Aviation Safety Digest 117

gently on the ground so that touchdown is made on th e mainwh eels fir st - as int ended by the manufacturer . Because the cent re of gravity is for ward of the mainwhee ls the a ircraft w ill pitc h sli ght ly forward a t touc hdown , thereby reduc i ng the a ngle of in cidence (and the lift) of the ma inpla n e, and the a ircraft stays on the ground. It is wh en the cor r ect technique is not observed that problems can arise. Before discuss in g the problems of bounced land in gs 4 I Aviation Safety Digest 117 in detail it is worth st a ti ng at this poin t that the best way to avoid occurrences of this so rt is to main tain your flyi ng skill at a safe level by fre qu ent and p roperly condu cted practice. Other wi se, the best ins ur ance is to tak e a check flight with your instructor a nd ensure your flying ski ll is st i ll at a safe level. If you have not bee n s ubject to any official fl igh t tests in the previous 24 months you will also be due for a flight rev iew, an d this can be used to brush up your technique, so h elping you to preven t accide n ts rather than cure th em . Mislandings: cause and effect Th ere are four basic ca uses of mislandin gs and each is likely to h ave predictable consequences: • No ro und out or insufficient roundout. The aircraft w ill e ither touch down on the nosewheel or on a ll three wheels simultaneously . S in ce the speed will be hi gh the aircraft will bounce, becom in g airborne aga in. Unless corrective act ion is t aken by the pil ot the nose will begin to drop as t he airspeed decays a t the top of the bounce, causing the aircraft to p itch d ow n heavi ly onto the nosewheel. If excess flying speed still exists thi s mot ion may be repeated several times with each oscillation becomin g sh orter, steeper a nd less contro llable. This mo t ion is ca ll ed 'po rp oisi ng' and can cause serious damage to the undercarria ge, propeller and airframe, n ot to menti on the hapless pilot and passengers. Worse, this oscill atory motion can be aggravated by the p il ot if his react ions are slow or ill- timed. T h e instinctive reaction to a b ou nced land i ng is to relax back pressu re or move the contro l co l um n forwa rd to reduce the he i ght of the bounce. However, if th e control inpu t is delayed it may no t take effect unt il the airc r aft has already begun to descend, ther eby increasing t he r ate of descent and steepen ing the ang le of the alr eady downpitch i ng nose. The result is an even h eav ier im pact on the nosewheel and perhaps propeller. • Ro u ndou t too large . The aircraft will balloon, lose ... A typical bounced landing accident Po i nt on runway where nose wheel collapse appears to have occ urred Final skid 60 metres Aircraft crosses thr eshold 17 knots fa st airspeed rap idly and then possibly sink at a high rate causing a h eavy lan di ng and damage to the undercarriage and ai r frame. • Insufficient hold -off or landing before the correct att it ud e has been reached. This can lead to 'porpois in g' if the nosewheel touches firs t, or a series of skips if all three wheels touch together. The undamped 'porpoise ' can cause severe damage. F u rt h er, a ground lo op may also occur if there is a loss of directional control . • Holding off too long and l anding with little or no control over the aircraft a tt itude or rate of descent . If a hold-off is continued for too long , so that the airspeed is at or near the stalling speed and the aircraft is then allowed to balloon or is lifted by an un expected gust, the consequent hi gh si nk rate and/or stall may be imp ossible to control beca use of the lack of a ir speed. On ce again, u ndercarriage and propeller damage are likely, while the consequences of a wi ng drop durin g the stall need no elaborat ion. Corrective actions In most cases the best cu re is to 'go round' as soon as a mislanding is recognised. If the landing has initiated a 'por poise ', h old the co ntrol column slightly aft of n eut r al and apply full power. This will dampen the 'porpoise' a nd the aircraft will eventually climb away . Oppos i ng the 'porpo i se' pitching action b y use of elevator almost in va ri ab ly accentuates the problem . If c ir cums tances militate against a go - around, e.g. a d am age d ai rcraft, bad weather , etc., then a mislanding can be r ecovered by skilful use of p~wer to red uce the des cent rate a nd to fly the aircr aft into a second flare a nd ' hold-off' . However , this technique requires pract ice and skill. If no t familiar with it yo u should ask your ins tru ctor to teach you during yo ur next check flight. The fo ll owing po i nters , applicable to a ny la ndin g, are all indi cative of a sound fl yin g tec hniqu e and s hould be borne in mind when t hinkin g about this article: • A gentle flare started early is better than a violent flare at the last m o ment. • Know t he landing attitude of yo ur aircraft - do not let the air craft to uch down until you achieve the landing attitude - do not attempt to hold -off by raisi ng the nos e above the landing att it ude - if you have reach ed the landing attit ude during the ' h old - off', maintain that attitude with the elevators and, if necessa ry, control the sink rate with power un til the a ir craft touches down. • Pick a point on the runway at which you will 'go round' if the aircraft has not to uched down . An old definition of a good pilot is one who has an equal nu mber of takeoffs and landings .. . think abou t it! Th ink about this article too, especially in relation to your flying technique righ t throughout the approach and land ing phases; perhaps the re may be some poin ts which wo uld lead to a worthwhile discussion with your local fl ying instructors on this fu n damental aspect of flying . If out of practice or still inexperienced, have yo ur instructor give you a lesson on recoverin g from mislandings, perhaps during your next check flight e Aviation Safety Digest 117 I 5 Aerobatics and pilot limitations 'The pilot conducted aerobatics at an altitude which wa s too low to ensure safe recovery.' A erobatic flig ht is very popular throughout Australia. Properly executed aerobatics are exhilar a tin g and also serve as an exce ll e nt medium for impro ving flying skills and learning to appreciate the capa bilities of a ir c raft. The y are demanding an d many manoeuvres leave the pilot with li ttle scope for er ror. It is for this reason that strin gent rules are pre scrib e d. The display at an a ir show which draw s approving comments from knowledgeable spectators is the en d result, not only of a skilled and enthus iastic attitud e towards flying, but also of a professional a nd mature u nderstanding of the natur e a nd de mand s of aerobatic flight , a nd of the safety rules pe rt ain ing to it . A local accide nt demo nstr ated - tra gically - th at to ignore those rules is to invite disaster. The pilot h ad been checked and a ppro ved to perfo rm aerobatics d own to 1000 feet abo ve ground level (AGL). A conditi6n 'of the a pproval was th at pa ssengers were not to be carried. He h ad sought, a nd received, permission to carry out an aerobatic di spl ay at a 'fly-in' held at a country tow n. Thi s di spl ay was carried out in acco rdan ce with the pilot' s low-level aerobatic a ppro val. Tow ards the e nd of the day's activity a television news team arranged with the pilot to take so me air-to- air film of th e aircraft p erformin g. aerobat ics. It was arranged for th e television team's h elicopter to fly at 500 feet AGL while filming th e sequence. Thi s took a bout 10 minutes. Dm·ing the seque n ce a passenger was occupying the front seat of the display aircraft. Recovery from some of the ma noeuvres was observed to be below th e level of the helicopter , which was 6 I Aviation Safety Digest 117 ma int ain ing its pl anned altitude of 500 feet AGL. When the filming was compl et ed the helicopter departed; the d isplay a ircraft fl ew to a p oint ab out on e kilometre from the aerodrome and cont inu ed pe rformin g aerobatics at a b out 500 feet AGL . Witnesses observed t he ai rcraft begin a looping mano e uvre from which it en t ered a spin to the left. Recovery was initiated but the a ir craft then began to spin to the ri ght. Rotation then stopped with t he aircra ft po in ting vertically downwards . Dur ing the r ecovery from the dive t he a ircr aft str uck the groun d, still over 30 degrees n ose down , with the wings level. Comment It will n ever be possible to deter mi ne a ll the c ontrib utory factors in this fatal accident. For exa mple, the unauthorised passenger was also an en dorsed aerobatic pilot - were there competitive peer pre ss ur es acting, directly or indirectl y? T h e immed iate cause, however , was spelt out in t he Investigation Report in one b rief clear sentence: ' The pilot con ducted aerobatics at an alti tut e which was too l ow to en sure safe r ecover y .' An art icle in Avia tion Safety Digest 102 addressed the top ic of 'Aero batics and structural limitation s'. That article, whi ch is com me nded to all pr actising or would- be aeroba tic pilots, i ncludes the co mm e nt th at 'No sensible pilot know in gly operates an aircra ft beyond its st ru c tur al design limits' . T h e same st and ard must also app ly to th e individu al's piloting l imits: limits which are u nequivocably spell out in relevant aut horisations • ... I .... 