What happened

On the evening of 18 January 2018, a Diamond DA42 aircraft departed from Parafield Airport, South Australia (SA) on an IFR^[1] dual training flight.

At about 2104 Central Daylight-saving Time (CDT), the aircraft was maintaining 3,200 ft, 5 NM north-west of Parafield Airport when the crew received a DOOR OPEN annunciator on the primary flight display. The crew checked and secured the front canopy and observed the rear door to be in the unlocked position. With the student pilot flying, the instructor attempted to latch the rear door. During the attempt, the rear door opened abruptly and detached from the aircraft. The instructor took over control and conducted a return to Parafield Airport, SA.

It was determined that the crew omitted to check and secure the door in the pre-flight inspection, the before-start checks and the hold point checks. The door was observed to be closed and down; however, it was unlatched and therefore not secured.

The aircraft flight manual (AFM) (Figure 1) in-flight emergency procedure when a door opens, advises to reduce speed and land at the nearest aerodrome. The crew did not reference the AFM and attempted to shut the door in-flight resulting in the door opening and subsequently detaching from the aircraft.

The operator conducted a search, but was unable to locate the door.

Figure 1: Diamond DA42 Emergency Procedure for an open door

Source: Diamond Aircraft Industries Inc.

Related occurrences

A search of the ATSB database revealed a similar occurrence:

AO-2014-164

On the afternoon of 14 October 2014, the pilot/owner of an amateur-built Van’s Aircraft Inc. RV-6A aircraft, registered VH-JON and operated in the ‘experimental’ category, departed Moorabbin Airport, Victoria on a local flight.

Shortly after reaching a cruise altitude of 2,900 ft, the aircraft descended to 2,500 ft. After that time, no further air traffic control radar returns were received from the aircraft. The aircraft descended rapidly, and a witness reported observing objects falling from the aircraft. The aircraft subsequently collided with the ground next to a house in the suburb of Chelsea, 8 km south of Moorabbin. The pilot was fatally injured, and the aircraft was destroyed.

Following the accident, members of the public found a number of aviation-related items away from the accident site that belonged to the pilot.

The liberation of the items from the aircraft’s interior indicated that the canopy likely opened in‑flight. However, this was based on the assumption that the items were initially inside the cabin.

It was possible that the pilot was startled and distracted after the canopy opened due to the severe cockpit wind, noise and debris flying about. Though, the extent to which this contributed to the occurrence was unknown.

Also, while the ATSB was unable to determine how the canopy opening would have affected aircraft control, there were indications that the pilot was attempting to respond to the situation. However, for reasons undetermined, recovery did not occur.

Safety action

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

The Head of Operations issued an email reminding crew of the correct procedures of obtaining a visual confirmation of the door being latched and secured, and when a door becomes open in flight.

Safety message

This occurrence serves as a reminder for pilots to check the security of their aircraft’s doors prior to departure. When a door opens mid-flight the risks can result in distraction, damage to the aircraft, personal injury, and if it becomes detached; damage or injury on the ground. The incident also highlights the importance of referencing the flight manual during emergency procedures.

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. 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 18 January 2018, at 1400 Eastern Daylight-saving Time (EDT), a DJI Matrice 600 Pro hexacopter remotely piloted aircraft (RPA) was conducting a flight above Roseville Chase oval, New South Wales (NSW). During the return-to-home procedure, at a height of 20-25 m, the RPA contacted a pole and subsequently collided with terrain. It sustained damage beyond repair.

The pilot speculated that it is possible that the return-to-home height was not checked after the application was started. This caused the RPA to return to home at an unsafe height.

Safety message

This incident highlights the importance of following pre-flight procedures for remotely piloted aircraft to ensure that all flight parameters are set correctly.

Further information about flying a drone (RPA) safely can be found on the ATSB website, under the news item: Know your drone and the rules to fly safely.

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 February 2018, at 0917 Central Standard Time (CST), a Cessna 210M commenced its take-off run on runway 34 at Port Keats, Northern Territory (NT) for departure to Bathurst Island, NT. At this time, a Cessna 404 was also at Port Keats, taxiing to depart for Darwin, NT, from the same runway.

