and with minimal interruption. Secondly, its shows the necessity of assessing a situation quickly and being prepared to conduct a diversion or return if there is an issue with the 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 29 April 2018, at 1330 Eastern Standard Time (EST), a Cessna 172N commenced taxiing on the southern apron at Archerfield, Queensland, in preparation for take-off. At the same time, a fuel truck was fuelling a Cessna 172S to the left side of the taxiway. As the Cessna 172N taxied past, the leading edge of the left wing contacted the fuel truck. The Cessna 172N was immediately stopped and the engine was shut down. Damage to the windscreen of the truck and leading edge of the Cessna 172N’s left wing was identified upon inspection. The Cessna 172N was then pushed clear of the taxiway.

A flying competition and social event was in progress, resulting in higher than normal air and foot traffic in the aerodrome vicinity. Visibility was good, with scattered cloud and a light southerly breeze.

Figure 1: Damage post incident, to the Cessna 172N and fuel truck

Source: Pilot in Command

Safety message

A number of taxiing collisions have been investigated by the ATSB, including Taxiing collision involving a Cessna 172S, VH-EOT and a Cessna 172S, VH-EOP at Moorabbin Airport, VIC on 29 January 2015 (AO-2015-011), which is available from the ATSB website. These incidents reinforce the importance of maintaining situational awareness^[1] and a good lookout during taxiing, particularly in instances of higher than normal activity and distraction.

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. Situational awareness: being aware of what is happening around you, where you are, where you are supposed to be, and whether anyone or anything around you is a threat to your health and safety. Source: Health and Safety Executive (HSE)

What happened

On 31 March 2018, at 1545 Central Daylight-saving Time (CDT), a Diamond DA40 departed from runway 26 at Port Pirie, South Australia for navigation training purposes. The pilot was the only occupant.

During initial climb, between 100 ft and 400 ft, the engine commenced rough running combined with reduced performance and a high cylinder head temperature indication. A low level circuit was completed to enable an immediate return to Port Pirie, where the aircraft landed safely. An observer noted smoke emanating from the engine cowling during return taxi. An inspection found that the pilot had inadvertently fuelled the aircraft with Jet A-1 (AVTUR),^[1] instead of AVGAS^[2] immediately prior to flight. The aircraft was recovered by road vehicle, to enable engine replacement.

Operator’s investigation

The operator found the student had undertaken one of three allocated briefing and monitoring sessions in refuelling operations, prior to assessment for competency, due to time constraints.

Figure 1: Refuelling point at Port Pirie, SA

Source: Operator

Safety action

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

A reinforcement to their instructors of the importance in ensuring student competence in unassisted refuelling, after previous instruction and monitoring, prior to solo refuelling operations.

Safety message

Pilots are reminded of the importance of checking fuel for the correct grade in addition to contaminants after refuelling operations are complete. The higher density of AVTUR in comparison to AVGAS, will cause it to settle to the bottom of fuel tanks, enabling distinction by colour and smell.

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. AVTUR: Aviation turbine fuel, designed for use in aircraft gas turbine engines. Either straw coloured or colourless. Source: Chevron Products Company
2. AVGAS: Aviation gasoline, designed for use in aircraft piston engines. Dyed green or blue for identification. Source: Chevron Products Company

What happened

On 22 March 2018, an Airbus A320-232 was on descent into Cairns, Queensland (Qld) when it encountered severe turbulence. A cabin crew member in the rear of the aircraft sustained a broken ankle as a result.

The aircraft was flying in and out of cloud at the time of the occurrence and the pilot reported that the weather radar only showed green patches, indicating nil significant turbulence. The seat belt signs were therefore not illuminated.

The pilot reported that no turbulence was forecasted or expected. No encounters with turbulence had been reported prior to the occurrence.

Safety message

The ATSB research report Staying safe against in-flight turbulence (AR-2008-034) details that while turbulence is normal and occurs frequently, it can be dangerous. It is rarely a threat to passenger aircraft or to pilot control of the aircraft. In a typical turbulence incident, 99% of people on board receive no injuries. The report discusses what you can do to stay safe.

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 22 May 2018, a SAAB 340B departed from Wagga Wagga, New South Wales (NSW) with 3 crewmembers and 30 passengers on board.

At about 1651 Eastern Standard Time, as the take-off roll commenced on runway 23, the crew observed four galahs rise up from the grass to the left and cross in front of the aircraft. As the aircraft’s speed reached V1^[1], the crew heard the distinct impact of the four galahs coming from the right side of the aircraft. The pilot flying^[2] (PF) proceeded to rotate^[3] at VR^[4]. The crew detected surges, power loss and vibrations from the no. 2 engine and the PF called “Positive rate, gear up, max power” initiating the engine failure at or above V1 procedure.

