Runway excursion

On 26 October 2012, a Piper PA-39 (Twin Comanche) aircraft, registered VH‑MMN (MMN), was landing at the Innamincka Township aeroplane landing area (ALA), South Australia. On board the aircraft were the pilot and a passenger.

MMN joined the circuit, and when on the downwind leg, the pilot noted that the windsock was indicating a strong crosswind. As a precaution, the pilot elected to increase the aircraft’s airspeed for the approach by about 5 knots and selected ½ flaps (about 15 degrees).

The pilot turned the aircraft onto final about 200 ft higher than normal. At that time, the windsock was showing a 15 kt crosswind, from the south-west. The pilot focused on the crosswind and ensured that the aircraft remained aligned with the runway.

During the landing, at about 100 ft above the runway, the flare was commenced. The aircraft floated and touched down about a quarter the way along the runway. The pilot reduced the throttle setting to the idle position and applied light braking.

When the aircraft was about half way along the runway, the pilot realised that the aircraft’s speed was too fast and he applied full braking. The pilot determined that it was too late to commence a go‑around. He reported that the braking appeared to be ineffective due to the surface of the runway and the aircraft continued beyond the runway end. The left landing gear struck a depression, and then the aircraft spun to the left and came to rest in a 1 m deep gully. The pilot and passenger exited the aircraft, the pilot received a minor injury whille the passenger was uninjured. The aircraft sustained serious damage.

This accident demonstrates the importance of assessing the operational and environmental conditions at the time in order to determine the most suitable landing type. Pilots should also establish a decision point along the runway at which a go-around should be initiated if the requirements for a safe landing can no longer be met. Additionally, it highlights the benefits of using all available resources, including persons on the ground, for gathering information on the actual conditions.

Aviation Short Investigation Bulletin – Issue 15

On 4 September 2012, the pilot of a Piper PA-28 aircraft, registered VH-SFK (SFK), was conducting solo touch-and-go circuits at Bankstown Airport, New South Wales.  After landing on the fourth solo circuit, when the pilot applied full power for take-off, SFK veered suddenly to the left onto the grass. The pilot reduced the throttle setting to the idle position and applied the brakes, however the aircraft collided with the airport perimeter fence. The aircraft sustained substantial damage and the pilot sustained minor injuries.

Aviation Short Investigation Bulletin – Issue 14

The Air Accident Investigation Bureau (AAIB) of Mongolia is investigating a runway excursion that occurred at Oyut Domestic Airport, Mongolia on 30 March 2012 and involved a Fokker 50 aircraft, operating as Aero Mongolia Airlines flight Ju 8257. The aircraft exited to the right of the runway and its nosewheel and propeller struck a frangible, stake-mounted runway edge light as the pilot manoeuvred the aircraft back onto the runway. The aircraft was substantially damaged and there were no injuries to passengers or crew.

The investigation is being carried out in accordance Mongolia's obligations as the State of Occurrence under Annex 13 to the Convention on International Civil Aviation. On 11 May 2012, the AAIB requested Australian Transport Safety Bureau (ATSB) assistance by providing investigator support to obtain relevant technical information and verify the correct lighting installation. In accordance with paragraph 5.23 of Annex 13, the ATSB appointed an Accredited Representative to assist the AAIB. To facilitate this support, the ATSB commenced an investigation under the Transport Safety Investigation Act 2003. The ATSB coordinated with the Australian aerodrome lighting manufacturer for technical information and diagrams, which were provided to the AAIB.

The AAIB of Mongolia is responsible for releasing the final investigation report on this occurrence. Any enquiries in respect of the AAIB investigation and report should, in the first instance, be directed to the:

Air Accident Investigation Bureau

Ministry of Road, Transportation, Construction and Urban Development of Mongolia
Chinggis Khaan International Airport
Ulaanbaatar 34 Mongolia

Telephone: +976 9595 3339
E-mail: aaib@aaib.gov.mn

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Released in accordance with section 25 of the Transport Safety Investigation Act 2003.

