What happened

On 15 January 2018, at 1245 Eastern Standard Time (EST), a Vans Aircraft RV-7A commenced take-off from runway 15 at Atherton airport, Queensland (Qld) for Charters Towers, Qld. The pilot was the sole occupant.

The pilot reported that upon rotation,^[1] the aircraft encountered a dust devil^[2] and was pushed to the left. The pilot then applied full power in an effort to regain directional control and land the aircraft. The left wing, however, contacted the ground, and the aircraft came to rest inverted. The aircraft was substantially damaged and the pilot received minor injuries.

A row of trees to the left of the runway combined with hot weather was conducive to the formation of dust devils. There was no visual indication of debris or dust plumes to indicate the sudden formation or location of the dust devil, causing difficulty in identification and avoidance measures.

Figure 1: Vans Aircraft RV-7A post-accident, including damage to the left wing

Source: Queensland Police Service

Safety message

The ATSB has investigated multiple take-off and landing accidents associated with dust devils, including Loss of Control; Mt Vernon Station, WA; 1 September 2006; VH-RIL, Cessna 172L (200605133), which highlights the risk of this phenomenon and how light aircraft may be affected. Further information on The Dangers of Dust Devils is available on 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. Rotation: The action of raising the nose wheel by applying back pressure to the yoke.
2. Dust devil: A dust filled vortex similar in shape to a tornado but of much less strength. Source: Bureau of Meteorology

What happened

On 13 February 2018, the pilot of a de Havilland DHC-1 departed Luskintyre, New South Wales (NSW) after conducting ground power tests. The pilot was the only occupant on board.

During initial climb, at about 100 ft above ground level (AGL), the engine lost partial power. The pilot lowered the nose of the aircraft while manipulating the throttle in an attempt to correct the power loss. Due to the proximity of fencing, trees, housing and roads immediately past the landing strip, the pilot elected to attempt a forced landing on an adjacent paddock 90 degrees to the right. The aircraft entered a stall, impacting the ground in a nose-down, right wing low attitude.

The pilot subsequently reported that an inspection of the carburettor identified a loose part had caused the priming float to jam in the open position, resulting in an excessively rich fuel-air mixture.

Figure 1: de Havilland DHC-1 post accident

Source: Pilot in Command

Safety message

Data illustrates that partial power loss in single-engine aircraft occurs three times more frequently than total engine failure. Due to unreliability of engine power in these circumstances, it can be advantageous to treat partial power loss as total engine failure and act accordingly. The ATSB website publication 'Managing partial power loss after take-off in single-engine aircraft' provides guidance on managing these situations. Pre-flight self-briefing is an important tool in reinforcing planned emergency actions, including in circumstances of unfavourable terrain immediately past the aerodrome.

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 4 February 2018 at 1200 Eastern Standard Time (EST), the pilot of an Aeroprakt 22LS was conducting solo training in the circuit area of Townsville Airport, Queensland (Qld). Having completed three of five planned circuits, with touch and go landings on both runways 01 and 07, the pilot commenced the fourth circuit. Due to a departing commercial jet on Runway 01, Air Traffic Control (ATC) instructed the pilot to extend the downwind leg of the circuit and, to avoid the jet’s wake turbulence,^[1] change runways again to Runway 07.

During this approach, the pilot encountered a rain shower and associated downdraft increasing the control workload required. The pilot did not acknowledge a call from ATC with instructions for a full stop landing. As the pilot was approaching the flare, ATC repeated the call. The pilot acknowledged the radio call and continued with the landing. The aircraft bounced and landed heavily, coming to a complete stop on the runway. The pilot exited the aircraft without injury.

The aircraft sustained substantial damage with a bent nose leg and damage to the firewall and the fuselage skin adjacent the main undercarriage.

The operator later advised that the pilot did not conduct a go-around as ATC had instructed them to make a full stop landing and they thought this precluded them from conducting a go-around.

Related occurrences

A search of the ATSB database revealed a number of similar occurrences including:

AO-2016-049

On 16 May 2016, the pilot of a Maule MT-7-235 aircraft, registered VH-DRS, conducted a private flight from Greenfields airstrip (near Noosa), Queensland, with two passengers on board.