The crew continued to follow the company departure procedure by flying out to the south-west of the aerodrome on the runway heading. During initial climb, the crew observed the no. 2 engine had reduced torque and subsequently the pilot monitoring (PM) shut down the engine using the engine failure “Memory Items.” Passing 2,000 ft on climb, the crew proceeded to turn the aircraft left to conduct a return to Wagga Wagga via the instrument landing system (ILS)-Z runway 23 approach. The PM made radio calls on the common traffic advisory frequency (CTAF) to advise everyone within the aerodrome vicinity of the crew’s intentions and declared a PAN PAN^[5] on the Melbourne Centre frequency. The aerodrome rescue and firefighting reponse team acknowledged the radio calls offering their assistance if required.

At a safe altitude, the flight crew advised the cabin crew of the birdstrike and briefed them on the intended plan of action. The cabin crew member moved a paxing crew member towards the front of the aircraft to provide assistance if required. The flight crew advised the passengers of the situation and the cabin crew subsequently recited from the precautionary landing card and continued to secure the cabin with the paxing crew.

After the aircraft landed safely, the crew stopped the aircraft on the runway. The PM briefed the passengers and the cabin crew, and made radio calls on the CTAF and Melbourne Centre to advise of their intended actions. The crew then taxied the aircraft back to the bay where the passengers disembarked. During the post-flight inspection, the flight crew and engineers found bird remains in the engine intake and an air scoop on the inboard side of the no. 2 engine.

The engineering inspection revealed a stage one rotor blade bent beyond limits in the no. 2 engine and the engine was subsequently replaced.

Safety message

This incident provides an example of how effective failure management and crew resource management can lead to the safe recovery of an aircraft when an unplanned incident occurs. Occurrences involving aircraft striking wildlife, particularly birds, are the most common aviation occurrence reported to the ATSB. Strikes with birds continue to be a potential safety risk and present a significant economic risk for aerodrome and airline operators.

The ATSB research report AR-2016-063, Australian aviation wildlife strike statistics: 2006–2015, is available from the ATSB website.

About this report

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

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1. V1: the critical engine failure speed or decision speed required for take-off. Engine failure below V1 should result in a rejected take off; above this speed the take-off should be continued.
2. Pilot Flying (PF) and Pilot Monitoring (PM): procedurally assigned roles with specifically assigned duties at specific stages of a flight. The PF does most of the flying, except in defined circumstances; such as planning for descent, approach and landing. The PM carries out support duties and monitors the PF’s actions and the aircraft’s flight path.
3. Rotation: the positive, nose-up, movement of an aircraft about the lateral (pitch) axis immediately before becoming airborne.
4. VR: the speed at which the rotation of the aircraft is initiated to take-off attitude. This speed cannot be less than V1 or less than 1.05 times VMCG. With an engine failure, it must also allow for the acceleration to V2 at a height of 35 ft at the end of the runway.
5. 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 10 March 2018 at 0945 Eastern Standard Time, a Piper PA-38-112 Tomahawk aircraft was on a training flight from Toowoomba City Aerodrome, Queensland with a student and an instructor on board.

During approach to land on runway 11, the student was in control of the aircraft. After crossing the threshold, the student initiated the landing flare,^[1] and at this time, the aircraft encountered gusty conditions, which unexpectedly increased the aircraft’s rate of sink. The student immediately applied forward pressure to the control column as the instructor stated “taking over” and attempted to pull back on the control column. However, the student inadvertently maintained some forward pressure on the control column during this time, preventing the instructor applying full back pressure prior to landing.

Subsequently, the aircraft landed on all three wheels with sufficient force to shear off the nose wheel. The instructor was able to apply full back pressure on the control column and steered the aircraft off the runway and onto a grassed area. The instructor then shut down the aircraft and both the student and instructor evacuated the aircraft without injury. The aircraft was later assessed to have sustained substantial damage including to the propeller blades and oleo strut.^[2]

Safety message

While conducting training activities, students are more likely to sustain a higher than normal workload, particularly during landing. This can result in a decreased sensitivity to verbal instructions, including an instructor stating that they have taken over control of the aircraft. (Orlady, H. and Orlady, M, 1999). ^[3] It is also possible that a student may not be aware that they are still applying control inputs. As this is a normal part of human performance, it is not possible to eliminate the likelihood of this occurring altogether, and difficult to limit the consequences of it when there is little time available for instructors to identify the problem. However, it may be possible to reduce the risk by conducting comprehensive pre-flight briefing sessions where the required actions for a student once an instructor states, ‘I have control’, are emphasised regularly, particularly for inexperienced pilots.

