Control - Other

Airbus A330-341, PK-GPC

Significant Factors

Water ingress into the aircraft radio altimeter antenna coaxial cables led to the loss of normal aircraft handling characteristics.

Analysis

During the first landing, the nosewheel remained airborne throughout the landing sequence, indicating that de-rotation did not occur. Consequently, the front wheels of the main landing gears probably did not contact the ground for a sufficient period to allow them to accelerate to the required wheel speed condition. That resulted in the logic conditions for ground spoiler deployment not being met. Those required compression of both left and right main landing gears ('weight on wheels'), and a radio altitude of less than 6 ft or a wheel speed greater than 72 kts on the front and aft wheels of the main landing gears. Without a valid radio altitude signal of less than 6 ft, and without ground spoilers deployed, the logic conditions for reverse thrust were also not met, and it too was unavailable. The absence of an AP OFF INVOLUNTARY WARNING indicated that the crew had intentionally disconnected the autopilot during the approach.

The loss of valid radio altimeter signals did not result in the automatic switching from flight mode to flare mode when the autopilots disengaged. That was due to the water ingress into the radio altimeter antennas, and which resulted in the radio altimeter signals being interpreted as out of range signals, rather than as a failure of the radio altimeters.

Summary

History of the flight

The Airbus A330-341 aircraft was operating a scheduled international fare-paying passenger service from Adelaide to Melbourne and the pilot in command was the handling pilot for the flight. During the initial descent into Melbourne, the crew configured the auto flight system to the approach mode. That action armed the auto flight system localiser and glideslope modes for the runway 16 instrument landing system (ILS), and permitted the crew to engage the second autopilot for the approach. As the aircraft descended through 2,500 ft, the crew placed the ground spoiler handle to the armed position. Shortly after, the radio altimeter indications disappeared from both pilots' electronic flight instrument displays. Both autopilots then disengaged. About 20 seconds later, both flight directors disengaged from the localiser and glideslope modes but re-engaged in the basic modes of current vertical speed and heading.

The pilot in command elected to continue the approach and to manually fly the aircraft, because he considered that he would be able to control the aircraft without auto flight system approach commands or radio altimeter information. The autothrust was unaffected by the disengagement of the autopilots, and remained engaged.

At the completion of the landing approach, the pilot in command flared the aircraft for the landing, and retarded both thrust levers, which disengaged the autothrust system. The aircraft landed on the left and right main landing gears, bounced, and became airborne for four and a half seconds before touching down again on both main landing gears. The aircraft bounced again, became airborne for one second, and then touched down for a third time on both main landing gears. The right main landing gear then lifted off the runway for about one second, after which the aircraft settled onto both main landing gears. Two seconds later, the thrust levers were advanced to go-around power, and after a further five seconds, the aircraft became airborne again. The nose landing gear remained airborne throughout this sequence. Additionally, the ground spoilers did not deploy, and the thrust reversers did not activate.

The pilot in command repositioned the aircraft for another approach onto runway 16. During the second landing, the aircraft again bounced following the touchdown, then settled onto the runway. Four seconds later, the ground spoilers deployed; however, the thrust reversers did not activate when selected by the crew. The landing rollout was completed without further incident, and the aircraft was taxied to the terminal.

There were no injuries to any persons on board the aircraft.

Aircraft information

The aircraft was a fly-by-wire type. Three flight control primary computers and two flight control secondary computers controlled the flight control system. The computers processed crew and autopilot inputs to provide appropriate electrical output signals to the hydraulically powered flight control surfaces.

Crew input to the flight control computers was made via electrical signals from either of the two side stick controllers, and autopilot input was made via an interface with the aircraft's Flight Management and Guidance System.

The inputs to the flight control computers were processed in accordance with respective flight control 'laws'. Regardless of the pilot's inputs, the control computers will prevent excessive manoeuvres and/or exceedance of the safe flight envelope. Those laws were dependent on whether the aircraft was in the ground, flight or flare mode of flight. In the ground mode, there was a direct relationship between sidestick deflection and the flight control surfaces. In the flight mode, deflection of the flight control surfaces was governed to achieve a load factor proportional to sidestick deflection, independent of speed. Flight mode provided 3-axis control of the aircraft, and provided flight envelope protection and manoeuvre load alleviation.