On Wednesday 21 March 2012 at 0530 Eastern Daylight-Savings Time an aerodrome reporting officer (ARO) reported a runway edge light outage at Williamtown Airport, New South Wales. A further inspection during daylight revealed a broken runway edge light and wheel marks in the grass adjacent to the runway. The evidence was consistent with an aircraft departing from the sealed operational readiness platform adjacent to the runway threshold onto the grass and colliding with the runway edge lighting.

The distance between the wheel marks was consistent with a Beechcraft Kingair aircraft. Air traffic control records show that no other aircraft with this wheel arrangement had operated between the runway inspections.

The pilot of a Beechcraft Kingair 350, recalled rejecting the take-off on departure from Williamtown Airport on the night of 19 March 2012 due to asymmetric power resulting in the aircraft deviating left of centreline. The pilot did not believe that the aircraft left the sealed runway area. A number of other Kingair aircraft operated at Williamtown during the considered period.

It was not possible to determine when the runway excursion occurred, however the wheel marks indicated that a Kingair may have inadvertently lined up on the runway edge lighting during take-off. A paper published by the ATSB, "Factors influencing misaligned take-off occurrence at night" highlighted the risk factors for a misaligned take-off.

On 10 January 2012, a Dornier Werke GMBH 328-100 aircraft, registered VH-PPJ, landed at Horn Island Airport, Queensland, after having departed Cairns, Queensland to conduct a search and rescue operation with two flight crew and three technical crew onboard.

The aircraft touched down on the runway normally, at about 48 kts, the pilot flying released the power levers from the reverse thrust position, the right propeller moved to a ground idle position, but the left propeller remained in the reverse thrust position and the aircraft veered off the side of the runway.

The FO attempted to correct the deviation through rudder input; however, despite full right rudder, the aircraft continued to diverge left. At the same time, the nose-wheel weight-on-wheels sensor showed the nose wheel alternating between ground and air modes, resulting in the nose-wheel steering not being operational.

A subsequent engineering inspection found that the left power lever appeared not to spring as far forward as the right power lever when released from reverse thrust. The levers and shaft assembly were inspected and found to be serviceable. A lubrication of the springs in the reverse thrust system was carried out.

The operator reported that the thrust levers required positive handling to move from the reverse thrust to the ground idle position, rather than relying on the spring tension. The first officer did not recall receiving specific instruction on operating the power levers.

The operator advised the ATSB that it had conducted the following safety action: All crew have been alerted to potential difficulties with the operation of power levers; an external advisor has been recruited to review the safety system and check and training program; the organisation is assessing the ongoing introduction of simulator training.

On 20 December 2011, at about 1500 Eastern Standard Time, a Cessna Aircraft Company 188B Ag wagon, registered VH-SHM, collided with terrain after experiencing difficulty becoming airborne from a station property near St George, Queensland. The purpose of the flight was the aerial application of herbicide to control weeds on the property. The pilot was the sole occupant of the aircraft and sustained serious injuries.

The pilot was relatively new to the aerial application industry and inexperienced on the aircraft type. The aircraft had recently had a new propeller and hub fitted pursuant to an engineering order.

Approved Agricultural pilots are reminded of the importance of supervision of newly rated agricultural pilots. The accident also highlights the importance of pilots being aware of the maintenance that has been performed on an aircraft and the value of a test flight being performed by a pilot experienced with the aircraft type following maintenance.

On 5 December 2011, at about 1030 EDT a Taylorcraft model BC12-D aircraft, registered VH-PEE, was engaged in taxi trails as part of a pre-flight inspection for a flight scheduled late in the day. The pilot reported that, while using a grass runway, 26 km to the south-east of Gunnedah Aerodrome, NSW the aircraft was struck by a strong wind gust or Willy-willy and, on attempting to correct with engine power and right rudder, the aircraft veered off of the runway. He was unable to regain control, and the aircraft subsequently struck a fence on the northern side of the runway and flipped over, coming to rest inverted. There were no injuries to the pilot. The aircraft incurred serious damage which included damage to the propeller, one wing strut and the wing surfaces.