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 final nose-up pitch of a landing aeroplane used to reduce the rate of descent to about zero at touchdown.
2. A hydraulic device used as a shock absorber in the landing gear of aircraft, consisting of an oil-filled cylinder fitted with a hollow, perforated piston into which oil is slowly forced when a compressive force is applied to the landing gear, as in a landing.
3. Orlady, H. and Orlady, M., Human Factors in Multi-Crew Flight Operations, Ashgate Publishing Ltd, Aldershot England

What happened

On 21 April 2018, a Cessna 210M aircraft was conducting low-level survey operations to the south-east of Laverton Aerodrome, Western Australia. The pilot was the sole occupant on board.

After completing survey operations, the aircraft was returning to Laverton when, at about 1315 Western Standard Time (WST), the aircraft engine experienced power loss. Power was regained briefly, before the engine again experienced a loss of power. The pilot conducted procedures to identify the problem; including switching the fuel selector between tanks to rectify the rough running, but this did not improve the engine performance.

By this time, the aircraft altitude had reduced to tree top level, when the pilot prepared for a forced landing into the trees. The pilot activated the aircraft emergency location transmitter^[1] (ELT) and Spidertracks^[2] unit. The aircraft then contacted a number of trees before coming to a stop. A small fire started in the engine bay, which was extinguished. The aircraft received substantial damage to the left wing, empennage, firewall and survey stinger. The pilot was not injured.

The aircraft was fitted with auxiliary fuel tip tanks. The pilot commented that the normal fuel transfer procedure from the tip to the main tanks was changed, to lessen the effects of electrical interference to the survey equipment when running fuel transfer pumps. By focusing on the changed procedure, the pilot was distracted and did not ensure that all fuel had been transferred from the tips to the main tanks. This resulted in the starvation of fuel to the engine.

Safety message

This occurrence is an example of what can happen when procedures are not followed. Pilots are reminded to follow published procedures when operating any aircraft system in accordance with the manufacturer’s recommendations.

Issue number 5 in the ATSB’s Avoidable Accident Series, Avoidable Accidents No. 5 - Starved and exhausted: Fuel management aviation accidents (AR-2011-112), provides more detail on these scenarios. This report is available from the ATSB website.

About this report

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

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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.
2. Spidertracks is a satellite based tracking system which includes an SOS function for use in emergency.

What happened

On 24 March 2018 the pilot of a Cessna 340 was on a private flight from Bankstown, New South Wales to Lilydale, Victoria. The aircraft was operating under the instrument flight rules (IFR)^[1]. The aircraft arrived at Lilydale at 1205 Eastern Daylight-saving Time.

During descent into Lilydale the pilot reported passing through broken cloud and becoming visual with the airfield. The pilot then cancelled IFR and proceeded to overfly the airfield to inspect the runway and windsock. The windsock indicated little wind. There was rain forecast in the area and showers in the vicinity, however there was no rain reported over the airfield at the time of arrival.

The pilot conducted a normal approach and touched down 250-300 m down the 850 m grass runway. After touchdown, the pilot applied moderate braking force. After realising that the aircraft was not slowing, the pilot applied further braking. The aircraft failed to slow and the pilot confirmed the throttles were at idle and pumped the brakes. The aircraft continued to slide down the runway. As the aircraft approached the end of the runway, the pilot applied full left rudder to turn the aircraft which resulted in a slight veer to the left. The aircraft collided with an embankment at the end of the runway, passed over a road and coming to rest against a fence (Figure 1). The aircraft was substantially damaged, and the pilot was not injured.

Post-flight it was determined that the airfield had received significant rain within around 1 hour before the landing which may have resulted in aquaplaning^[2]. The pilot reported that flap was set at 30 degrees for landing, less than the maximum available of 40 degrees. Contributing factors to the overrun include;

• wet grass runway (with possible standing water)
• nil wind conditions
• selection of less than full flap
• touchdown one third down the runway.

Figure 1: Final resting position of the aircraft 

Source: Victoria Police

Safety message

Wet runways present a hazard as the braking ability of the aircraft may be limited, particularly if there is standing water. Pilots should familiarise themselves with the pilots operating handbook for their aircraft and make allowances for runway length, size, slope, construction and condition.

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1. Instrument flight rules (IFR): a set of regulations that permit the pilot to operate an aircraft 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.
2. Aquaplaning: occurs when a layer of water builds up between the tyres and the runway. This results in loss of traction, preventing effective braking and aircraft control.