In the flight mode, the normal laws were:

  • Nz law for pitch control, including load factor protection. (Nz law is vertical acceleration in the normal axis of the aircraft);
  • lateral normal law for lateral control (roll and yaw), including bank angle protection; and
  • protection against high speed (VMO), pitch angle (theta), and stall (angle of attack).

In flare mode, the normal laws were:

  • flare law in place of Nz law for pitch control to allow for conventional flare;
  • lateral normal law for lateral control (roll and yaw) including bank angle protection; and
  • protection against stall.

Flare mode permitted crews to use the same landing technique as for non-fly-by-wire aircraft. Transition from flight mode to flare mode occurred when the aircraft's radio altimeters sensed that the aircraft altitude was less than 100 ft above ground level.

If faults were detected in both radio altimeters, switching from flight mode to flare mode would occur when the landing gear was extended, provided the autopilot was off. If the autopilot was engaged, switching from flight mode to flare mode would occur when the autopilot was disengaged, provided the landing gear was extended.

The manufacturer reported that flight tests for the A330 type included landing in flight mode. ie without transition to flare mode. Landing in that condition was not considered difficult, however, it required a different handling technique than would otherwise apply for non-fly-by-wire aircraft. In such circumstances, a pilot would need to apply back pressure on the sidestick to initiate the landing flare, then release that back pressure to maintain the desired pitch attitude until touchdown.

The aircraft was equipped with two radio altimeter systems that provided information about the aircraft height above ground level. Data from the radio altimeters was also used by many of the aircraft systems' logic sequences to determine whether certain operating parameters had been met to permit operation of a particular system. The radio altimeter antennas were located along the keel of the aft fuselage of the aircraft, and were connected to the aircraft electronic system by coaxial cables. Inspection of the radio altimeter system antennas subsequent to the occurrence revealed that they had sustained water ingress at the antenna coaxial cables. The water ingress into the radio altimeter antennas resulted in the radio altimeter signals being interpreted as out of range signals, rather than as a failure of the radio altimeters.

During the period 11 June 2001 to the date of the occurrence, there were 19 entries in the aircraft's maintenance log reporting problems with the radio altimeters fitted to the aircraft. Repairs had been carried out on the radio altimeters, including replacement of a transceiver unit and cleaning of components due to water ingress.

The aircraft was equipped with autoflight and flight director systems. Radio altitude signals from the aircraft radio altimeters were used to engage the autoflight system into the LAND mode when the aircraft altitude was 400 ft above ground level. The loss of valid radio altimeter signals in LAND mode would result in the loss of both autopilots and the flight directors reverting to the basic modes of vertical speed and heading. The autopilot also used radio altitude signals to adapt the autopilot gains during an ILS approach, with the required gain being dependent upon the distance of the aircraft from the runway threshold. Any involuntary disconnection of the autopilot triggered an AP OFF INVOLUNTARY warning message to the crew.

The aircraft was equipped with wing mounted ground spoilers. The ground spoilers would arm when the crew placed the speed brake control lever to the armed position, and would activate after landing provided certain parameters had been met. Those parameters included both main landing gears transitioning from flight to ground ('weight on wheels'), and a radio altitude of less than 6 ft or a wheel speed higher than 72 kts on the front and rear wheels of the main landing gears.

The aircraft's engines were equipped with thrust reversers. Deployment of the thrust reversers would not occur unless the aircraft was on the ground with the ground spoilers extended, radio altitude less than 6 ft, and the engine thrust levers in the reverse position.

The aircraft was equipped with an Allied Signal solid state digital flight data recorder. The recorded data was examined and revealed that each of the flight control primary and secondary computers had operated normally throughout the flight. The recorded data revealed that during both approaches, the autopilots oscillated in the lateral and longitudinal axes.

Both autopilots disconnected simultaneously, but an AP OFF INVOLUTARY warning did not accompany the disconnection. The LAND mode engaged at 400 ft radio altitude. One second later, both flight directors disengaged from the localiser and glideslope modes, then re-engaged in the basic modes of current vertical speed and heading. The recorded data also revealed that the signals from both radio altimeters were invalid throughout most of both approach sequences into Melbourne.

The investigation was unable to determine the relevant experience and training of the crew.

