What happened

On 18 May 2018, test flights were being conducted on an experimental category aircraft Spacewalker II at Denmark, Western Australia (WA). The first five flights were completed with a test pilot, to fine-tune details of the aircraft and to make engine adjustments.

At about 1300 Western Standard Time (WST), having previously completed two successful landings, on the third landing, the aircraft bounced and landed hard resulting in the landing gear collapsing and the aircraft veering off the runway. The aircraft sustained substantial damage to the propellers, landing gear, engine, engine mount and firewall (Figure 1).

The pilot advised that he typically had flown aircraft with the side stick on the left and the throttle in the right hand. The Spacewalker II aircraft has the side stick on the right and the throttle in the left hand. While he was aware of this issue, in the moment of the bounce, the pilot inadvertently pulled the throttle back and pushed the side stick forward. This resulted in the aircraft moving towards the ground rather than the intended action of conducting a missed approach.

Figure 1: The Spacewalker II post-accident 

Source: Owner

Safety action

As a result of this occurrence, the pilot has advised the ATSB that he is taking the following safety actions:

The pilot will conduct further training in similarly configured aircraft and will spend more ground time in the Spacewalker II aircraft cockpit simulating flight to build more control familiarity.

Safety message

This accident serves as a reminder for all pilots that aircraft have different flight characteristics and systems. Pilots may have many hours experience, but that experience may be specific to one aircraft type or configuration.  The ATSB research report AR-2012-035: Avoidable Accidents No. 6: Experience won't always save you highlights that good training, focussed preparation and a readiness for the unexpected has a significant part to play in preventing an accident.

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 6 March 2018, a Cessna 206 was being operated on a training flight from Mareeba, Queensland (Qld) to Dimbulah, Qld (Figure 1) with a student and instructor on board.

Figure 1: Map showing locality

At about 1045 Eastern Standard Time, as the aircraft was on approach to Dimbulah, with flaps selected to 20 degrees and at 80 knots, the flight crew heard a loud clunk. The flight crew thought that they may have struck a bird and discontinued the approach. They commenced climbing and found that they required significant right aileron to remain tracking straight. Once at a safe altitude, the crew raised the flaps in stages.

The crew diverted the aircraft to Mareeba to conduct a flapless straight-in approach. As the aircraft slowed during the landing roll, the flaps extended towards 20 degrees.

The operator inspected the aircraft and found several issues, including:

• failure of the synchronising rod at the rod-end
• disconnection of the transmission worm drive between the actuating tube and the collar
• damage to the preselect cable clamp
• damage to the right flap track
• failure of the right centre aft roller. 

Figure 2: Diagram showing position of synchronizing rod assembly on aircraft

The operator replaced the damaged parts. The operator then carried out a return to service flight. The flaps system cable tension was found to be low. Maintenance subsequently readjusted the cable tension.

Safety message

This incident highlights the importance of conducting a go-around if something unexpected occurs during an approach to land. The flight crew immediately conducted a go-around, which allowed them time to consider the implications of the technical failure and the opportunity to conduct a diversion to an airport where appropriate emergency response facilities were available if required.

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, a Boeing 787-8 departed Bali, Indonesia on a scheduled passenger flight to Melbourne, Victoria (Vic.). After arrival in Melbourne, at about 0230 Eastern Standard Time, maintenance engineers were investigating a right engine anti-ice fault indication, when they discovered a cabin passenger blanket within the engine cowling (Figure 1).

Investigation by the operator found that maintenance had been performed in Bali prior to the aircraft returning to Australia, and five blankets from the passenger cabin had been used in place of correct personal protective equipment to prevent burn injuries to the engineers while maintenance was conducted. One of these blankets was inadvertently left on the engine after maintenance. The area in which the blanket was discovered was protected by fire suppressant, should it have been required.

Figure 1: Passenger blanket as found on engine

Safety message

This incident highlights the importance of maintenance personnel remaining vigilant in the conduct of their duties. There are a number of factors that can lead to errors occurring. The ATSB research report AR-2008-055, An Overview of Human Factors in Aviation Maintenance is available from the ATSB website.

Utilising an independent inspector may also minimise the possibility of items being missed upon the completion of maintenance.

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 May 2018, a Gippsland Aeronautics GA-8 Airvan departed Bundaberg, Queensland (Qld) for Hervey Bay, Qld. The pilot was the only occupant.