'The pilot continued flight into weather conditions ... ' Readers of the Aviation Safety Digest will be, unhappily, all too familiar with the type of accident addressed in this article. Just why VFR pilots continue flight into weather conditions in which they are unable to maintain the visual references necessary to ensure adequate terrain clearance remains unclear, for most pilots involved in such accidents do not survive to explain their reasoning. It appea rs th at the 'it-ca n't-happen-to -me' syndrome affects many in dividuals. Anyone who believes it cannot happen to h im is advised to consult the index in Aviation Safety Digest 113 a nd review some of the occurrences referenced unde r the heading of 'Weather'. T he urge to get to a destination - to 'get t hrough' or 'get-home - itis' - also seem s a likely influence on pilots when making operational decisions. Yet we are rarely, if ev er , in as mu ch of a hurr y as we think we are - certain ly not at the expense of our lives. W h atever the reasons, this topic is essential reading for all pilots, for investigations have shown tha t a high experien ce lev el , an extensive aviation background and a conscien tious attitude towards fl ying are no guarantee against weat her -related accidents. It takes only one hasty or ill -conside red decision, regardless of one's experience, to give the elements a potentially dangerous edge over your mach in e, your passengers and you. For almost all weather-related accidents it is possible to identify a point, or points, at which the flight should have been diverted or abandoned. This may come, for example, in the fo rm of a preflight weather forecast, an amended infli ght forecast or report, or by actually en counteri ng con ditions approaching VMC minima . Re ader s are invited to assess the following account of a weather -related accident with the obje ctive of identifying those po int s and deciding what actions they would have taken . If they subsequently ever find th emselves faced with a decision of that type, then perhaps the careful th ought that an analysis of this accident warrants will help them reach the right dec ision in t ime . * * * A flight by an experienced pilot was pl ann ed from Alice Sp rin gs to Adelaide via Leigh Creek. The pilot was fam iliar with the route , hav ing flown it often. H e held a Class Four instrume nt rating but was not qualified to fl y in in strum en t me teorological conditions. H e atte nded t he Alice Springs briefing office and was issued with meteorological forecasts which indicated tha t wea ther conditions were expected to deteriorate south of Leigh Creek. In part icular, low stratus was likely over the Fl inders Ra nges. Copies of the forecasts issued at Alice Spr ings fo r the section of the flight from Leigh Creek to Adelaide are reprinted below: A rea 51 covers the firs t half of that section and Area 50 the second half. Area 51 forecas t issued at Alice Springs ARFOR 2300 TO 11 00 AREA 51 WIND 2000 24020 5000 24025 7000 24025 10000 25030 ZERO 14000 25035 MS05 18500 25040 MS15 CLD SCT ST 1200/1800 FT MON TIL 0200 BUT BKN IN DZ . SC T CU 2500/700 0FT SCT SC 3000/7000FT TEND BKN MON AND IN D Z V I S 40KM DTRT 4000M D Z 400M FG WX ISOL FG PATCHE S TIL 0100. I SOL DZ TIL 0200 CHIEFLY MON FZL lOOOOFT TUR B MOD IN CU. MOD BLW 6000FT ON AND TO LEE MON Area 50 forecast issued at Alice Springs AM D ARFOR 2300 TO 1100 AR EA 50 W IND 2000 25030 5000 25030 7000 25035 10000 25040 MS05 14000 25045 MS08 18500 25050 MS18 CLD BK N ST 800/2000 FT IN R ASH/DZ. B KN ST 800/2000FT WINDWAR D COT/ MON BEC SCT AFTER 0100 AND RED EVELOP I NG AFTER 0900. SCT CU 2500/ 8000FT WIT H I SOL TOPS 12000FT S OF 34S. SC T SC 3000/6000 FT BK N SC 2000/ 6000FT IN DZ AND COT/ MON AMD V I S 40KM DTRT 6KM RASH 1500M XXSH 3000M DZ 400M FG AM D WX I SO L FG PATCHES TI L 0100. ISOL RASH TEND SCT COT/ MONS 34S. I SO L XXSH S 35S. I SOL DZ COT/ MON FZL 5000FT IN S R ISING TO 8500FT IN W I CE OCNL MOD INC ABV FZ L TUR B OCNL MOD IN CUF . OCNL MOD BLW 6000FT ON AND TO LEE MON A delaide TAFOR issued at A lice Springs COR TAF AMD AAAD 2304 31018 9999 80RASH 2 ST012 4CU020 4SC030 RAPID 0203 23020/ 41 0414 23020/ 30 9999 80RAS H 4CU020 3SC030 INTER 2305 3000 81XXS H 5ST008 11 12 13 11 1012 1010 1009 1009 A VFR flight plan was submitted and the pilot indicated that if he encountered adverse weather south of Port Augusta, he would divert to Port Augusta or Port Pirie . W i th his two passengers the pilot departed Alice Springs mid-morning in his Piper Seneca and comp leted an unev entful flight to Leigh Creek , although the weat her at Leigh Creek was marginal for VFR operations. At Leigh Creek the a ircraft was refuelled to capacity and th e pilot ob tained ame nd ed forecasts for Area s 51 a nd 50. These were as follows: Aviation Safety Digest 11 7 I 7 - ---+ 340 R P • k Po1n ~ho W2tor Pont PLANNED TRACK REVISED TRACK CRASH SITE Cape El1nb th P me Wnr n Reef Pot t B atr1 R k Goo e I nd 8 I Aviation Safety Digest 11 7 \PORT PIRIE Jarr Id P int "> Wo d P '" W 1 g Po ... Area 51 forecast issued at Leigh Creek AR FOR 0500 TO 1400 AREA 51 W IN D 2000 25020 5000 24025 7000 24030 10000 23035 MSOl 140 00 25040 MS07 18500 26045 MS19 CLD SCT ST 1500 /3000FT ABOUT MON AN D IN PRE C IPI TATI O N SC T CU 2500/7000FT SC T SC 3500/6000FT DT RT BKN SC 2500/6000 FT IN DZ AN D ABOUT MON V IS 40KM DTRT 4000M DZ/ RA SH WX ISOL DZ MON . ISOL RASH MON S HAW FZL 9000FT T U RB MOD CU F AND BLW 6000FT ON AND LEE MON Area 50 forecast issued at Leigh Creek AMD ARFOR 0400 TO 1400 AREA 50 WI ND E OF FRO NT 2000 28030 5000 28035 7000 28035 10000 27040 MS06 14000 24040 MSll 18500 24045 MS21 W OF FRO NT 2000 25025 5000 25030 7000 25030 10000 24035 MS04 14000 24040 MSl l 18500 24045 MS21 AMD CLD SCT COT ST 1000/2000FT DTR T BKN ST 1000/2 000FT WINDWARD MON. BK N ST 800/2000 FT IN RASH/DZ. SCT C U 2500/8000FT I SO L TOP S 14000FT S 34S. SCT SC 3000/6000 FT DTR T BK N SC 2000/6000 FT IN D Z AND COT/MON V IS 40KM DTRT 6KM RASH 1500 XXSH , 3000M D Z wx SC T RASH. I SOL XXSH S 35S, I SOL D Z COT/ MON FZL 7000FT ICE MO D OCNL INC ABV FZL TURB MOD OCNL CUF AN D TO LEE MON A delaide TAFOR issued at L eigh Creek TAF AAAD 0208 31018 9999 80RASH 2ST012 4CU020 4SC030 RAPID 0203 23020/4 1 I NTE R 0205 3000 81XXS H 5ST008 0820 23015 9999 80 RASH 2ST0 12 4CU 020 3SC030 13 12 11 9 1012 1010 10 1110 11 W hile the re were still some 45 minutes before the ar ea 51 forecas_t became val id , it gave the pilot an in di cation of the expected trend. A comparison of the two sets of forecasts would also have enab led the pilot to make an assessment of the changes, if any, in the gener al weather pattern , thus giving him a better apprecia tion of en route conditions . In add ition to receiving the ame nd ed forecasts at L eigh Cree k, the pilot was also informed that both Adela id e an d Parafield were currently closed to V FR traffic be cau se of adverse weat her . As t he pilot taxied for departure at 0419 hours GMT , there were six oktas of cloud, base 1500 to 2000 feet, over Leigh C reek. T he pilot advised that he inten d ed cruising below 5000 feet instead of 7 500 fee t as orig inally planned. He departed at 0424 hours and at 0429 ho ur s acknowledged receipt of an amended Adelaide termi na l forecast giving visibility of 10 km or greater , rain