Aviation occurrence briefs

Foreign object found during pre-flight inspection involving a Diamond DA 40 NG, Port Macquarie Airport, NSW, on 27 March 2020

Number:
AB-2020-012
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 27 March 2020 at around 1822 Eastern Daylight-saving Time, a Diamond DA 40 was being prepared for a training flight. There was a student and instructor on board.

During the pre-flight inspection, while the student was conducting the flight controls free and correct movement check, he observed abnormal elevator movement. The elevator required more force than usual to move, and was unable to be deflected through its full and normal operating range. The student notified the instructor of the issue, the flight was cancelled and the aircraft was deemed unserviceable.

Engineering inspection

The engineers removed the right pilot seat to examine the flight control mechanism. They found a plastic navigation ruler lodged within the elevator push rod mechanism, which was restricting the movement of the elevator. It was determined that the ruler fell between the seat and the centre console in the cockpit.

Figure 1: Navigation ruler lodged in elevator push rod mechanism

Figure 1: Navigation ruler lodged in elevator push rod mechanism.
Source: Operator’s engineering department

Source: Operator’s engineering department

Operator comments

It is important that Diamond DA 40 and DA 42 operators and pilots are alerted to the fact that items and equipment placed on the seat or between the seat and centre console can, in some instances, work their way down through the narrow gap between the inner seat edge and the centre console (Figure 2). This could allow thin items and equipment to find their way into the area under the seat which contains the elevator and aileron control push-rods.

Figure 2: Narrow gap between front seats and centre console

Figure 2: Narrow gap between front seats and centre console.
Source: Operator’s engineering department

Source: Operator’s engineering department

Safety action

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

  • Providing a briefing and the publication of photos to all instructors for awareness.
  • Placing a renewed emphasis in pre-flight briefings to solo students on objects taken into and out of the aircraft, to reduce the instances of foreign object debris (FOD) being left in the cockpit.
  • Requiring that all navigation equipment and similar items carried in aircraft be labelled with the owner's name. This will increase accountability and source tracing when FOD is located and help to ensure pilots place the aircraft unserviceable for a FOD inspection if an item is missing at the end of a flight.

Safety message

This incident highlights the importance of ensuring that all pre-flight checks and procedures are carried out comprehensively and systematically. It also serves as a reminder for flight crew to ensure that any misplaced or missing items from their flight bag be identified and located. If unable to locate any missing items, this information should be reported promptly so an aircraft inspection can be carried out.

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.

General details
Date: 27 March 2020   Investigation status: Completed  
Time: 1822 EDT    
Location   (show map): Port Macquarie Airport    
State: New South Wales    
Release Date: 01 May 2020   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer Diamond Aircraft Industries  
Aircraft model DA 40 NG  
Type of operation Flying Training  
Sector Piston  
Damage to aircraft Nil  
Departure point Port Macquarie Airport, New South Wales  
Destination Port Macquarie Airport, New South Wales  
Last update 01 May 2020