Occurrence summary

Investigation number 200104399
Occurrence date 27/08/2001
Location Melbourne, Aero.
State Victoria
Report release date 14/05/2003
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Control - Other
Occurrence class Incident
Highest injury level None

Aircraft details

Manufacturer Airbus
Model A330
Registration PK-GPC
Serial number 140
Sector Jet
Operation type Air Transport High Capacity
Departure point Adelaide, SA
Destination Melbourne, VIC
Damage Nil

Cessna 404, VH-WGB

Safety Action

Local safety action

As a result of the uncertainty surrounding the specification and manufacture of the cable, the operator changed all of the primary flight cables for the aircraft before further flight.

The operator's senior engineer reported that he had also developed, and submitted to CASA for approval, an upgraded inspection procedure for examining the cables in the area of the control pedestal during scheduled maintenance inspections. The company plans to include the procedure in the company maintenance manual for its Cessna C404 fleet.

Summary

A Cessna 404 Titan aircraft was engaged in low level geophysical survey work near Tennant Creek, NT. The pilot reported that as he was manoeuvring the aircraft at the completion of a survey run, he became aware that the aircraft's response to aileron control input was reduced. He was able to roll the aircraft to wings level attitude using a combination of aileron and rudder, before climbing the aircraft to approximately 6,000 ft and returning to Tennant Creek aerodrome.

Examination of the aileron control system by company maintenance personnel revealed that one of the aileron cables had separated near a change of direction pulley below the control pedestal in the cockpit. Company maintenance personnel reported that there were no obvious signs of fatigue or wear at the failure point and that the reason for the failure was not immediately apparent. The cable could not be identified by manufacturer or part number.

The aircraft had undergone a routine scheduled maintenance inspection 29 hours prior to the event. The engineer reported that it was difficult to inspect the cable in the area beneath the control pedestal during normal scheduled inspections. It was suggested that the only way to adequately examine it would be to disconnect and remove it in accordance with the manufacturers major maintenance requirements.

The aircraft logbooks showed that the aircraft was manufactured in 1981, and had been imported into Australia from Indonesia. At the time of the occurrence, it had a total time in service of 3,853 hours. The aircraft logbooks did not indicate any previous replacement of the aileron cable.

The maintenance engineer advised that, following the incident, he submitted the cable and a detailed major defect report to the local CASA office. CASA Airworthiness advised that their examination was not able to identify the reason for the failure with any certainty. They confirmed that there were no serial or part numbers on the cable and that it was probably not the correct specification for this type of installation. The most likely scenario was that the cable was manufactured and fitted to the aircraft in Indonesia.

Occurrence summary

Investigation number 200003412
Occurrence date 01/08/2000
Location Tennant Creek
State Northern Territory
Report release date 16/10/2001
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Control - Other
Occurrence class Incident
Highest injury level None

Aircraft details

Manufacturer Cessna Aircraft Company
Model 404
Registration VH-WGB
Serial number 0435
Sector Piston
Operation type Aerial Work
Departure point Tennant Creek, NT
Destination Tennant Creek, NT
Damage Nil

Beech Aircraft Corp 1900D, VH-NTL

Summary

On 13 February 2000 a Beech 1900D Airliner, VH-NTL, was on a local training flight. The pilot in command simulated a failure of the left engine shortly after take-off by retarding the left power lever to the 'FLIGHT IDLE' position. The handling pilot applied full right rudder and right aileron to counter the resultant yaw to the left, but the yaw continued until power was restored to the left engine to regain directional control. In the 21 seconds following take-off, the aircraft did not climb above 160 ft above ground level, and at one stage had descended to 108 ft.

The aircraft was then climbed to a height of 2,000 ft where the pilot in command simulated another failure of the left engine by retarding its power lever to the 'FLIGHT IDLE' power setting. The aircraft again lost controllability. Power was restored to the left engine, and the aircraft landed without further incident.

There was no evidence that any aircraft or systems malfunctions contributed to the controllability problems experienced by the crew during the occurrence flight.

Since 1992, it was the practice of the operator's check pilots to simulate one-engine inoperative by retarding the power lever of the 'failed' engine to 'FLIGHT IDLE'. That was contrary to the procedure prescribed in the Federal Aviation Authority-approved Beech 1900D Airplane Flight Manual, and also to that specified in the operator's Civil Aviation Safety Authority-approved Training and Checking Manual. Reducing power to 'FLIGHT IDLE' also had the effect of simulating a simultaneous failure of the engine and its propeller auto-feather system. The simulation of simultaneous inflight failures was contrary to the provisions of the CASA-approved Training and Checking Manual. During each of the simulated one-engine inoperative sequences, control of the aircraft was not regained until the power on the 'failed' engine was advanced to the manufacturer's prescribed one-engine inoperative thrust power setting.