showers, one okta of cloud at 1000 feet and six oktas at 2000 feet with visibility intermittently reduced to 3000 metres with three oktas of cloud at 800 feet. The flight plan submitted by the pilot at Alice Springs indicated his intention to track via Quorn, Wokurna and Ardrossan, but at 0449 h ours he advised that he would be proceeding direct to Po r t Augusta and then to Wokurna. He subsequently reported to Adelaide Flight Service Unit (FSU) passing a.beam of Port Augusta at 0515 hours, below 5000 feet, and advised tha t he would be tracking to D ublin . No reason was given for this change of route, but clearly adverse weather was the cause. Adelaide FSU informed h im that restr icted area R252 , which is situated south -west of Port Augusta, was active and he confirmed that he would be remaining clear of that area. T he pilot of another aircraft in the area then reported there was a storm in the Gulf north of P ort Pirie, the weather was clear to the west, and suggested that if the Seneca were to track via P oint Lowly it would have no problems. This was acknowledged by the Seneca pilot who responded: 'Th ank you very much . I shall do.' He was then instructed by Adelaide to call Whyalla FSU . Contact was established at 0523 hours. The pilot did not, however, reply to any subsequent calls directed to him. Following unsuccessful attempts to re -establish communications with t he aircraft, search and rescue action was comm en ced. Search action was hampered by ar ea s of low cloud and reduced visibility associated with rain and st rong winds. The wr eckage of the aircraft was located at 0435 hours on the following day. It was situa ted on the eastern side of Mount Remarkable some 300 feet below the 3150 feet summit . At impact the a ir craft had been in essentially level flight on a south - westerly heading. All three persons on board had been killed. D etailed examination of the wreckage did not re veal any defect or malfunction which might ha ve contribu t ed to the accident. It was established that at about the time of t he accident, extensive low cloud and rain areas obscured t he ranges in the vici nity of Mount R emarkable . Comment T he forecasts obtained by th e pilot at Alice Springs indicated that he would be heading towards an area of dete rior ating weather . This was co nfirmed b y th ose recei ved at Leigh Creek , bu t the pilot did not express concern at any stage on receiving this information; nor did he express any anxiety en route despite th e tracking ch anges he had to make. Perhaps his famil iarity with the area led h im to believe he could find his way despite the poor conditions. In fact it would appear that he was no t ab le to navigate adequately by reference to the ground and eventually tracked to the east of Mount Remarkable. W h en he turned south -west - presumabl y to track to Poin t Lowly following the ad vice th at th e weather was clear there - he obviously was un awa re of the dangero us proximity of Mou nt Rem arkable. Uncertain of his position and operating in adverse weather conditions, the p ilot tu rned towards and flew into the highest ground in the immediate vicini ty • Aviation Safety Digest 117 I 9 Acasual approach Two different kinds of approach were fea tu res of this accident to a Beech Bonanza. The first was a ve ry experienced pilot's rather casual approach to hi s pref light preparation. The sec on d was an unorthodox final approach into a difficult landing area. The result was substantial damage to the aircraft wit h, fortunately, no injuries to its occupants. The purpos e of t he flight was for t he pilo t an d two passenger s to visit a co tton fa rm on which th e re w ere s everal landin g s trip s. S eve n weeks pre vio usly th e pilot had operated into the strip he intend ed us ing this da y. The three men drove to th e aero drom e wher e th e Bonanza was pa rked and , while the pilot co mpl eted his pr eflight insp ect ion , on e of the passenger s tele ph o ned the manager of the cott on fa rm to che ck the wea ther , en s ure that everything w as rig ht for the a irc raft's ar rival and to advise their ETA. A flight plan was not s ubm i tted be cau se of diffic ultie s with the local (m a nual ) tele ph o ne ex c hange and becau se in t he past the pilot had occas ionally experi e nced problems with the airc raft 's radio s. F urth er, t he farm mana g er was aware of t heir plan s. On arri v al at the farm the pilot ov erflew th e manager' s hous e a t a bout 1000 feet AGL to a le rt him to their a rriv al . He the n flew to th e a ir s trip , w hi ch is a li g ned 08 5 /2 65 de g ree s a nd is a pproxim a tely 1050 m e tres lon g, to ca rr y out a visua l insp ec tion at 500 fee t AGL. 10 I Avia tion S afety Dig est 11 7 A s th e wind was o nly 2-3 kn ots fro m th e eas t , the d ec is ion was ma de to lan d on t he 2 65 str ip to av o id l oo kin g in to th e mo rni ng sun . Th e t hresho ld ar ea of thi s st rip wa s obs tru ct ed by a se ve n-m et r e- h igh cot t on mo d ule m a ker (a m ach ine for making l arge cot ton bale s) to the s ou th , and by four o r five cot t on pickers, e ach ab o ut five m etre s hi gh, to t he n or th . AU of these ob st ru c tions we re w it h in th e str ip b o un d ar y b u t ou tside th e central 15-m et re sectio n. At th e e nd of the i nspe ctio n run the pil ot turne d south to give roo m for a left ba se . A fter ca rr ying ou t the pr e -landin g checks a nd select in g gear down and full flap in st ages, he a pp roac h ed ov er th e top of the ob stacles ne ar the easte rn t hre sh old . R eal isi ng t ha t he was too fas t (10 0 kno ts) he we n t aro un d . H e clim b ed to a bout 700 feet A GL , r et racted th e flap bu t left the gea r down a nd flew a downwind leg. On th e second ap p roac h he deci de d to fly to the n ort h of the obstacles and make an S- tu rn to l ine up on th e strip after pass i ng them . Full fl ap was aga in u sed . A fter pass in g the obstacles and turni ng left to in t erce pt T j l .#,. ~T~,,_, PICKERS I • \.M.VliiH ' ~I ! 1s M X.__ 100M+ I~ I '--~~~~~4-0_0_M~----------~~~=.. ~-M-OD_U_L~E ~~~~~~~~~~~-#, Ill I MAKER , ... MODULE MAKER i-7 M HIGH , &::;jl Fl;ghr:::th Diagram of Flight Path. (not to scale) th e cen tr eli ne, the pil ot started the turn r i ght to align the aircraft wi th t he strip but at t hat stage realised he d id no t h ave en oug h he i ght to turn. H e rolled to the left to l ev el the w in gs, at the same t ime appl y ing full power . T his d ecision , however, had been left too late . Th e a ir cr aft sank on to the gro und, touching initially abo u t 50 me tres in front of t he module maker and abo ut 15 d egrees off runw ay heading. The aircraft ground l oo p ed and s ki dded backwards , finally coming to r est abo ut 45 m etres sou th of the strip centre line, on a head ing o f 115 degrees and with t he engine dislodged from i ts mo u n t ings . T h e su bse qu en t in vestigation revealed significant d efic ienc ies in the pl anning and conduct of this flight. • Be ca use of the ob stacles parked within its boundaries th e str ip d id n ot meet the requirements for a private cate gory Au th or ised Landing Area. The landing d ista n ce availabl e, allowing for the obstacles, was 310 m et r es. From the aircraft 's fl i ght m anual perfo rm ance ch arts, the landing distance required fro m a hei gh t of 50 feet in nil wind was calculated to be 50 0 metres . • T he decis io n t o fl y an S-turn on sh ort finals to avoid th e o bs tacles was contrary to the r equ irem ent that the l ast 500 m et res of an approac h for landing must be m ad e in a s trai ght line . • In sufficien t atte n ti on was paid to airspeed, probably bec au se of th e d emands involved in attempting to li ne up t he aircraft . T he pilot advised that he did not n ot ice th e spee d on the final approach, b u t that the a i rcraft a tti tude fel t normal. He stated that he n ormally a pp roac h ed at about 80 knots, but used the aircraft fli gh t m a n ual to calculate speeds for 'reall y sho rt ' str ips . It seem s likely th at dur i ng the turn close to the g round, wi th the pilot applying consid erab le b ack pres s ure on the control colum n , the an gle of a tt ack i ncreased and the airsp eed decayed to th e st age where the late application of power was ins uffici ent to ar rest the sink rate . There is no sh ortage of lessons in this accident, and h ope fully the expe r ien ces of this pilot can be used as a teachin g medium for all of us who fly aeroplanes . Fr om the outset, the wi sdom of leavin g one of the passengers - who had no piloting experience - to make contact with the man a ger at the desti n ation m us t be questioned. Operations into any AL A should be conducted with caution, especially if you are unfamiliar with the area or have not been there for some t ime . If someone is available at the area - as they were in this case - then the pilot should contact them himself to confirm such variables as the condition of the surface, obstructions, and alterations to the ALA dimensions. That conditions can change is amply illustrated by this accident. In this case, the passenger who did the telephoning ap p arently did not raise the question of t he state of the A L A. Just as the pilot 's approach to preflight preparation was casual, so too was h is attitude to landing when he arrived, found that he was faced with a demanding approach , but decided to press on witho u t properl y reassessing the situation. Cle a rly it would have been impractical for him to calculate the ALA dimensio ns air borne, but a check of his aircraft's landing data performance figures, allied to his v isual observation of the obvious encroachmen t of the machinery on the availab le l anding length , would have alerted him to t he danger . Had the pi lot done this - or i ndeed asce r tained the condit ions at the ALA himself prio r to depar t ure - then he doubtless would have abandoned any attempt to land at that part i cular airstrip . A final word. T his pilot was offhand in his attitude towards se ve ral types of fundamental safety material , pa rtic ul arly the aircraft performance da ta and certain operational rul es . T he temptation to bend the rules is familiar to all of us . It is , however , a luxury pilots can n ot afford. The r ules have been framed , not to frustra te u s, but because the y are the basis of safe, sound airmanship . Know th ose applicable to yo ur ope r ations, and ab ide by them • Aviation S afety Digest 11 7 I 11 Military firing ranges The danger of fli ght through active military restricted areas was highlighted in Aviation Safety Digests 87 and 111. Digest 111 paid particular attention to the ways in which pilots could avoid this potentially serious br each of regulations, discussing such aspects as preflight planning, the curre nc y of en route charts and documents, and navigational techniques. Notwithstanding this good advice, breaches are still occurring a nd there remains a sm all group of pilots in Australia who, probably without realising it, owe a vote of thanks to the vigilant range safety officer who commanded a 'Cease Fire ' on sighting an unwitting and unwanted intruder. Are y ou one of these recent transgressors? • An unidentified aircraft flew through R352 near Puckapunyal at 1000-1500 feet while firing was in progress. • A cream-co lou red s ingle-engin ed Cessna penetrated R329 near Westernport while the range was active. • An unidentified s ingle-en gined, silver-coloured aircraft flew th rough R353 at Greytown from east to west at 2000 feet when line firin g of mortar shells was in progress. • A sing l e-eng in ed, high-wing aircraft wit h orange and ye ll ow st rip es on the fuselage fle w through an active range R524 near Parkes at about 1000 feel. While these incidents relate to penetration of Army la nd-based firin g ranges, transgressions h ave also taken place through Navy ove r-water ranges. Some data on the prime weapons fired by the Army will be of interest to any pilot planning a flight adjacent to a military range: 12 I Aviation Safety Digest 117 • 81 mm mortar - vertical extremity of rounds 5800 feet, maximum rate of fire 10 to 15 rounds per minute. • 105 mm howitzer - ve rtical extremity of rounds 18 OOO feet, maximum rate of fire six rounds per minute. • 155 mm h owitzer (to come into service in 1983 /8 4) - ve rtical extrem ity of rounds 63 OOO feet, maximum rate of fire four rounds per minute . The point h ere is that, while firing ranges a re c ir cu ms c ribed by ve rt ical as well as horizontal boundaries, normal l igh t a ir cr aft operating altitudes are unlikely to pro vide any sa fety 'buffer' if t ra n sitti ng b elow the upper li m it of a restricted area. Further, t he rate of fire can be r apid, in cr easing the pos sibility of a target being hit - so don' t think it ca n't happen to you. The only certain way to ensure the safety of your ai r craft, you r self and your passengers near active firing ranges is to avoid them; and this comes back, again, to thorough and thoughtful preflight planning and adhe r ence to correct inflight pro cedures • - Aircraft accident information reports FIRST QUARTER 1983 Prepared by The Bureau of Air Safety Investigation The fo ll owing information has been extracted from accident data files maintained by the Bureau of Air Safety Inves tigat ion. The intent of pub li shing these reports is to make availab le informat ion on Australian aircraft accidents from which the reader can gai n an awareness of the circumstances and cond itions which led to the occurrence . At the time of pub lication many of the accidents are still under investigation and the informat ion contained in those r eports must be considered as pr eliminary in nature and possibly subject to amendment when the investigation is final ised. Readers should no te that the information is provided to promote aviation safety - in no case is it intended to imply blame or liability. Note 1: All dates and t im es are local Note 2: In ju ry classification abbreviations C =Crew P = Passengers F =Fatal S =Se r ious N =Nil 0 =Others M = Minor e.g. C1S, P2M means 1 crew member received serious injury and 2 passengers received m i nor injuries. PRELIMINARY REPORTS (The fo l low ing accidents are st il l under investig ation) Date Aircraft type & registration Kind of flying lniuries Time Location Depar ture point / Destination Record number 02 Jan 1430 Cessna 310 L VH-EOZ Berwick Sin ., NSW Non-commercial - pleasure Noondoo Stn., Old./Berwick Stn., NSW C1N , P1N 210023 The pilot was landing uphi ll in hea vy rain with a moderate right crosswind. After touchdown on the narrow s trip the aircraft d ri fted to the left into sof t ground. The pilot used right brake, rudder and nosewhee l stee ring to correct the drift but the aircraft began to slide and collided with a rock. 02 Jan 1400 Piper 28 140 VH-TVH Ho xton Park, NSW Non-commercial - pleasure Bankstown, NSW /Bankstown, NSW C1N, P2N 210013 In ca lm conditi ons, the pi lot made an app roach that was steepe r and faster than normal. After floa ti ng for some distance t he aircraft touched down n osewhee l first and commenced to porpoise. The bounces increased in magnitude unt il the nosewh ee l tyre burst and the prop el ler struck the runway. 03 Jan 1345 Piper 25 235 VH-PIK Gatton, Old. Commercia l- aerial agriculture/baiting Gatton, Old./Gatton, Old. C1F 11 0013 The aircra ft had been sp raying corn crops on a property adjacent to the pilot's own property. After adding more spra y to the aircra ft it returned to spray crops on the pilot 's property. It was seen to fly under a power line, bank right then hit anot her power line which had been recently installed. The aircraft then struck the ground inverted. 03 Jan 1015 Beech 35 C33 VH-DDC Lismore, NSW Non-commercial-pleasure Lismore, NSW/Coffs Harbour, NSW C1N, P1N 210033 The pilot elected to return to his departure aerodrome because of deteriorating weather. While manoeuvr in g to avoid low cloud and rain in the circuit area, the pilot did not complete his pre-landing checks and landed with the gear up. 03 Jan 1205 Cessna 180 VH-RBE Wagga Wagga, NSW Non-commercial-p ractice Wagga Wagga, NSW/Wagga Wagga, NSW C1N 210043 Du ri ng the landing roll the port wing tip scraped the runway and the aircraft came to rest balanced on its right wingtip, right whee l and spinner. 