The 404 entered runway 34 while the 210 was in the take-off run resulting in the pilot of the 210 rejecting their take-off, stopping approximately 50 m from the 404. The 404 taxied clear of the runway and the 210 repositioned and departed without further incident.

The pilot of the 404 reported that while the 210 was taxiing for runway 34, they were awaiting traffic information from air traffic control (ATC). The pilot of the 404 made a taxi call on the Port Keats common traffic advisory frequency (CTAF) which the pilot of the 210 reported hearing prior to broadcasting that they were rolling for take-off. It was during this rolling broadcast that ATC contacted the pilot of the 404. This radio call required repeating of information twice due to transmission difficulties. As a result, the pilot of the 404 did not hear the pilot of the 210 making the rolling call.

Prior to entering runway 34, the pilot of the 404 reported scanning the circuit area, presuming the 210 had already departed. They reported that they had not focused on the runway environment during the scan.

Safety message

According to ATSB publication A pilot's guide to staying safe in the vicinity of non-controlled aerodromes (AR-2008-044(1)) and the associated research report Safety in the vicinity of non-towered aerodromes (AR-2008-044(2)), runway incursions are amongst the most common occurrences at non-towered aerodromes.

Both publications highlight common errors leading to conflicts in operations at or near non-towered aerodromes and strategies are discussed to assist pilots to ensure that safe operations are always maintained.

About this report

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

What happened

On 10 March 2018, at about 1600 Eastern Standard Time (EST), an Agusta AW139 helicopter was ground-taxiing to its parking area when it struck a maintenance work stand with the main rotor blades. At the time of the impact, the helicopter was being positioned short of the refuelling area to allow another aircraft to utilise it.

The helicopter was travelling at a slow walking pace when the impact occurred. The impact was felt as a vibration through the rotor system and had no effect on the fuselage or forward movement. The crew conducted a normal shutdown.

Post-flight, engineers inspected numerous components of the helicopter. Damage was isolated to the tip cap assemblies of the main rotor blades (Figure 1).

Figure 1: Damage to main rotor blades

Source: Owner

Safety message

Even when operating in familiar environments, flight crew need to remain vigilant for potential hazards in the area and maintain a good look out to ensure distances from obstacles are maintained.

About this report

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

What happened

On 19 March 2018, a Boeing 737-8 departed Brisbane, Queensland (Qld) on a scheduled passenger flight to Townsville, Qld. On descent, at about 2130 Eastern Standard Time (EST), cabin crew became aware of smoke emanating from a point of sale (POS) machine.

The cabin supervisor contacted the flight crew and relayed guidance obtained from the flight crew to the cabin crew member managing the event. The cabin crew subsequently removed, isolated and submerged the battery and the device in water. However, communication difficulties between the cabin supervisor and the cabin crew were experienced during the event.

Safety message

Fire and smoke on an aircraft can eventuate from a range of sources. As such, crew members must remain vigilant during all stages of flight to ensure that any situation that arises is handled effectively.

In addition to operational procedures, non-technical skills for cabin crew, such as crew communication and coordination are imperative in any abnormal or emergency situation. An example of effective crew coordination between flight and cabin crew can be found in previous ATSB investigation; Tailstrike involving Airbus A320, VH-VGF, at Melbourne Airport, Victoria on 11 May 2016. Operators are therefore reminded of the benefits of providing cabin crew with the opportunity to practice these skills. The International Civil Aviation Organization (ICAO) and the Civil Aviation Safety Authority (CASA) provide guidance in the Cabin Crew Safety Training Manual as well as Civil Aviation Advisory Publication (CAAP) SMS-3(1) Non-Technical Skills Training and Assessment for Regular Public Transport Operations.

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 March 2018 at 1006 Eastern Standard Time (EST), the pilot of a large remotely piloted octocopter was conducting stockpile surveys at a commercial salt field near Bajool, Queensland (Qld).

The aircraft, with propellers mounted on eight outrigger arms, had been built by the licensed operator and was powered by a 21-amp-hour, six-cell lithium-ion polymer battery. It had been configured to transmit to the operator a low battery warning at 3.5V per cell, return to home at 3.4V per cell and land immediately at 3.3V per cell.