The operator's training and checking organisation and its check pilots were aware that the likely consequences of simulating an engine failure by retarding its power to less than zero thrust were reduced aircraft climb performance and increased air minimum control speed (VMCA). They were also aware that risk increased when inflight training exercises involved the simulation of multiple failures. The prescribed procedures were therefore necessary defences to minimise those risks. The circumvention of those defences significantly increased the risks associated with the operator's training and checking procedures, and was a safety-significant concern. This occurrence demonstrated the potentially serious consequences of degraded aircraft performance by setting 'FLIGHT IDLE' to simulate one-engine inoperative. The practice has the potential to jeopardise the safety of flight and should be strongly discouraged.

The ATSB's investigation established that the failure to achieve predicted performance during take-off and subsequent climb was the result of an incorrect procedure. As a result of this serious occurrence, the ATSB recommended that the Civil Aviation Safety Authority (CASA) publish information for the guidance of operators and pilots regarding the correct procedures for simulating engine failures in turbo-propeller aircraft. CASA advised that it will publish an amendment to Civil Aviation Advisory Publication 5.23-1(0) to highlight appropriate engine-out training procedures in turbo-propeller aircraft. CASA also advised that it would ensure that operators' manuals contained appropriate procedures for the conduct of multi-engine training, and that it would draw attention to those procedures during forthcoming safety promotion activities. The operator advised that it had instructed its check pilots that an engine's power lever must not be retarded below the zero thrust torque setting when simulating an engine failure on take-off, and that those simulations were not be carried out until the aircraft had reached 250 ft above ground level.

Occurrence summary

Investigation number 200000492
Occurrence date 13/02/2000
Location Williamtown, Aero.
State New South Wales
Report release date 21/12/2001
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Control - Other
Occurrence class Serious Incident
Highest injury level None

Aircraft details

Manufacturer Beech Aircraft Corp
Model 1900
Registration VH-NTL
Serial number UE-117
Sector Turboprop
Operation type Air Transport Low Capacity
Departure point Williamtown, NSW
Destination Williamtown, NSW
Damage Nil

Sikorsky S-76A, VH-BHM, Barrow Island Aerodrome, Western Australia, on 4 August 1999

Safety Action

Operator safety action

The operator issued an alert message for its fleet of S76 helicopters to undergo an inspection of the subject area. A defect report was also submitted to the Civil Aviation Safety Authority.

Manufacturer safety action

As a result of this incident and a similar incident experienced by another Australian S76 operator in 1995, and following consultation between the operator, helicopter manufacturer and BASI; the manufacturer conducted a design engineering review of the cyclic stick base hardware to determine if it was possible to reduce the effect of foreign object entry to the tub area.

Following the review, the manufacturer advised that a field modification of the pilot's side bracket was being prepared to increase the gap between the torque tube rig boss and the bracket foot. On 28 August 1999, the manufacturer also advised of its intention to issue an Alert Service Bulletin, in due course, to address the results of the engineering review.

BASI safety action

BASI will monitor the progress of this manufacturer's proposed safety action.

Summary

The pilot of the Sikorsky S76 helicopter reported that while approaching Barrow Island and immediately after he reduced the helicopter's airspeed for landing gear extension, he found that the cyclic could not be moved aft. He also found that with any further forward movement of the cyclic stick, the stick then could not be moved aft of the new position. The pilot froze the cyclic longitudinal position and the helicopter stabilised in a level pitch attitude at about 85 kts indicated airspeed. Using only lateral cyclic movements to manoeuvre the helicopter, the pilot conducted an 80-kt run-on landing on the runway at Barrow Island.

The subsequent maintenance inspection found a panhead type screw at the base of the cyclic stick. The screw had lodged between the lower protrusion on the casting on the end of the cyclic stick torque tube and the lugs on a support bracket. The lodgement of the screw in that location had caused the cyclic restriction experienced by the pilot.