03 Jan Cessna 172 E VH-DKK Non-commercial-p leasure C1 N, P2N 1336 Warrnamboo l, Vic. Me rton, Vic ./Warrnamboo l, Vic. 310013 Th e approach to land was made on Runway 22 in strong gusty weste rl y wind cond iti ons. Du ring the hold-off the aircraft began to drift to the left. The le ft main wheel brushed the runway and the right wing lifted. As the a ircraft turned left the nose dropped and the aircraft struck the ground nose first , breaking away the nosewhee l and right main whee l. Aviation Safety Digest 117 I i PRELIMINARY REPORTS (The following accidents are still under investigation) Date Aircraft type & registration Kind of flying Injuries Time Location Departure point/Destination Record number 04 Jan 1505 Cessna 210 L VH-SMP Lindeman Is ., Old. Non-commercial-pleasure Cairns, Old./Lindeman Is., Old. C1N, P5N 110023 After checking the wind direction the pilot elected to make an approach towards the south. Severe turbulence on the approach caused the pilot to go around. After rechecking the windsock the pilot decided to accept a slig ht tailwind and land towards the north . The aircraft touched down with 700 m remaining and the pilot applied moderate braking. About 155 m from the runway end harsh braking became necessary. The aircraft did not stop in time and overran the strip. 06 Jan 1240 Cessna 172 N VH-WCW Northcliffe, WA Non-commercial-pleasure Jandakot , WA/Albany, WA C1N, P1M, P2N 510013 The pilot was unable to locate hi s desired landing point but found another stri p about 30 km away. He inspected the strip from about 200 ft agl and carried out a landing. Shortly after touchdown the nosewheel sank and the aircraft overturned. The strip was under construction and had been recently ploughed. 07 Jan Rolladen LS 4 VH-llY Non-commercial-pleasure C1N 1917 Renmark, SA Waikerie, SA/Waikerie, SA 410013 The pilot was making a 300 km triangular cross-country flight when he became unsure of his position . After prolonged attempts to recognise ground features without success, and with evening approaching, he decided to out-land in a paddock. There was a line of trees at the threshold boundary. On final approach the glider struck the top of a tree and dropped heavily to the ground. 07 Jan 1005 Hughes 269 C VH-PHN Strathmay Stn., Old. Commericial-aerial mustering Strathmay, Old./Strathmay, Old. C1M, P1M 110033 The engine of the helicopter lost power during catt le mustering. The pilot reduced collective pitch and the engine rpm increased but application of collective caused a loss of engine rpm again. While crossing trees during an attempted forced landing the main rotor rpm decayed. The helicopter entered a rapid descent and made a heavy landing. 07 Jan 1300 Bellanca 8 GCBC VH-ADP Tocumwal, NSW Towing gliders Tocumwal, NSW/Tocumwal, NSW C1N 210053 During the landing roll the pilot was unable to prevent the tall of the aircraft from rising. A small thermal was seen passing at the same time, and a lm ost immediately afterwards the aircraft overturned. 12 Jan 1115 Cessna R182 VH-SDG Bankstown, NSW Non-commercial-practice Bankstown, NSW/Bankstown, NSW C1N 210063 The pilot was conducting a refamiliarisation flight on the aircraft. On his first approach the aircraft landed heavily on the nosewheel while also drifting to the left. 13 Jan 1213 Piper 28 140 VH-RSM Bankstown, NSW Non-commerc ial-pleasure Medlow Bath, NSW/Bankstown , NSW C1N, P4N 210073 Having misjudged his approach the pilot was still 100 ft. high and on the verge of stalling when one-third along the runway. The pilot said he then lowered the nose and applied some power but was unable to arrest the ensuing high rate of descent before the aircraft impacted the ground. 13 Jan 1600 Glasflugel Club Libelle VH-GVI Rankin Springs, NSW Trial/race/show Leeton, NSW/Leeton, NSW C1S 210083 Because of low thermal activity the pilot decided to make an out-landing. Shortly after touchdown the aircraft encountered a strong willy-willy which lifted it into the air and moved It violently to the left. The aircraft collided with a tree and fence before impact with the ground. 17 Jan Schneider ES60 VH-GPM Non-commercial - practice C1S 1730 Beverley, WA Beverley, WA/Beverley, WA 510023 As he approached the aerodrome from the east, the pilot gained the impression that the wind was light and variable and he planned to land into the south. Having arrived over the aerodrome at about 450 ft. he noted that the wind was a strong westerly. He then decided to land downwind but, shortly afterwards, realised this was not possible. While turning to attempt to land into wind, the aircraft stalled and entered a spin from which it did not recover. 19 Jan 1450 Glasflugel Libelle VH-GJG Leeton., NSW Non-commercial - pleasure Le eto n, NSW/Leeton, NSW C1N 210093 Several gliders were approaching the start gate during a championship event. One was overtaking ano th er from below at about 3400 ft when the two collided. One, though damaged, was able to land safely. The pilot of the second parachuted onto the airfie ld, landing about 150 m from the wreckage of his aircaft. 19 Jan 1450 Szybowcowy Foka-5 VH-GZW Non-commercia l-pleasure Leeton, NSW Leaton, NSW/Leeton, NSW C1N 210093 Several gliders were approaching the start gate during a championship event. One was overtaking another from below at about 3400 ft when the two collided. One, though damaged, was able to land safely. The pilot of the second parachuted onto the airfield, landing about 150 m from the wreckage of his aircraft. 20 Jan 0626 Cessna 172 N VH -INH Thylungra Stn ., Old. Non-commercial - ae rial mustering Thylungra, Old./Thylungra, Old. C1F 110043 On th e evening preceding the accident the pilot indicated hi s intenti on to com mence mustering early the next morning. The pilot arose at about 0530 ho urs and it is believed that the a ircraft took off at about 0600. The aircraft was seen at about 0620 by two stockmen. It was flying at about 100 ft agl and, when the engine noise ceased and the aircraft was not seen aga in , one stockman rode to a nearby bore and found th e inverted aircraft wreckage. ii I Aviation Safety Digest 11 7 PRELIMINARY REPORTS (The fo ll owing accidents are sti ll under investigation) Date Aircraft type & registration Kind of flying Injuries Time Location Departure point / Destination Record number 20 Jan 1556 Schemp Cirrus-75 VH-COO Tocumwal, NSW Instruc tional-solo-supervised Tocumwal, NSW/Tocumwal, NSW C1S 210103 The pilot was carrying out his first flight in thi s type of glider. The aircraft was observed to enter a spin, at a l ow height , at the start of the downwind leg. The aircraft struck the ground, spinning to the right. 21 Jan 1200 Cessna 182 H VH-PLA Dunk Island, Old. Non-commercial - pleasure Townsville, Old./Dunk Island , Old. C1N, P3N 110053 The pilot assessed the wind as south-easterly, 15-20 knots and joined downwind for Runway 14. As the aircraft was turning onto final approach one of the passengers took ill. The pilot found a sick bag and passed it to the passe nger. By this time the aircraft was on short final and the pilot noticed that the a ir speed was 10 knots high. Full flap had been selected so the pilot closed the throttle. The aircraft sank rapidly and hit the ground nosewheel first . 22 Jan 1605 Glaser Dirk DG 200/17 VH-COJ Tocumwal, NSW Non-commercial-pleasure Tocumwal, NSW/Tocumwal, NSW C1N 210113 Following a spin entered at 6000 ft the pilot was unable to effect recovery. He decided to bail out but excessive " g" loading prevented him from doing so until the wings separated from the fuselage at about 1700 ft agl. He was then thrown from the cockpit and parachuted safely to the ground. 23 Jan 1730 Piper PA34-200 VH -FSO Mansfield, Vic. Non-commercial - pleasure Sydney, NSW/Mansfield, Vic. C1N , P5N 310023 Before commencing his landing approach, the pilot made a low pass to clear sheep from the strip. Th e sheep ran to one end o f the field in which the strip was located. On the landing flare the pilot saw four sheep stand up out of grass at the opposi te end of the field. During the landing roll the four sheep ran across the strip and one was struck by the aircraft's ri ght propeller and main gear. 25 Jan 1410 Cessna 150 G VH-KPO Canberra, ACT Inst rue t ional-solo-su pervi sed Ca nberra, ACT/Canberra, ACT C1N 210123 The stud en t pilot reported that the landing was normal. However, the nosewheel ax le bolt failed. The nose strut th en collapsed and the aircraft skidded on its nose f or 47 m. 26 Jan 0935 Cessna 152 VH-BUE Redcliffe, Old. Instructional - solo-supervised Redcliffe, Old./Redcliffe, Old. C1N 110063 Following a dual fl ight of five circuit s th e student pilot was au thorised for his first solo. The c ircuit and final approach we re normal. On touchdown the aircraft bounced . The pilot did not take the correct recovery action and following several bounces, each becoming progressively worse, the nosegear collapsed and the aircraft sl id to a stop . 