On final approach to land, the pilot noticed they were getting low on the approach path and at about 500 ft, they increased the power to regain their approach path. The pilot subsequently assessed that the aircraft was too high and lowered the nose to re-intercept the approach path. The pilot flared the aircraft for landing, the aircraft landed heavily and bounced into the air. As the aircraft landed again, the nose wheel touched down first (before the main landing gear) with sufficient force that the nose wheel strut fractured. The nose landing gear and propeller then dug into the ground and the aircraft rotated over its nose and slid a short distance inverted before coming to rest. The pilot and one passenger were uninjured, the other passenger sustained minor injuries, and the aircraft sustained substantial damage.

AO-2012-107

On 23 August 2012 at 1733 Central Standard Time, a Cessna 210N, registered VH-WPD, departed Numbulwar for Urapunga, Northern Territory, on a charter passenger flight with the pilot and two passengers on-board. The pilot reported intermittent sun glare during descent to Urapunga, when at 3 NM for runway 28. On late final the sun glare on the windscreen greatly restricting visibility. During the flare, the pilot identified a runway edge marker in line with the nose of the aircraft. The pilot maneuvered the aircraft back in line with the centre of the runway and the aircraft continued to float down above the runway.

The sun glare increasingly restricted visibility during the landing. The aircraft touched down and the pilot applied heavy braking in short bursts. The aircraft departed the end of the runway and travelled through two fences before coming to a stop. The pilot and two passengers evacuated the aircraft. The pilot received minor injuries and the two passengers were uninjured.

Safety message

All pilots, regardless of their experience level, should be prepared to undertake a go-around rather than continuing with an unstable approach. The Flight Safety Foundation released a briefing note Approach-and-landing accident reduction Briefing Note 6.1 to remind pilots of the importance of being prepared to conduct a go-around during all approaches.

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. Wake turbulence: turbulence from wing tip vortices that result from the creation of lift. Those from large, heavy aircraft are very powerful and persistent, and are capable of causing control difficulties for smaller aircraft either following or below.

What happened

On 5 March 2018, as boarding for a domestic flight from Melbourne to Sydney was nearing completion, a passenger noticed his mobile phone was smoking and emitting popping and crackling sounds.

The mobile phone was dropped on the cabin floor in front of seat 23C and the cabin crew were alerted. Those passengers already aboard were directed to leave any personal items behind, move towards the front of the aircraft and exit through the forward door. The flight crew were advised, and they requested that the Aviation Rescue and Fire Fighting Service (ARFFS) attend.

Cabin crew poured bottled water sourced from passengers and the galley onto the mobile phone and by the time the ARFFS arrived through the aircraft’s rear door the device (shown in Figure 1) had ceased smoking.

After the burned mobile phone had been removed from the aircraft by the ARFFS the operator’s engineering services employees cleaned up the spilled water and conducted an inspection for any damage. Passengers were subsequently allowed to return to the cabin to retrieve their belongings and the operator arranged for another aircraft to work the scheduled service.

Figure 1: Damaged mobile phone after removal from aircraft by ARFFS

Source: ARFFS

Safety message

This incident is a dramatic reminder of the hazards of transporting personal electronic devices powered by lithium or lithium-ion batteries, and a demonstration of the importance of including mobile phones, laptop computers, power banks, wireless headphones, watches and cameras in carry-on baggage, rather than checked baggage.

If the overheating device had been included in the passenger’s checked baggage and placed in the aircraft’s cargo hold it may have presented a much greater hazard. A significant quantity of water was required to contain the thermal runaway event that developed as the mobile phone short circuited and overheated and Figure 2 shows the water bottles emptied onto the device by the cabin crew.

While the risk of these devices catching fire and exploding in-flight is low, airlines and flight crews have well-established procedures and methods to contain battery fires in-flight. The Civil Aviation Safety Authority web page Travelling safely with batteries and portable power packs provides information on the safe transport of devices with lithium or lithium-ion batteries on aircraft.