During cruise at 2,500 feet, the pilot recalled hearing a loud noise from the engine area and immediately after experienced airframe vibration. The pilot observed the engine instruments fluctuating and the engine running rough.

The aircraft lost airspeed and was unable to maintain altitude. The pilot elected to conduct a forced landing on Woodgate beach approximately 40 km SE of Bundaberg. The pilot completed a successful forced landing and was uninjured.

Engineering inspection

The post-flight inspection revealed the engine crankcase to be cracked adjacent to the number six cylinder. The operator replaced the engine and the aircraft returned to service.

Safety message

Following a complete engine failure, a forced landing is inevitable. For a partial power loss, pilots are faced with the decision as to whether to continue the flight or land immediately.

Pilots should:

• Conduct a thorough pre-flight and engine ground run to reduce the risk of a partial power loss occurring
• Plan their decision making for emergencies and abnormal situations prior to flight. ATSB investigations Engine failure involving Gippsland Aeronautics GA-8, VH-AJZ (AO-2011-125) and Partial engine failure involving a Gippsland Aeronautics GA-8, VH-FGN (AO-2015-123) highlight the importance of having thoroughly rehearsed emergency procedures.
• Constantly monitor engine instruments as they can provide early indication of a problem
• Take positive action and maintain aircraft control when conducting a forced landing until on the ground, while being aware of flare energy and aircraft stall speeds.

About this report

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

What happened

On 11 April 2018, at about 1250 Eastern Standard Time (EST), the pilot of a Piper PA-31 aircraft was preparing for departure on a freight charter flight from Moorabbin, Victoria (Vic.), to Wynyard, Tasmania (Tas.). Once lined up on the runway and cleared for take-off, the pilot advanced the throttle to the required settings, to stabilise the engines and check the temperatures and pressures, which were all in the normal operating range. The pilot released the brakes and commenced the take-off run. During the take-off, the aircraft yawed to the left and the pilot immediately closed the throttles and a rejected take-off was conducted. The pilot observed that the left propeller was stationary and therefore completed the shutdown procedure for the left engine. The pilot notified air traffic control and taxied to the parking area where the aircraft was shut down. The pilot observed fuel draining from the left engine for 5 to 10 minutes after both engines had been shut down. The engineers and the chief pilot were notified of the sequence of events.

Engineering inspections, ground and flight tests were carried out. No maintenance or mechanical issues could be identified which may have contributed to the power loss or fuel venting.

Safety message

This incident reinforces the importance of conducting a rejected take-off if any aircraft malfunctions or abnormalities are detected. In this instance, the pilot followed standard operating procedures to ensure a safe outcome was achieved. Decisive actions by the pilot ensured this emergency situation was contained safely before it could develop further.

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, at about 0158 Western Standard Time (WST), an Airbus A330-303 was en-route from Perth, Western Australia (WA) to Sydney, New South Wales (NSW) with 297 passengers and 11 crew members on board.

At the time of departure from Perth Airport, there was a known fault with one of the engine bleed air systems on the aircraft, which was permitted under the minimum equipment list. During cruise at flight level (FL) 390^[1], the crew received an ECAM^[2] ‘ENG 2 BLEED FAULT’ message, indicating a fault with the second engine bleed air system. The crew followed the ECAM actions to reset the system, but this was unsuccessful in restoring cabin pressurisation. Loss of the second bleed air system resulted in the depressurisation of the cabin.

The crew declared a PAN PAN^[3] and received clearance from air traffic control (ATC) to conduct a descent to 10,000 ft. Shortly after commencing the descent, the crew received an ECAM ‘CAB PR EXC CABIN ALT’ message, indicating an increase in cabin pressure, which requires a mandatory emergency descent. Oxygen masks deployed in the cabin, and the crew initiated the descent to 10,000 ft. Flight and cabin crew conducted regular passenger announcements throughout to keep passengers informed of the situation.

Once the aircraft was level at 10,000 ft, the flight crew continued to follow the non-normal procedure checklists and were able to reset the no. 2 engine bleed air system. The cabin crew manager informed the flight crew that there were no passenger injuries during the descent, however they had observed fumes and mist in the cabin, both of which dissipated after a short time.

The flight crew had initially intended to divert the aircraft to Adelaide, however, due to poor weather conditions and the fact that the no. 2 engine bleed air system was reset, the decision was made to divert the aircraft to Melbourne. The flight crew contacted ATC and received a clearance to climb to FL170, as requested.