The cyclic stick base hardware was accommodated in a tub-like area formed by the cabin structure supports. A leather boot mounted at the base of the cyclic normally prevented foreign objects from entering the tub. The subsequent maintenance inspection found the leather boot on this helicopter to be intact. With the boot in place, the only possible entry points where a screw could be inserted was through a rigging pin hole in the aft mid-height position of the boot-halves joint, or vertically through an opening provided for the cyclic stick electrical wiring loom. Due to the unlikelihood that a screw could enter the tub area when the boot was fitted, the screw was probably introduced to the area during prior maintenance while the boot was removed.

Occurrence summary

Investigation number 199903789
Occurrence date 04/08/1999
Location Barrow Island , Aero.
State Western Australia
Report release date 20/10/1999
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Control - Other
Occurrence class Incident
Highest injury level None

Aircraft details

Manufacturer Sikorsky Aircraft
Model S-76
Registration VH-BHM
Serial number 760107
Sector Helicopter
Operation type Charter
Departure point Cossack Pioneer, WA
Destination Barrow Island, WA
Damage Nil

Boeing 737-377, VH-CZH

Summary

During take-off from runway 17 at Melbourne the Boeing 737-300 aircraft experienced a single, rapid, right rudder deflection. This occurred when the aircraft was accelerating between V1 (135kt) and Vr (141kt). The co-pilot was handling the aircraft and was able to apply left rudder and arrest the developing yaw. The co-pilot advised that he applied between 2 and 3 inches of left rudder movement. The take-off and climb were completed without further problems and the flight proceeded normally to Adelaide.

An inspection of the aircraft failed to find any airframe or engine anomalies that could have contributed to the reported event.

After consultation with the manufacturer, it was determined that there was two possible causes for the right rudder deflection, namely a gust or a short duration rudder pedal pulse. Accordingly, the rudder power control unit (PCU), the standby rudder power control unit (SPCU), and the digital flight data recorder (DFDR) were removed for examination.

The DFDR recorded a maximum right pedal deflection of 0.17 inch. Because the DFDR only samples rate of pedal deflection twice per second it is possible that the maximum right pedal deflection recorded was not necessarily the peak of that particular deflection. The manufacturer advised that simulation of the event showed that a 3.3 inch right pedal pulse with a duration of 0.5 seconds would be needed to generate the lateral acceleration and heading changes recorded by the DFDR. This equates with the crew's report of between 2 and 3 inches of corrective rudder movement being applied.

The PCU was bench tested in accordance with the manufacturers requirements and found to be serviceable.

The manufacture advised that an identified cause of involuntary rudder movement was the binding of the input lever on the SPCU resulting in pedal feedback if the input lever binding force is sufficient to overcome the feel and centering unit restoring forces. Previous analysis of the SPCU input lever binding conditions indicates that approximately 20 lb resistive force at the input lever is required before any measurable uncommanded rudder pedal movement would occur. A mechanical binding force of this magnitude would be repeatable and would worsen over time. A limit of 1 lb binding force on the input shaft has been mandated. The removed SPCU was tested and the input lever binding force was found to be below the mandated limit. All other test requirements were found to be satisfactory.

A comparison of the airspeed and ground speed recording on the DFDR showed a fluctuation of airspeed at the time of the event accompanied by a fluctuation in the angle of attack vane. This suggests that a wind gust could have affected the airspeed and contributed to the yawing motion experienced by the aircraft.

The take-off had been commenced from intersection C on runway 16 with a reported surface wind of 10 to 15 knots from 130 degrees. Four minutes prior to the B737 take-off a B747 aircraft had departed using the full length of the same runway. The parameters for the B737 take-off would normally preclude wake turbulence from the B747 being considered as a factor.

The investigation was not able to determine if the gust that affected the aircraft was due to a local atmospheric disturbance or was as a result of lingering wake turbulence from the departing B747.