Near the end of the mission the wind speed increased to 25 km/h, with gusts up to 35 km/h. The pilot received a low battery warning, indicating that half of the battery had been used, and switched to manual control to fly the aircraft home into the wind.

It was determined later that two of the battery’s six cells had a resistance of more than 9 ohms and as a consequence the aircraft’s battery voltage dropped much faster than expected. The pilot calculated that the aircraft had insufficient battery voltage to complete a 300 metre flight over the salt water ponds and instead chose to land it on an island approximately 250 metres away.

While landing the aircraft, the pilot misjudged its position above the ground and cut power at an altitude of 7 m. The aircraft landed heavily and sustained minor damage to its propellers, motors, gimbal and wiring. Some of the outrigger arms were also broken.

Safety action

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

• Implementing maintenance checks on batteries every six months
• Using seven-cell (rather than six-cell) lithium-ion polymer batteries in windy conditions
• Establishing an alternative landing zone at the other end of the mission plan
• In similar circumstances, allowing the aircraft to auto-land, rather than attempting to land it manually
• Considering a prohibition on flight operations when wind gusts exceed 30 km/h.

Safety message

This incident demonstrates the adverse effect that operating in windy conditions can have on remotely piloted aircraft. Windy conditions typically reduce flight endurance. Aircraft trying to maintain a steady position or fly into the wind expend more battery power than flight operations in calm conditions.

Operators of remotely piloted aircraft flying in windy conditions should consider the effect increased battery-expenditure may have and plan accordingly. Operators should consider using larger batteries, raising the low-battery return-to-home threshold and establishing alternative landing zones.

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 1 February 2018, at about 1535 Eastern Daylight-savings Time (EDT), an OAS Parts LLC UH-1H helicopter was conducting fire control operations when the pilot noticed a strong smell of oil in the cockpit and oil droplets hitting the water, under the helicopter, in a dam. The pilot manoeuvred the helicopter to a paddock close by for a precautionary landing. In the last metre or so of landing, the hydraulic warning light indicated a loss of hydraulic pressure and the controls stiffened up during the last positioning movements onto the ground. The pilot was able to land the helicopter without incident. On landing, the hydraulic oil was diminished with an empty hydraulic tank and the belly of the aircraft was covered in oil.

On inspection it was found that two hydraulic lines had rubbed together causing one to split. Engineers replaced a hose that had been injected by the adjacent hose causing a hole. Both hoses and the hydraulic pump were also replaced as per the maintenance manual.

Safety message

Emergency situations can rapidly develop from initial signs and symptoms to a complete failure. The proactive response of the pilot to the initial signs of this malfunction enabled the helicopter to be manoeuvred into a much safer position by the time the full failure occurred.

About this report

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

What happened

On 7 March 2018, at about 0810 Central Daylight-savings Time (CDT), an Evektor Sportstar Plus departed Naracoorte on a private flight to Mount Gambier, South Australia (SA). During the cruise at approximately 600 feet above ground level, 21 kilometres south of Naracoorte, the pilot noticed cattle in a paddock on his flight path and banked right to avoid overflying the cattle. During the manoeuver, the pilot’s flight bag fell from the passenger seat and became lodged between the seat and the control column, causing an abrupt pitch down.

The pilot tried to extricate the bag as the aircraft rapidly descended, but the aircraft struck a powerline and collided with terrain. As he exited the aircraft, the pilot stepped on the downed but still live powerline, causing burns to his foot.

The aircraft was extensively damaged, and the pilot suffered injuries to the knee, shin and foot.

Figure 1: Evektor Sportstar Plus damage

Source: South Australia Police

Safety message

Even a planned routine flight in good flying conditions can encounter unexpected hazards at any time. The cockpit should always be arranged to minimise the hazard of loose articles, regardless of the type of flight expected.

