Aviation occurrence briefs

Incorrect configuration involving a Piper PA-44 Seminole, Moorabbin Airport, Victoria, on 28 February 2020

Number:
AB-2020-010
Status: Completed
Investigation completed

Brief

Occurrence Briefs are concise reports that detail the facts surrounding a transport safety occurrence, as received in the initial notification and any follow-up enquiries. They provide an opportunity to share safety messages in the absence of an investigation.

What happened

On 28 February 2020, a Piper PA-44 Seminole was conducting a circuit assessment flight with a student and instructor on board, using runway 17L at Moorabbin Airport, Victoria. the instructor reported, the student had conducted three normal circuits to the required standard including the normal procedure of turning the fuel pumps off once above 500 ft AGL.

After the circuits, the instructor obtained a clearance from ATC to conduct asymmetric operations and planned to carry out a practice engine failure on the upwind leg of the circuit. As the aircraft climbed through 700 ft AGL, the instructor initiated the practice by announcing it and slowly closing the throttle on the right engine. The student carried out all the required initial actions, identifying that it was the right engine and verbalising the appropriate steps to secure the engine.

As the instructor then attempted to set a zero thrust power setting to complete the circuit, he identified that the aircraft was not performing as it normally would and was still yawing.[1] Upon identifying the right engine was no longer running the instructor took over, feathered[2] the right propeller, and continued a slow climb. Air Traffic Control was informed of the situation as the instructor continued in the circuit. Once established on downwind, the instructor found that both right engine magnetos were in the off position. Despite returning the magnetos to on and attempting a restart, it could not be achieved prior to landing. The aircraft subsequently landed without further incident. Once the aircraft was on the ground, the right engine was restarted normally.

Crew comments

During the debrief about the incident, I identified that the student had mistakenly turned the right engine’s magnetos off when the practice engine failure was initiated. It appears that the practice emergency had occurred as the student was preoccupied conducting the normal after take-off checks that include turning the fuel pumps off above 500 ft AGL. Under normal circumstances, this would be more readily noticeable as the yaw and noise reduction would immediately alert the crew to the error, however, in a less than zero thrust condition the loss of power from the right engine was not immediately identified. Once the mistake was identified, the propeller had been feathered and a restart in the circuit would have been difficult to achieve.

Figure 1: Cockpit layout of magneto and fuel pump switches

Cockpit layout of magneto and fuel pump switches. Source: Operator

Source: Operator

Safety action

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

  • All multi-engine instructors have been directed not to initiate a simulated engine failure while the student is preoccupied with other tasks and particularly when the after take-off checks are being carried out.
  • Any simulated failure should be conducted either before or after take-off checks and comply with the minimum height restrictions.
  • Fuel pumps are now to be turned off one at a time as a further way of mitigating the possible reoccurrence.

Safety message

This incident highlights the need for instructors to comprehensively pre-brief simulated emergency procedures noting potential errors, and closely monitor the actions of their student pilots when they are reacting in a high workload environment to any simulated 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.

__________

  1. Yawing: the motion of an aircraft about its vertical or normal axis.
  2. Feathering: the rotation of propeller blades to an edge-on angle to the airflow to minimise aircraft drag following an in-flight engine failure or shutdown.
General details
Date: 28 February 2020   Investigation status: Completed  
Time: 1236 EDT    
Location   (show map): Moorabbin Airport    
State: Victoria    
Release Date: 03 April 2020   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer Piper Aircraft Corp  
Aircraft model PA-44  
Type of operation Flying Training  
Sector Piston  
Damage to aircraft Nil  
Departure point Moorabbin Airport, Victoria  
Destination Moorabbin Airport, Victoria  
Last update 01 May 2020