26 Jan 1105 De Hav 82 A VH-BIN Serpentine, Vic. Non-commerci al-pleas ure Kyneton , Vic./Serpen tin e, Vic. C1N , P1N 310033 The landing was made into a strong westerly wind. The touchdown was normal but towards the end of the landing roll a gust of wind tipped th e aircraft onto its nose and le ft wingtip. 28 Jan 1615 Piper 32 300 VH-STV Noorong , NSW Non-commercial-pleasure Adelaide, SA/Canberra, ACT C1N , P3N 210153 Whi le cruis ing at 8000 ft the eng in e failed ab ruptl y. Attempts to restart the engine were unsuc cess fu l so the pilot carried out a forced landing onto an agricultural st ri p. Th e nosegear collapsed after the aircraft overran the strip and str u ck a mound. of dirt. 29 Jan 1145 Piper 36 375 VH-TKZ Carrathool, NSW Comme rcial-assoc. agricul tu re/baiting C1 F " Boree" prop., NSW/" Boorambi" prop., NSW 210133 While tracking between the next area to be fertilised and the destination, the aircraft was seen to col lide with a tower about 44 m high, apparently without avoiding action being initiated. 29 J an 2030 De Hav C1 TMKIO VH -UPD Point Gawler, SA Non-commercial-pleasure Two Wells, SA/Two Wells, SA C1N, P1N 410023 After takeoff , at approximately 300 ft , the air cra ft developed a rough-running engine. As the area ahead was unsuitable for a landing the pi l ot elected to make a 180 deg turn before attempting a precautionary landing. During the turn an excessive sink rate developed and the aircraft hit the ground heavily during the landing flare. 31 Jan 1930 Rockwell 114 VH-SCM Wanaaring , NSW Non-commercial - pleasure Gr if fith , NSW/Wanaaring, NSW C1N , P1N 210143 While flaring to land on a roadway used as a stri p the aircraft suddenly drifted s id eways. Full power and some bank were applied in an attempt to go-around but the propeller struck a smal l tree. The aircraft struck the ground , collapsing th e gear, and hit several more tr ees before coming to rest. 01 Feb 0800 Cessna A188B A1 VH-EVO Commerci al-aer ial agriculture/baiting Weimbi Downs Stn. Weimbi Down s Stn ./Weimbi Downs Sin . C1N 11 0073 Th e pilot was conducting spraying operation s from a landing area with two strips. He had been bri efed about a power line across the western end of the sho rt cross strip . During the fourth approach for landing on that st ri p the landing gear struc k t he power line, the air craft decelerated rapidly and landed heavily on the main wheel s. The right mainwheel broke free and the aircraft s lid to a hall. Aviation Safety Digest 117 I iii PRELIMINARY REPORTS (The fol l owing accidents are still under invest igation ) Date Aircraft type & registration Kind of flying Injuries Time Location Departure point/Destination Reco rd number 02 Feb 0815 Piper 25 235 VH-BMF Donnybrook, WA Commercial-aerial agriculture /bai ting Bunbury, WA/Donnybrook, WA C1N 510033 After a low pass to clear catt le, the pilo t landed on an airstr ip situated on the si de of a hil l. As the aircraft rol led onto a flat port ion of the strip t he pilot was alarmed to see that cattle were again on the airstrip . He applied heavy braking and t he aircraft nosed over onto its back. 02 Feb Cessna A 188B A 1 VH-UWH Commercial-aeria l agricu lt ure/baiting C1 N 2000 Goondiwindi Goondiwindi, Old./Bogabilla, NSW 210163 During the takeoff roll, at about 40 kt, a propeller blade detached from t he hub. The aircraft slewed uncon trol lably, col lapsing the left-hand undercarriage. 03 Feb 1259 Enstrom F28 C VH-IYP Castle Hill, NSW I nstruct ional -so lo Hoxton Park, NSW/Castle H i ll , NSW C1N 210173 The helicop ter was approaching the hover over the helipad at abo ut 20 ft. It suddenly yawed to the ri ght and continued th roug h several level 360 deg turns . The pi lot was unable to stop this turning motion and the helicopter landed heavily, sti ll rotating to th e right. 04 Feb 0900 Piper 28 151 VH·PZM Wagin, WA I nstructional-solo-supervised Wagin , WA/Wagin , WA C1N 510043 The pi lot was practising circuits and land ings in strong cross -wind conditions. Short ly after touc hdown on t he firs t solo circu it of the period directional control was lost and the aircraft ran off the side of the st rip. The nosegear collapsed when the ai rcraft struck an embankment. 05 Feb 1308 Romainian IS·28B2 V H· COE Instructional - Dual Camden, NSW Camden, NSW/Camden , NSW C2S 210183 Shortly after takeoff , at a height of approximately 300 ft , the glider was seen to release from the tow lin e. An immed iate ri ght turn was initiated accompanied by a nose-up pitch change. The glider then stal led, entered a sp in and struck the ground at a hi gh rate of descent. 05 Feb z Cess na 150 M VH-WWM Urawa, WA Non-com me rcial-aerial musterin g Urawa Homest ead, WA/Urawa H mstd, WA C1F, P1F 510053 Aft er comp l eting an aerial spotting task the aircraft was observed to c li mb above 1000 ft and depart on what was thou ght to be a windm il l inspecti on flight. When the aircraft failed to return search proc edures were inst it ut ed. The wreckage was located by a sea rching aircraft shortly af ter f irst light on the fo ll ow i ng day. 06 Feb 1710 Blanik L13 VH·G IK Lake Keepit , NSW I nstr u ctional-solo-supervised Lake Kee pit , NSW/Lake Keep it , NSW C1N 2101 93 At about 50 ft, af ter takeoff on aero-tow, the tug and gl ider en co untered a therma l. The glider was t hrow n upwards and to the side and the p ilot released . The subsequent forced landing was off t he edge of th e strip . 09 Feb 1030 C ess na 172 G VH -SHV Maryborou gh , Old. Charter- passenger Maryborough , Old./Happy Val ley, Old. C1N, P3N 110083 The pilot abandoned the takeoff short ly af ter becoming airborn e. The ai rcraft was land ed b ack on the runway but fa iled to stop before collid in g with the aerodrome bo undary fence. 10 Feb 0700 C ess na 172 N VH-TDH Fraser Island, Old . Non -co mmercial- pleasu re Maryborough, Old./Fraser Is land , Old. C1N, P1N 110093 Fol lowing a low pass along the intended landing area, fu ll throttle was applied to commenc e an overshoot. The pi lot stated that the engi ne fai l ed to respond and th e aircraf t co lli ded with trees 100 m beyond the end of the strip. 12 Feb 0830 Cessna 182 0 V H- A IV Ardlethan, NSW Non -co mmercia l - pleasu re Moorabbin , Vic ./Ar dlet han, N SW C1N, P3N 210213 The pi l ot fl ew several passes to c lea r sheep from the str ip. When no sheep were vis ible an approach and land ing were carried out. As the aircraft to uched down a sheep ran across the strip from the right. T he pi lot steered the aircra ft to the left and it ran off the strip i nto rough ground. 12 Feb 0900 Piper 36-285 VH-B RV T ull y, Old. Co mmercial -ae rial agricu lt ure/baiting Tully, Old./Tully, Old . C1M 110103 Aft er refuelling hi s aircraft from drum s tocks , the pi lot started the engine and taxied to the end o f the strip. T akeoff was commenced and at abo ut 100 ft agl the engine ran rou ghly and then stopped. Attempt s to r estar t the engi ne were unsu ccess fu l and the ai rcraft co llided with trees. 14 Feb 11 07 Beech C23 VH-UML Ar cherfield, Old. In st ruc tional-solo -supervised Archerfield, Old ./Arc herfi eld , Old. C1N 110113 On the th ird bo unce of th e landing attempt the propeller st r uck the ground and the undercarriage nose leg co l lapse d. The aircraft slid along the runway for 270 m from the first point of touchd ow n before co m ing to rest. 14 Feb 1514 Cessna 180 D VH-GCW Bankstown, NSW Non-co mm erc ial -p leasure Ba nkst ow n, NSW/Gulgong, NSW C1N 210203 Dur ing the ta keoff run the pi l ot's se at -bac k co llapsed. The pi lot fell backwards, los ing cont rol of the ai rcraft, which subseq uently gro und-l ooped s harp ly to the l ef t . iv I Aviation Safety Digest 117 1 j 1 1 } PRELIMINARY REPORTS (The following accidents are st i ll under investigation) Date Aircraft type & registration Kind of flying Injuri es Time Location Departure point/Destination Record number 14 Feb 1430 Cessna 180 VH-BDN Goulburn , NSW Inst r uct ional - training Goulburn, NSW/Goulburn, NSW C2N 210223 The pilots were engaged on t he second o f two per iods of circu it and landi ng pr act ice. Towards the end of the twel ft h landi ng , the aircra ft ground-looped to the le ft and the starboard wingtip and ta ilplane con tacted the ground. 