Past studies have indicated that Willy-willies are unseen, unpredictable and can adversely affect light aircraft and helicopters when they are operating on or close to the ground. Pilots must be vigilant when operating in these areas and be prepared to react to mitigate the effects of Willy-willies and maintain control of the aircraft.

On 30 November 2011, a Cessna 210L aircraft, registered VH-SKQ, departed Derby for Kalumburu, Western Australia, on a passenger charter flight. There was one pilot and six passengers (including an infant) onboard.

On landing, the aircraft touched down about 400 m from the landing threshold. The pilot attempted to slow the aircraft using brakes, however there was no brake pressure available.

The aircraft ran off the end of the runway at about 40 kts, colliding with some large rocks. The aircraft was seriously damaged, however there were no injuries to the passengers or the pilot.

The pilot stated that the normal approach procedure was to check the brake pressure prior to lowering the landing gear during the descent, however this step was missed during the pre-landing checks. If a brake fault had been detected prior to touchdown, the pilot would have had more time to consider the options available.

It is important for operators, training organisations and individuals to consider scenarios like this one as training scenarios, so pilots can formulate a plan prior to an actual event occurring. The pilot had not received any training for a brake failure.

Aviation Short Investigation Bulletin - Issue 11

On 24 November 2010, a Boeing Company 737-8FE aircraft, registered VH-VUX, was being operated a scheduled passenger service from Melbourne, Victoria to Hobart, Tasmania. The crew were advised that the runway would be wet for their arrival into Hobart. During the landing on runway 12, the crew reported that the initial braking was normal, however, in the final stage of the landing, the braking was not effective despite increasing brake pressure. Both crew stated that the aircraft felt as if it was sliding or aquaplaning.  The crew reactivated the thrust reversers, and the aircraft came to a stop beyond the end of the runway in the stopway area. There was no damage to the aircraft, or the tarmac and the aircraft was turned and taxied to the terminal.

A post-incident inspection of the runway found that there was rubber build up near the runway 30 touchdown markers and portions of the runway had been resurfaced but not re-grooved.

As a result of this incident, the aircraft operator issued a flight crew communication notice modifying the take-off and landing procedures for Hobart Airport in wet conditions. The airport operator issued Notices to Airmen (NOTAMs) stating that there had been reports of aquaplaning on landing in heavy rain and that the runway surface was ungrooved. In addition, they have brought forward a scheduled full resurfacing of the runway to November 2011, removed a runway surface treatment from the area around the centreline of the runway and grooved the resurfaced sections of the runway.

The ATSB has completed its technical analysis of flight recorder data from several Indonesian aviation accident events that occurred between 2009 and 2011.

The National Transportation Safety Committee (NTSC) of Indonesia is responsible for investigating these occurrences. The NTSC requested technical assistance from the Australian Transport Safety Bureau (ATSB) in the determination of the appropriate data frame layouts for the flight data recorder (FDR) information recovered from the occurrence aircraft. In accordance with clause 5.23 of Annex 13 to the Convention on International Civil Aviation, the ATSB appointed an accredited representative to assist the NTSC and initiated an investigation under the Australian Transport Safety Investigation Act 2003.

In cooperation with NTSC staff, suitable data frame layouts were determined for all recovered FDR data, and the information was provided in a report to the NTSC. The NTSC is responsible for releasing the final investigation reports on these occurrences.

National Transportation Safety Committee
Ministry Of Transportation Republic Of Indonesia
Transportation Building 3^rd Floor
Jalan Medan Merdeka Timur No. 5
Jakarta Pusat 10110
Indonesia

Phone  :  +62 21 384 7601
Email    :  knkt@dephub.go.id

Website: http://knkt.dephub.go.id/knkt/ntsc_home/ntsc.htm

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Released in accordance with section 25 of the Transport Safety Investigation Act 2003.