The flight crew updated the cabin services manager with the latest information, and regular passenger announcements were made to keep passengers informed throughout the remainder of the flight. The aircraft landed at Melbourne without incident, where engineers subsequently replaced the no. 2 engine bleed valve and solenoid.

Safety message

This occurrence provides a good example of effective handling of non-normal, in-flight indications. It demonstrates that a positive outcome can be achieved through a combination of following documented procedures, information sharing between flight and cabin crew and regular, clear passenger communications.

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. Flight level: at altitudes above 10,000 ft in Australia, an aircraft’s height above mean sea level is referred to as a flight level (FL). FL 390 equates to 39,000 ft.
2. Electronic centralised aircraft monitor (ECAM): Electronic system used to monitor and display aircraft systems information and provide required flight crew actions in most normal, abnormal and emergency situations.
3. 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 16 March 2018, the crew of a Piper PA-32R-301 was conducting a series of circuits at Bacchus Marsh, Victoria (Vic). Following approximately seven circuits, the instructor reduced power on the aircraft to allow the student to fly a practice forced landing on runway 27.

As the aircraft neared the runway, the student pilot reduced the power to idle and the landing gear position warning sounded. The instructor reported that both he and the student mistook this for the stall warning^[1] and the aircraft subsequently landed with the gear retracted.

Prior to the circuits, the aircraft departed Essendon, Vic. for a navigation training flight. Despite having flown approximately 5 to 6 hours, the student wanted to practise circuits. The instructor reported that the student did not require a great deal of instruction in circuits, having performed previous circuits to a very good standard.

Pilot comments

The Instructor provided the following comments:

• The instructor felt confident with the student’s performance, resulting in relaxed supervision.
• Both pilots were focusing outside the aircraft at 300 ft, when they should have been focused on completing the final landing checks.
• Distraction also played a part in both pilots missing the final landing checks, as they had been following the progress of a student who had conducted their first solo flight and had landed on a different runway to the one from which they had taken off.
• The landing gear warning was mistaken for a stall warning due to the higher than normal landing attitude.

Safety action

As a result of this occurrence, the instructor and student undertook a full debrief and formulated a plan to continue the student’s training. The instructor’s self-debrief focused upon maintaining vigilance regardless of the performance of the student.

Safety message

This occurrence highlights the importance of vigilance during critical phases of flight. Distraction and complacency can result in critical tasks being omitted and not being detected until it is too late.

Pilots should also familiarise themselves with aircraft warning systems to ensure correct responses to those warnings.

The Flight Safety Australia article, Those who won’t: avoiding gear-up landings includes valuable information to assist pilots in avoiding these incidents.

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. Stall warnings indicate to the flight crew that the aircraft will approach a stall if action is not taken to reduce the angle of attack (ATSB AR-2012-172). A stall occurs when the smooth airflow over an aeroplane’s wing is disrupted, and it loses lift rapidly. This causes the aircraft to descend. This is caused when the wing exceeds its critical angle of attack (the angle of the wing relative to the direction of the airflow). This can occur at any airspeed, at any attitude, and at any power setting (FAA, 2004).

What happened

On 28 March 2018, a Boeing 787-8 departed Melbourne, Victoria (Vic.) on a scheduled passenger flight to Bali, Indonesia. On arrival into Bali, while the aircraft was being unloaded, the ground crew noticed smoke emanating from the cargo hold and identified a burnt passenger bag as the potential source. The ground crew subsequently removed the bag from the aircraft. Following further inspection, it was found that a power bank^[1] (Figure 1) contained within the passenger bag was the cause of the smoke.

Figure 1: Power bank removed from passenger bag

Source: Operator

Safety message

Spare lithium and lithium-ion batteries can present a significant hazard when carried in the cargo hold of an aircraft. If a battery is damaged or overheats, it can result in a fire. Such fires require the device or battery to be cooled with non-alcoholic liquids. Cabin crew and flight crew are specifically trained in the management of lithium battery smoke and fire incidents in the cabin. If a battery in the cargo hold catches fire, however, it might not be possible to extinguish the fire, with potentially catastrophic results.

Power packs and power banks are classified as spare lithium-ion batteries, therefore only permitted in a passenger’s carry-on baggage. The Civil Aviation Safety Authority (CASA) provides guidance on their “Travelling safely with batteries and portable power packs” webpage and via the ‘Can I pack that? dangerous goods app for passengers.