Occurrence summary

Investigation number 199703237
Occurrence date 06/10/1997
Location Melbourne, Aero.
State Victoria
Report release date 23/07/1998
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Control - Other
Occurrence class Incident
Highest injury level None

Aircraft details

Manufacturer The Boeing Company
Model 737
Registration VH-CZH
Serial number 23660
Sector Jet
Operation type Air Transport High Capacity
Departure point Melbourne, VIC
Destination Adelaide, SA
Damage Nil

Boeing 747-300, N124KK

Safety Action

As a result of the investigation, the Bureau of Air Safety Investigation issued recommendation R970128, to Qantas and Ansett on 29 September 1997. The recommendation stated:

"The Bureau of Air Safety Investigation recommends that Australian operators of aircraft manufactured by the Boeing Commercial Airplane Company:

  1. develop a simulator training procedure to ensure that aircrew are familiar with the procedures to be used in the event of lateral control jamming; and
  2. ensure that aircrew are aware of the control wheel forces required when the override mechanism is being operated in the event of jammed lateral controls".

A similar recommendation (R970145) was issued to the Boeing Commercial Airplane Company on 29 September 1997.

The following response was received from Qantas on 26 November 1997:

"I refer to your letter reference B97/099 which detailed a recommendation that a simulator training procedure be developed to ensure that all aircrew are aware of the procedure to be used, and control forces required, in the event of aileron control jamming.

Qantas simulators (with the exception of the B767-200 simulator) are equipped to simulate aileron control jamming and the control wheel forces required to override and regain control.

This scenario will be made a subject, both for discussion and demonstration, in the first available recurrent training simulator session. This will apply to the Boeing 747-400, 747-200/300, 767, 737 and Airbus A300 fleets".

Response classification: CLOSED - ACCEPTED.

The following response was received from Ansett on 24 June 1998:

"I refer to the above recommendation, which resulted from an incident involving a Boeing 747 aircraft at Sydney on 2 May 1997, and provide the following response to that recommendation.

The company conducts ground training for technical crews that includes instruction on aileron control jamming procedures. Additionally, simulator training is presently conducted for Boeing 737 aircraft and will be conducted in the Boeing 767 simulator when that simulator is upgraded to allow such training. For the Boeing 747, training is conducted in the aircraft, whilst on the ground, during type endorsement".

Response classification: CLOSED - ACCEPTED.

The following response was received from the Boeing Commercial Aeroplane Company on 13 February 1998:

"We have not yet committed any changes in our simulator training procedures or manuals. We are reviewing the reported event and looking at possible training and manual changes which would be implemented for all applicable Boeing models, not just 747.

However, additional time is necessary for this review before we can come to any conclusion. I anticipate that this review may take three more months. We plan to keep your office advised of the progress of our review".

A further response was received on 27 May 1998, and stated:

"Earlier this month I reviewed proposed changes to our operational documentation concerning flight control jams across all our various model airplanes. This has been a slow process trying to get agreement on. I anticipate that we will have some changes to be released in a couple of months. These changes would affect the Flight Manual, the Flight Crew Training Manual, the Operations Manual and the QRH".

Response classification: OPEN.

Local safety action

Boeing have also advised that Service Letter 747-SL-27-134, which addresses the need to replace deteriorated cable guards, is to be upgraded to service bulletin status in the near future to add more emphasis to this discrepancy.

Significant Factors

  1. The aircraft maintenance organisation had not replaced deteriorated parts with improved parts as suggested by the aircraft manufacturer.
  2. A cable guard had deteriorated to the extent that it failed and resulted in high control forces in the lateral control system.
  3. The operating crew were not aware of the high control inputs required to overcome the load limiter in the lateral control system.

Analysis

The deteriorated condition of the plastic cable guards, and the use of tape to effect a "repair", suggests that the manufacturer's advice regarding replacement of the guards had not been heeded during major maintenance inspections.

It is likely that, when the plastic cable guard failed, a piece or pieces of plastic lodged in the left side cable run aileron control pulley, restricting the cable movement in one direction. The debris probably dislodged when the aircraft was at about 400 ft on final approach.

Summary

The aircraft was being operated as a scheduled passenger service from Sydney to Seoul, with the co-pilot as the handling pilot. The crew reported that the pre-departure flight control checks were normal. Shortly after becoming airborne from runway 34L, the co-pilot advised the pilot in command (PIC) that his control wheel had become jammed when attempting to make right wing down aileron inputs. The PIC took control of the aircraft and confirmed that his control wheel also had become jammed. He retained control of the aircraft and the co-pilot advised Air Traffic Services (ATS) that the aircraft was unable to turn to the right. He requested left turns and radar vectors to the south for fuel dumping prior to returning to land. ATS initiated a distress phase. The crew actioned the emergency/abnormal checklist for jammed or restricted flight controls, which includes the statement "use maximum force, including a combined effort by both pilots, if required", but they reported that their attempts made no change to the system. After fuel dumping was completed, the aircraft was vectored, using left turns only, to the runway 34L localiser and configured for the landing. At about 400 ft on final approach, the aileron controls became free and an uneventful landing was carried out.