Figure 2: Water bottles emptied to cool and extinguish mobile phone

Source: ARFFS

Other ATSB news stories and investigations about lithium or lithium-ion batteries are available:

• Personal electronic device fire in-flight involving Boeing 747, VH-OJS, 500 km WNW of John F. Kennedy International Airport, United States, on 21 June 2016
• Crew’s prompt in-flight response to smoking device.

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 1631 Eastern Daylight-saving Time (EDT), an Airbus A330-202 was pushing back^[1] from the gate for a scheduled departure from Sydney, New South Wales (NSW) to Melbourne, Victoria (Vic.).

During the pushback, the tow was disconnected and an aircraft engineer instructed the flight crew to apply the park brake. The brakes were applied by the flight crew while the aircraft was still moving. The aircraft stopped suddenly and the nose subsequently pitched upwards, resulting in multiple minor injuries and one serious injury to cabin crew who were standing at the time.

Safety message

ATSB report

Ground and flight crews need to maintain situational awareness and communication during pushback procedures to ensure the most appropriate actions are taken.

Operators should ensure cabin crew are made aware of the hazardous nature of conducting duties while the aircraft is moving on the ground.

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. Pushback is where an aircraft is pushed backwards away from an airport gate by external power. It involves a tug connected to the nose wheel, or a power unit connected to the main landing gear.

What happened

On 15 February 2018 at 1845 Eastern Daylight-saving Time (EDT), the pilot of a Zenith Zodiac 601 was conducting stall recovery training approximately 16 kilometres east of Temora Airport, New South Wales (NSW). At approximately 6,000 feet, during a stall recovery, a bag containing tie down equipment dislodged from its stored position. The bag subsequently broke through the canopy of the aircraft before grazing the rudder and falling to the ground.

The flight continued without further incident and the pilot landed the aircraft safely at Temora Airport. The aircraft operator informed that ATSB that the bag punched a hole, approximately 400 millimetres in diameter, in the canopy of the aircraft causing damage to the leading edge of the rudder.

Safety message

Prior to departure, it is important for pilots to ensure that all passengers, cargo and equipment are secure inside the aircraft. If the pilot is intending to undertake aerobatic flight or stall manoeuvres, they should always apply the HASELL^[1] checklist. The HASELL checklist is a mnemonic designed to ensure that:

• the aircraft has sufficient height for the manoeuvres
• the airframe can be configured correctly
• the cabin is secure with no loose articles that may move, even during violent or negative g manoeuvres
• the engine can be properly configured
• the location is acceptable, not over populated areas
• the pilot should keep a lookout for other traffic during the manoeuvres.

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. CASA Civil Aviation Advisory Publication Issue 155-1(0) Section 8.3

What happened

On 1 February 2018, the helicopter was operating a charter flight with one pilot and five passengers from Gold Coast Airport, Queensland (Qld).

At approximately 1300 Eastern Standard Time (EST), the pilot conducted visual checks of the seatbelts and doors, and the helicopter commenced its take-off, climbing to 500 ft. As the helicopter turned onto crosswind, the pilot detected a popping noise and turned around to see the main door was open. The pilot then slowed the helicopter to 80 knots and conducted a return to Gold Coast, Qld.

Post-flight, the passengers were disembarked, and the helicopter was inspected. The inspection revealed that the rear door window was missing, and the door was unable to be closed. It is suspected that the door was not correctly secured prior to the flight.

Safety message

It is important for flight crew and ground staff to ensure the security of doors during pre-flight checks. The risks of a door opening in-flight can result in pilot distraction, damage to the aircraft and objects falling from 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 10 February 2018, the pilot of an American Champion Aircraft 7GCBC was conducting solo circuit training at Orange, New South Wales (NSW), on the unrated cross runway 04, which has a grassed red clay surface.

At 0930 Eastern Daylight-saving Time (EDT), during a touch-and-go landing in gusty wind conditions, the aircraft landed hard and bounced. After the aircraft bounced a second time, the pilot applied power and attempted to go-around but during the initial climb, struck the airport perimeter fence.