18 Feb 0900 Beech 58 VH-FIV Nt h. St radb roke Is., Old. Demonstrat io n Archerfie ld , Old./ Archerfie ld , Old. C1N, P2N 110133 In order to il lustra te t he high cru isin g speed of the aircraft to a potentia l customer, the pi lot elect ed to fly along a beach at a low level. The aircraft flew into a fl ock of b ir ds which rose from t he beach as t he aircraft approached. 21 Feb 1003 Pi per 28 R200 VH·CJV Bu ck ingham Downs, Old. Non-commerc ial - pleasure Gunpowder, Old./Buckingham Downs, Old. C1N , P1N 110143 During the la ndi ng ro ll on a disused str ip, the ri ght main wheel struck a ridge of dirt located on t he side of a road that crosses the strip. The resultant damage was not d iscovered unt il completion of the subsequent fl ight. 21 Feb 1520 Conaero LA4 200 VH-BDK Renmark, SA Charter- passenger Renmark, SA/Goolwa, SA C1N, P3N 410043 At 50 ft after takeoff t he aircraft failed to continue to cl i mb , t he airspeed decayed and t he aircraft began to l ose he ig ht. To avoid trees ahead the pilot tu rned the aircraft. The rig ht float st r uck the water, the ai r craft yawed to the r i ght and sk ipped sideways to the lef t acros s the water before com ing to rest. 21 Feb 1204 Burkhart Twin Ast ir VH-IKB Instruct ional - check Waikerie, SA Waikerie, SA/Waikeri e, SA C2S 410033 After lift-off on an aero t ow the gl id er entered an uncontrol led cl i mb , effo rts to correct the cl i mb with elevator were unsuccess ful. T he g lider pi l ot released the tow rope and the gl ider cont inued to cl imb until it stalled . The glide r turned left, ente red a div e and struck the ground. 22 Feb 0736 Cessna 150 G VH-RNJ Canberra, ACT Instr uctional - Dual Canberra, ACT/Canberra, ACT C2S 210233 During the pre·tak eoff chec ks the student f ou nd the carburet tor heat control cou ld be pul led out further than usua l and that t here was no rpm drop assoc iated with the app licat ion of hot air. On takeoff the aircra ft was s low to acce lerate. It became airborne and was observed to enter a gentle r i ght turn. A wing dropped and the aircraft imp acted the ground. 22 Feb 0430 Cessna 402 VH-DI L Nagoorin, Old. Charter- Cargo Brisbane, Old./Gladstone, Old. C1F 110153 A ft er mak ing a posit ion report no further communications were rece ived from the aircra ft. The wreckage was located afte r two days' search. The aircraft had struc k th e ground in hilly count ry in a near vertical atti t ude. 24 Feb 1130 Piper 28 R200 VH -S WB Pama tta Sin ., SA Non-commercia l- bus iness Panatta, SA/Orr oroo , SA C1N, P3N 410053 The takeoff was made from a 650 m long str ip. Early in the takeoff run the pi l ot tried to l ift the nosewhee l off the st rip but reduced ba ck pressure when the stall warn ing l ight flashed on. Approach ing the end of the strip t he ai rcr aft became airborne and to faci li ta te acce leration, the pilo t re tracted the landing gea r. The aircraft then sett led back onto the s tri p and came to rest afte r a 100 m sli de . 25 Feb 0830 Bell 47·G381 VH·CSI Gl en Hills Yard, WA Charter-aeria l ambu lance Glenn Hills Yard, WA/Camp Nicholas , WA C1S, P2S 510063 While establ ished in cruis ing fl i ght the pi lot felt someth in g strike the airframe, and no ti ced t hat a pi l low supporting an exte rn al l itte r patie nt h ad been dis lodged. About one minute later the heli copter began to yaw to the r igh t with increasing speed. The pi lo t entered aut o-rot atio n, aim ing for a run-on land ing in a smal l clearing . However, as co l lective p itc h was reintrod uced cont rol was l os t , the air craft s tr uck the ground heavily and was destroyed. 26 Feb 1800 Cessna 172 N VH-DDV Bourke, N SW Non-commercia l- practice Bourke, NSW/ Bourke, NSW C1N 210243 The pilot was carry ing out the fourth land ing in a series of pract ice c i rcuits . Fo l low ing a reported ly normal f lare and to uchd ow n the aircraft bo unced several times befo re coming to rest on the r unway . The damage to t he ai r craft was discovered after the pi l ot had tax ied to the termi nal area. 27 Feb 1346 Boe ing 727 276 VH ·TBI Adelaide, SA Schedu led Domestic Passenger Se rv ice Adelaide, SA/Melbourne, Vic. C3N, P123N 410061 The airc raft was using a t ax iway which had a row of cones pos it ion ed abou t 11.5 m from the cent r e- line to ind icate a step in the sealed su rface. The pilo t saw a fuel tanker pa rked some d istance away from t he cones. Assum ing that the co nes were tax iway clearance markers, he continued to tax i along the centre -line. The port wing st r uck the top of the tanker about 15 m from the aircra ft cent re-lin e and about t wo metres from the win gt ip. 27 Feb 2055 Cessna 172 F VH·DOX Wi tchel li na, SA Non-commerc ia l- aerial muste rin g Witchellina , SA/Witche lli na, SA C1 N, P2N 410073 The pi l ot flared t he a ir c raft for l anding but then decided he was undershoo tin g and app li ed f ul l po wer to go around. The ai rc raft cl imbed to about 7 ft when the left wing dropped and struck the ground. The ai r craft yawed sharply to the le ft and the nose st r uck the gro und heavily. Aviati on Safety Digest 117 I v PRELIMINARY REPORTS (The fo ll ow in g acciden t s are s till under investigat ion) Date Time 02 Mar 1139 Aircraft type & registration Location Cessna 421 VH-MOZ Daralingie, SA Kind of flying Departure poin t/Destination Charter- passenger Adelaide, SA/Daralingie, SA Injuries Re c ord number C1N, P7N 410083 After touchdown the pilot veered the aircraft to the right side of the strip to avoid another aircraft parked near the left side. The right main gear encou ntered so ft soil and th e aircraft began to sw in g further right. The pil ot corrected with left brake and rudder but the nosewheel dug i nt o the soft s ur face and the nosegear supports were broken. 02 Mar 1450 Victa 115 VH-CAP Mundijong, WA Non-commercial-practice Jandakot, WA/Jandakot, WA C 1M , P1S 5100 73 On comple tion of a pract ice forced landing the pi l ot ope ned th e throttle to go-around. The engine produced only pa rtial power and the aircraft touched down in a paddock. After se lec ting car burettor heat to co ld the engine developed fu ll power but because of the extremely rough s ur face of the paddock the aircraft did not acce lerate beyond 60 k t. The airc raft became airborne bu t co llid ed w ith trees on the paddock boundary and crashed to the ground . 03 Mar 1424 Beech C23 VH-UMF Goulburn, NSW In st ru ctional-solo-supervis ed Ba nkstown , NSW/Goulburn, NSW C 1N 210263 The pi lot , on his first so lo navigation exerc ise, was lan ding with a moderate right crossw ind . During the landing t he p ilot thought t hat he had made a very smooth touchdown and released cont rol column back press ur e. The aircraft then landed heavily on the nosewheel whic h collapsed . 03 Mar 1010 Cess na P206 B VH-DVT Por tland , NSW N on-commercial-business Camden, NSW/Portland, NSW C1N 210253 On final approac h to t he 780 m long strip the pilot observed sheep on the s tr ip near the th reshold. He decided to land beyond that area but the aircraft did not to uch dow n until only 320 m remained . The pilot co ntinu ed wi th the landing and att~mpted to groun d· loop the aircraft. It did not respo nd and ran through a fence at l ow speed. 04 Mar 1658 Pilatu s B-4 VH-GID Cuballing, WA Non-commercia l-plea su re Cuballing, WA/Cuball ing , WA C1N ,0 1N 510083 Durin g an aero-tow la un ch, the engine of the tu g aircraft failed before it became airborne. The pi lot of the g lid er re leased the t ow , attempted to stop the glider but was un able to avoid a coll ision w ith the tug . 04 Mar 1658 Piper 25 235/A6 VH-TUG C ub all ing, WA Towing g lid ers Cub alling, WA/Cuballing, WA C1N, 01N 510083 Du ring an aero-t ow launch, th e engine of t he tug aircra ft failed before it became airborne. The pil ot of the g lider released the tow , att empt ed to sto p the glide r but was unable to av o id a coll i sio n with the tug . 05 Mar 1645 De Hav 82 VH-ADW Maitland , NSW Trial/race/sh ow Maitland, NSW/Maitland, NSW C 1N 210273 Three DH82 aircraft competing in a formation flying compe titi on were making a V format ion landing with a moderate le ft crossw ind. After touchdown the aircraft on t he left side of the leader was a ff ected by a gust , it swerved to the right and co llided wi th the aircraft in No. 2 position. 