Inspection by ground engineers determined that a plastic cable guard in the left aileron control cable system had broken. Pieces of shattered plastic were found in the vicinity of the left lower cable pulley system in the vertical cable run behind the cabin sidewall, forward of door 1L. The debris and all the remaining guards were removed from both left and right side vertical cable runs. The lateral control system, including the load limiter system, could not be faulted during full system testing. As there were no replacement cable guards available, the aircraft was approved to return to service with the guards removed.

The lateral controls on the aircraft consist of hydraulically powered inboard and outboard ailerons and flight spoilers on each wing. The controls are connected to the cockpit control wheels by cables, for pilot input. The cable runs are duplicated on each side of the aircraft. The left and right cable runs terminate at quadrants at the bases of the left and right control columns respectively. The control columns are interconnected by a cable loop connected to separate quadrants at the bases of the columns. The right quadrant includes a load limiter which consists of a detent and spring-loaded cam assembly. The load limiter is designed to "break away" under applied force by the crew to enable one control wheel to provide lateral control input should the other side jam for any reason. Roll control is then available, but considerable force is required to overcome the detent cam in the load limiter. Other Boeing aircraft types utilise similar systems.

The aircraft manufacturer issued a Service Letter, 747-SL-27-134, in December 1993, advising that broken cable guards could result in high control wheel forces and suggesting that operators should replace the guards with improved parts when replacement is required. The guards on the right control system on the incident aircraft showed evidence of deterioration, as one guard had been previously repaired with adhesive tape.

The aircraft was leased from an overseas operator. Under the terms of the lease agreement, all major maintenance was conducted by the lessor. The last major maintenance inspection was completed on 25 August 1995. At the time of the incident the aircraft total time in service time was 50,400 hours.

The crew remained at the aircraft whilst the defect was rectified. Both crewmembers remarked that they were surprised at the force required to overcome the load limiter when the system was tested. Though they were aware of the load limiting system from ground training instruction, they had never been physically exposed to the forces required to operate the system.

Occurrence summary

Investigation number 199701423
Occurrence date 02/05/1997
Location 5 km N Sydney, Aero.
State New South Wales
Report release date 01/02/1999
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Control - Other
Occurrence class Incident
Highest injury level None

Aircraft details

Manufacturer The Boeing Company
Model 747
Registration N124KK
Serial number 23244
Sector Jet
Operation type Air Transport High Capacity
Departure point Sydney, NSW
Destination Seoul, ROK
Damage Nil

Beech Aircraft Corp A36, VH-MVM, Skye, Victoria

Summary

The aircraft was operating on to a 617 m grass strip with a fence at each end. The orientation of the strip was north/south and threshold markers were positioned on either side of the strip 79 m in from the fence at the northern end. Some 40 m beyond the southern end of the strip was a group of trees 14 m high.

The weather at the time of the accident was fine with good visibility. The Bureau of Meteorology estimated the surface wind to have been from the north-west at 12 kt. There was no windsock at the landing strip.

Observers saw the aircraft, apparently operating normally, fly towards the landing area and make an approach to land to the south. One witness said the aircraft touched down at the threshold markers. A second witness reported that the aircraft touched down about 200 m in from the fence, bounced to a height of 3-4 ft, then touched down again about 25 m further on. The witnesses then saw the aircraft continue along the strip at speed, with a significant level of engine power applied. Approaching the southern end of the strip, the aircraft swerved right, probably to avoid the group of trees beyond the end of the strip. The witnesses heard an increase in engine noise and saw the aircraft become airborne. The landing gear contacted the boundary fence, and the aircraft continued across a road, through a line of bushes, and struck the side of a house. An intense fire broke out, destroying the aircraft and much of the building. The pilot escaped from the wreckage, but the passenger did not.

The first marks identified on the airstrip surface were main wheel tyre tracks which commenced about 300 m from the threshold. These marks indicated that skidding had occurred from 350 m from the threshold and continued for about 50 m. From there the aircraft ran straight ahead for about 170 m before veering to the right by approximately 12-15 degrees. The tyre tracks continued to within about 20 m of the boundary fence.