The pilot sustained a minor bump on the head but was otherwise uninjured. The aircraft’s right wheel was torn off and there was damage to the right side of the tail and the right wingtip. The aircraft’s propeller was also bent.

Safety message

This incident highlights the importance of maintaining directional control when landing, particularly in gusty conditions. A Safety Alert produced by the National Transportation Safety Board in the United States, Stay Centred: Preventing Loss of Control During Landing, addresses this issue and directs pilots to other resources which provide guidance in conducting crosswind approaches and landings.

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 17 January 2018, at about 1320 Eastern Daylight-saving Time (EDT), a Hawker Beechcraft Corporation B200C was en-route to Essendon, Victoria (Vic.), with a pilot, flight paramedic and passenger on board. On passing through flight level (FL) 130,^[1] the flight paramedic advised that an oxygen mask had fallen from the stowed position. The cabin altitude indicator showed a positive rate of climb, with the indicator displaying 9,500 ft. Reducing cabin pressure confirmed the loss of pressurisation.

The pilot conducted the non-normal checklist and obtained a clearance from air traffic control to descend to 10,000 ft. As the aircraft levelled at 10,000 ft, the pilot observed that the cabin altitude was stable at 9,500 ft. The pilot followed the appropriate failure management procedures, however, none of these actions restored the pressurisation system to operational. The flight continued at 10,000 ft and landed without further incident at Essendon Airport.

Following the incident, the fault was confirmed during a ground run and the safety valve solenoid switch was replaced.

Safety message

This incident highlights the importance of flight crews maintaining awareness of all system states and being prepared to act. Quality training in failure management procedures assists in equipping crew members with the required knowledge to effectively respond to a time critical emergency.

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 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 130 equates to 13,000 ft.

What happened

On 11 February 2018, at 1227 Eastern Daylight-saving Time (EDT), the crew of a Robinson R22 Beta helicopter were conducting flight training on the western grass area of Bankstown Airport, New South Wales (NSW). There were an instructor and a student on board. The weather at the time was fine with 15 knots of wind from the south-east gusting to 25 knots.

While practicing hover drills at 2–3 m above the ground, with the student at the controls, the helicopter commenced a yaw and started to spin anti-clockwise. The rate of rotation increased and the instructor took control of the helicopter, but was unable to arrest the spin. The helicopter impacted the ground, the tail boom separated and the skids were flattened. The instructor shut down the helicopter, and both crew members walked to the flight school. Both crew members sustained minor injuries.

Figure 1: Accident scene, indicating direction of rotation at time of impact.

Source: NSW Police Force

Safety message

Instructing ab-initio students in rotary wing flight is a complex task. The instructor must allow the student the experience of controlling the helicopter while moderating the student’s inputs in order to ensure controllability of the aircraft. Flight in gusty conditions increases difficulty for both the instructor and the student.

Wind gusting between 15 and 25 knots places the helicopter in and out of effective translational lift.^[1] Students may have trouble reconciling the effect of their inputs against movement created by the wind. Instructor workload increases as the student’s control inputs are likely to be larger and less predictable than those used in calm conditions.

CASA Australia and CAA New Zealand produced a Helicopter Flight Instructor Manual which describes hovering as requiring a high degree of coordination. It advises that hovering should not be taught until the student is competent in manipulation of flight controls in forward flight, climbing, descending and turning. The manual also advises to ‘keep a close watch on temperatures, pressures and wind velocity during prolonged hovering’.

While conducting flight training instructors should consider meteorological conditions and the limits of the student’s ability to manage them. Safety Notice SN-42 in the Robinson R22 Pilot’s Operating Handbook advises that ‘…pilots should be aware of conditions (a left crosswind, for example) that may require large or rapid pedal inputs’. To assist instructors, flying schools should publish policies to limit flight in unfavourable conditions and accommodate the competence of their students in varying weather conditions.

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. Effective Translational Lift (ETL) increases the efficiency of the rotor system and is achieved between 16 and 24 knots of wind. FAA Helicopter Flying Handbook Chapter 2