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 power bank is a portable device that can supply power to another device through a USB port.

What happened

On the morning of 27 March 2018, a Robinson R22 helicopter landed at Delamere Station, Northern Territory (NT) to conduct a refuel from the drum stock.

At about 0730 Central Standard Time (CST), after the refuelling was complete, the pilot proceeded to take-off from the station. During the take-off, the downwash from the main rotor blade spun the fuel pump around the top of the fuel drum resulting in the fuel hose hooking over the helicopter’s skid. The fuel hose subsequently pulled the helicopter to one side causing dynamic rollover.^[1] The helicopter collided with the ground resulting in substantial damage (Figure 1).

Figure 1: Robinson R22 post-accident, in the vicinity of the fuel drum

Source: Operator

Safety message

The pivoting of the helicopter with the skid in contact with the fuel hose, and subsequent loss of control is consistent with the phenomenon known as dynamic rollover.

Once started, dynamic rollover cannot be stopped by application of opposite cyclic^[2] control alone. Even with full opposite cyclic applied; there is not sufficient control authority to arrest the roll once it is developed and the main rotor thrust vector and its moment serves to accelerate the roll. Quickly reducing collective^[3] pitch is the most effective way to stop dynamic rollover from developing.

This occurrence serves as a reminder for pilots to never hover close to fences, sprinklers, bushes, runway lights or other obstacles a skid could catch on.

The R22 Pilot's Operating Handbook includes a safety notice (SN-9) which provides advice about how to avoid dynamic rollover situations.

About this report

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

__________

1. Dynamic rollover: A rolling tendency, when close to the ground. For dynamic rollover to occur, some factor has to cause the helicopter to roll or pivot around a skid or landing gear wheel until its critical rollover angle is reached.
2. Cyclic: a primary helicopter flight control that is similar to an aircraft control column. Cyclic input tilts the main rotor disc, varying the attitude of the helicopter and hence the lateral direction.
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.

What happened

On the morning of 24 March 2018, the pilot of a Robinson R44 was conducting aerial application operations on a crop near Whitton township, New South Wales (NSW). The pilot was aware of a powerline in the vicinity of the paddock and was verbally calling ‘wire at the end’ on each run towards the powerline in order to heighten his awareness of the obstacle and focus on its location.

After about ten minutes of operation over the crop at about 40 ft above ground level, the pilot commenced a run towards the powerline. As he did so, he noticed an unusual obstacle protruding about half a metre above the crop canopy and 20 m to the right of the helicopter’s track. The pilot focussed his attention on the obstacle, momentarily interrupting the verbal annunciation of the position of the powerline at the end of the spray run.

The obstacle was a water moisture probe located approximately 100 m from the end of the spray run. Although it posed no immediate danger to the operations of the helicopter, the pilot was distracted by its presence and watched it as it passed the aircraft, which was enough to interrupt his situational awareness.

As the pilot turned his focus back to the front of the aircraft at the end of the spray run and pitched the helicopter up to commence a turn, the aircraft struck the wire. After contact, the helicopter was able to proceed straight ahead for approximately 100 m with the wire dragging behind it before contacting the ground and rolling over.

The pilot exited the aircraft and sustained minor injuries in the accident. The helicopter was substantially damaged.

Figure 1: Helicopter final resting site

Source: Aircraft operator

Safety action

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

• requesting customers to detail any potential obstacles prior to operation
• conducting a site inspection prior to commencing the operation
• debriefing and discussing with pilots the use of unbroken situational awareness techniques to enhance awareness of obstacles and distractions.

Safety message

This accident highlights that distractions can arise unexpectedly during any phase of flight and demonstrates the dangers of such, especially in the low-level environment.

The ATSB research report B2004/0324, Dangerous distraction: An examination of accidents and incidents involving pilot distraction in Australia between 1997 and 2004, is available from the ATSB website.

The ATSB has also released, in association with the Aerial Agriculture Association of Australia, an educational booklet, Wirestrikes involving known wires: A manageable aerial agriculture hazard (AR-2011-028). This booklet contains numerous wirestrike accidents and the lessons learnt from them. It also highlights the role of landholders and utility owners in contributing to safe operations. This includes installing markers on wires, particularly where regular low-level flying takes place.

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.