Inspection of the wreckage did not reveal evidence of any defects that might have contributed to the accident. The landing gear was down, and the wing flaps were extended 17 degrees.

The Aircraft Flight Manual landing chart does not provide for landing distance calculation where the tailwind component exceeds five knots. The Beechcraft A36 Pilot's Operating Handbook indicated that, with a 10 kt tailwind and when approaching over a 50 ft obstacle, a landing distance of about 700 metres would be required. However, when approaching over a 20 ft obstacle, this distance is reduced to about 500 m.

The available evidence indicates that the pilot conducted an approach to land in a manner which was not appropriate in the prevailing conditions. The pilot misjudged the approach and touched down well into the strip. The decision to go-around was delayed until too late to safely complete the manoeuvre.

The pilot declined to make himself available for interview during the investigation.

Significant Factors

The following factors were considered relevant to the development of the accident:

  1. The pilot attempted a landing with a significant tail wind component.
  2. The landing approach was misjudged.
  3. An attempt to go around was made with insufficient airstrip remaining.

Occurrence summary

Investigation number 199201218
Occurrence date 02/05/1992
Location Skye
State Victoria
Report release date 30/07/1996
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Control - Other
Occurrence class Accident
Highest injury level Fatal

Aircraft details

Manufacturer Beech Aircraft Corp
Model 36
Registration VH-MVM
Serial number E-398
Sector Piston
Operation type Private
Departure point French Island VIC
Destination Skye VIC
Damage Destroyed

Winching incident involving Sikorsky Aircraft S92A, near Broome, Western Australia, on 26 March 2019

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 the morning of 26 March 2019, a Sikorsky S92 crew was conducting a search-and-rescue/medevac training sortie in conjunction with a contracted training vessel. On arrival at the rendezvous location, the crew established themselves in a stable hover over the vessel that was underway in relatively calm conditions. At approximately 0900 Western Standard Time, the crew commenced a winching operation to lower an Intensive Care Paramedic (ICP) onto a clear exposed area of the deck. As the ICP came over the intended landing area he was slightly spinning, which is normal in winching operations. The ICP’s foot contacted a fitting on the boat and with the momentum of the spin his knee struck a hatch cover causing a serious knee injury. After some consideration of the situation, the crew recovered the ICP and transported him to Broome for medical assistance.

The ICP’s knee injury required admission to hospital for surgery.

The operator conducted a review, identifying and confirming that all controls in place for this exercise are effective. No causal human factor has been identified that would contribute to, or instigate, an injury to the ICP, and no shortfall or omission in any existing formal documentation, training, competencies or operator processes could indicate a root cause.

Safety message

The company has established policy, procedures and training for conducting winch operations. This crew had seemingly done everything to conduct the training correctly. Weather and sea conditions were suitable to carry out the winching practice. So what can be learnt?

This occurrence is a first for this operator and from the collective prior experiences of aircrew staff members, it was noted that bump/impact injuries are not uncommon, and have occurred with most operators in similar roles. The occurrence of injury has been as low as reasonably practicable and the likelihood of a re-occurrence, whilst it is considered possible, is remote. This brief indicates that there were no faults in the performance of the crews during the training exercise, and despite all conditions being suitable, it still resulted in an accidental serious injury. Although this incident is comparable to a slip/trip/fall in the workplace environment with causal factors that are unlikely to be able to be ‘trained’ for, it is the recognition and understanding that winching operations are inherently hazardous.

This incident therefore provides a reminder to operators and crews to ensure all organisational policy, procedures and training mediums are current and comprehensive. For all crews undertaking any complex exercises, it is important to review, understand, and brief the hazards involved and recovery actions to follow in the event of an unplanned incident.

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.

Occurrence summary

Mode of transport Aviation
Occurrence ID AB-2019-013
Occurrence date 26/03/2019
Location Near Broome
State Western Australia
Occurrence class Accident
Aviation occurrence category Control - Other
Highest injury level Serious
Brief release date 03/05/2019

Aircraft details

Manufacturer Sikorsky Aircraft
Model S92
Sector Helicopter
Operation type Aerial Work
Departure point Broome, WA
Damage Nil