Unrestrained items in the cockpit increase the risk of both flight control interference during normal flight and injury to occupants during an accident. Pilots should take care to ensure that all items and cargo are adequately restrained to prevent movement during flight and improve survivability in the event of 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 19 February 2018, just before 0910 Eastern Daylight-saving Time (EDT), the crew of a Boeing 737-800 was preparing for departure from Sydney Airport, New South Wales (NSW) to Gold Coast Airport, Queensland (Qld). There were six crew and 168 passengers on board. The planned flight time was 1 hour 20 minutes. To prepare for the short sector the crew programmed their anticipated approach for Gold Coast Airport into the aircraft’s Flight Management System (FMS).^[1] The approach was a series of waypoints described by the GREAV SIX Standard Arrival Route (STAR).^[2]

Prior to descent into the airport, the crew received and read back a different approach – the ROONY FOUR STAR – and were cleared to descend to flight level (FL) 250.^[3] As the aircraft passed ROONY it commenced a turn 11º to the left, deviating from the agreed route. Route 2 in the FMS carrying the GREAV SIX STAR was still active in the aircraft’s FMS. The crew did not detect the anomaly.

Air Traffic Control (ATC) identified the deviation and asked the crew which STAR they would like to follow. The crew, recognising the GREAV SIX STAR was already programmed and checked, requested that approach from ATC. The aircraft was re-cleared on the GREAV SIX STAR and a normal approach and landing was conducted.

Safety message

This incident highlights the importance of ongoing verification, by flight crews, of the data the aircraft is working with at various stages of flight. The route data that was entered into the FMS was correctly keyed and had an intended purpose at the time of entry; however, it was no longer suitable for use in the later stages of the flight, when a different clearance requiring different waypoint data was provided.

ATC was able to alert the crew to the flight path deviation. ATC was also able to support the crew at a critical time by providing the opportunity to continue the approach utilising the data that was programmed and active in the FMS. This changed the circumstance of the operation to render the data valid again.

The ATSB SafetyWatch highlights the broad safety concerns that come out of our investigation findings and from the occurrence data reported to us by industry. One of the safety concerns relates to data input errors.

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. Flight Management System (FMS): a navigation, operations and performance computer used by the crew to manage the aircraft and flight. (Skybrary)
2. Standard Arrival Route (STAR): a published approach procedure used to deconflict traffic, and provide predictable movement of traffic to simplify management of airport arrivals. (Airservices Australia)
3. 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 250 equates to 25,000 ft. (Airservices Australia)

What happened

On 20 January 2018, a remotely piloted aircraft (RPA) was being operated on a training exercise over water off Wategos Beach near Byron Bay, New South Wales.

At about 1318 Eastern Daylight-saving Time (EDT),^[1] while maintaining 100 ft above ground level, the crew detected a propeller malfunction on one of the RPA’s six propellers. The crew elected to conduct a precautionary landing of the RPA into the water about 200 m offshore. The RPA operator indicated that this was in accordance with their emergency procedures for a propeller malfunction in order to reduce the risk to the beach-going public.

The RPA was recovered from the water and inspected by the operator. The initial inspection indicated that bolts fastening the propeller to the motor unit had failed. Figure 1 shows the failed bolts (left) along with a picture of a non-damaged propeller assembly (right). The RPA has been sent back to the manufacturer for further examination.

Figure 1: Failed bolts that secure the RPA propeller to motor (left) and example of an undamaged propeller and motor assembly (right)

Safety message

The ATSB’s research report A safety analysis of remotely piloted aircraft systems 2012 to 2016: A rapid growth and safety implications for traditional aviation found that, there has been rapid growth in the number of RPA systems in Australia. This incident highlights the importance of contingency planning for RPA operations. While the manufacturer indicated that, for this RPA configuration, control could be maintained in the event of a single propeller failure, a loss of a control surface would result in a degradation of performance. In this case, the crew identified the reduced performance and acted accordingly by landing the RPA offshore, thereby reducing the risk to third parties.

The Civil Aviation Safety Authority has published guidance on the operation of RPA’s in the advisory circular, Remotely piloted aircraft systems – licencing and operations. Section 4.6 specifically states that, procedures to be followed in the event of an engine/propeller failure should be in place and included in the RPA system mission plan.

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. Eastern Daylight-saving Time (EDT): Coordinated Universal Time (UTC) + 11 hours.