05 Mar 1645 De Hav 82 VH·RNI Mait l an d , NSW Trial/race/show Maitland, NSW/Mai tland, NSW C 1N 210273 Thr ee DH 82 ai rcraft co mpeti ng in a format ion flying competi tion were making a V formation land ing w ith a moderate left crosswin d. After touchdown th e aircraft on the left side of the leader was affected by a g ust , it swerved to the right and col lided with the aircra ft in No. 2 position. 06 Mar 1230 Piper 18 150 VH-SBO Galway Downs, Old. Commercial - ae rial mu ste rin g Galway D. St n., Old./Galway D. Stn., Old. C1N 11 0163 The pilo t mi sju dg ed his approach to a claypan landing area and decided to go around. The throttle was advanced bu t the engine failed to respond and the pilo t was fo rced to land. As an over-run seemed probable the pi l ot ground-looped the aircraft. 06 Mar 1045 Cessna 1 85 A VH -U PI Mered ith , Vic . Sport parac hut e jump Mere dith, Vic ./Meredit h, Vic. C1N , P5N 3100 53 The strip was aligned 140 deg and the wind was about 5 kl from 045 de g. On takeoff the aircraft yawed left then right and r an off the s id e of th e strip. It became airborne jus t short of the bo undary but the tail s tru ck the fence and the tail wheel broke off. After despatching four parach uti sts at the planned height the fifth parachutist who was the aircraft owner landed the aircraft, ho lding the tail off th e gro un d. Just before it st opped the air craft tipped forward onto its nose. 07 Mar 0900 Cessna 182 K VH-KRI Couta Rocks , Ta s. Non-commer cial - pleasure Smi t ht o n, Tas ./ Couta Rocks, Tas. C1N, P1N 310063 A lt er landing the pi l ot t ax ied the aircraft along a track leading to a parking area. Nearing the parking area the nosewheel entered a wombat hol e, pus hin g back the nose s trut and buckli ng the firewall. 09 Mar 0945 Cessna T1 88C VH -M OT Tansey , Old. Commercial -a erial agric ul ture -b ai tin g Tan se y, Old./Tan sey, Old. C 1N 11 0173 Th e pil ot was engaged in s praying tw o paddock s, sepa ra ted by a third . Whi le flying over the inte rv ening paddo ck the pil ot' s att enti on was div erted by l ook in g at the next area to be sprayed. The aircraft str uc k and broke a thr ee -s t ra nd power line. A prec au tionary landing was made straig ht ahead in a flat paddock but th e aircraft overran it and co llided with two fences an d a d itc h. vi I Aviation Safety Digest 11 7 PRELIMINARY REPORTS (The fo ll ow ing accidents are st il l under inves tigat ion) Date Airc raft type & registration Kind of flying Injuries Time L ocation Departure point/Destination Record number 10 Mar 0850 Beech A36 VH-BKM Arche rfield , Old. Non-commerc ial-pleasure Caloundra, Old./Archerfield, Old. C1N 110183 Fo llowing a normal touchdown the landing gear partially retracted when the pilot inadvertently se lected gear up ins1ead of flaps up. 10 Mar Transav PL 12 VH -SUO Commercial - ae ri al agriculture -baiting C1 M 1800 Brun sw ick Jun Ag r icultural stri p/Agricu l tu ral st rip 510093 The pilot decided to change fuel tank se l ection during t he pre-takeoff checks. While the aircr aft was being reloaded, the pilot was distracted by an un serviceability on a second aircraft an d omi tt ed to al ter the fuel tank selec tion . Short ly after the aircraft became airborne, there was a co mplete l oss of engin e power and the pilot was required to carry o ut a forced landin g on unsuit able terrain. 12 Mar 1200 Schleicher KA-6 VH-GNA Gin Gin, Old. Trial/race/show Bundaberg, Old./Mundubbera, Old. C1N 110193 The pilot was attempting a Go ld Distance cross-coun tr y exercise. Al though the cloud base at the start was lower than optimum t he pilot elected to proceed as planned. While searc hin g for t hermals and waiting for the cloud base to rise, height was lost. An outland ing on a golf course was necessary. During the landing roll the left wing s tru ck a small bush which was growing around a tree stump . 12 Mar 0528 Beech 58 VH -CTU Hampshire, Tas. Non-commercial-aerial ambulance Devenport, Tas./Wynyard, Tas. C1F 310073 The pilot was called out at about 0400 hours local time for an urgent medical fli ght from Wynyard to Me lb ourne. This required posi tioning the aircraft from its base at Devenport to Wynyard. The takeoff from Devenport was made in darkness wi th an overcast sky and light drizzle. The aircraft then apparen tly conti nued on the takeoff heading at high power and low level until it st ru ck the ground at high speed in a forest area 25 km south of Wynyard and 56 km from Devenport. 12 Mar 1720 Piper 32 300 VH-PWI Walpole, WA Non-commerc ial-pleasure Wagin, WA/Walpole, WA C1 N, P2N 510103 Following a heavy landing the aircraft bounced several tim es, w ith the bo unces increasi ng in magni tude. The pilot made a go · aro und and noticed a wheel spa t on the run way during th e seco nd approach. A smooth touch -down was made and the nose held up as lo ng as possible. When th e nos e was lowered the nosegear fo lded and the propel ler str uck the grou nd . 16 Mar 1922 Cessna 172 N VH-MNW N ullar bor, SA Non-commercial-pleasure Esperance, WA/Nullarbor, SA C1N, P1N 410093 Concerned about the fuel remaining the pilot hur riedly joined the c ircu it area. When he found the ap proach obstructed he tig htened the tu rn to land on th e cro ss s tr ip. During the turn th e engine stopped. Unable to glide to the stri p the pilot att emp ted to turn the aircr aft into wind. The righ t mainwheel s truck the ground fo llowed by the no sewheel whi ch collapsed , and the ai rcraft overturned before coming to rest. 18 Mar 1820 Grumman GA 7 VH-JSK Nambu cca Rvr., NSW No n-commerc ia l- pleas ure Nambucca Rvr., NSW/Port Macquari e, N SW C1M, P3N 210283 The aircraft failed to accelerate normally during takeoff from a wet and boggy strip. Al thoug h the a ircraft became airborne near the end of the strip , flying speed could not be maintained and th e a ircraft ditched in to a nearby river. 19 Mar Beech A60 VH-DUK Charter- passe nger C1 N 0515 Port Macquari e, NSW Port Macquarie, NSW/Sydney, NSW 210293 During the takeoff roll the p ilot n oticed some ka ngaroos bounding toward s the aircraft. During the a tt empted avoid ing manoeuvres the aircraft ran o ff th e side of the str ip and s tr uck a drain. 19 Mar 0832 Piper 23 160 VH-DBF Schof i elds , NSW Non-co mm ercial -p leas ur e Ca md en, NSW/Schofields, NSW C1 N 210303 The a irc raft was cross i ng the threshold , abo ut 300 m behind an Iroquo is he licopte r, w hen the right wing dropped. The nose al so dropped and the nosewheel co n tac ted t he runway heavily and was broken o ff . The a ir craft slid along the runway for some 200 m on its no se before coming to rest. 19 Mar 1112 Rutan Vari EZE VH-EZI Schofields, NSW Trial/race/show Sc hofields , NSW/Schofields, NSW C1N 210313 Just b efo re touchdown th e airc raft enco untered wake turbul ence from a preceding la ndin g aircraft. The pi lo t applied f ull power and attempted a go -arou nd, but the a ir craft contact ed the runway heavily and the nosegear co llapsed. 20 Mar 114 5 Cessna 21 0 L VH-FOC Gooiwa, SA Non-commercial - pleasure Mt. Gambler, SA/Goolwa, SA C1N, P2M, P3N 410103 Alter crossing some trees o n the ap pro ach path the pilot reduced power to land. The a ircraft landed heavi ly and bounced several times. The pil ot in creased power to go around but t he aircraft , which had lost its no sewheel , slid to a halt. 24 Mar 1545 Cessna 182 P VH-MIG Portland , Vic. Non -c ommerc ia l- pl eas ure Portland, Vic ./Portland , Vi c. C1N, P1N 310083 The a ir cra ft had been parked in the open fo r several days during which 10 cm of rain fel l. The pi lot drained water from the wing tank and main filt er drain s but twi ce o n start-up and taxi the engine ran roughly and further water was drained from the fu el system . On th e thi rd start th e e ngine ran up satisfac tor ily. The pil ot made a normal takeo ff but th e engin e failed at a bout 300 ft. In t he ensu in g forced landing the air craft touched down heavily and th e no segear co lla ps ed . Aviation Safety Digest 11 7 I vii PRELIMINARY REPORTS (Th e f o llo w ing a ccident s a re still und er investigat ion) Date Time 24 Mar 1000 Airc raft type & regis tration Location Cessna 150 L VH-PQX Warambie, WA Kind of flying Departure point/Des tin a tion Non-commercial-aerial mustering Warambie, WA/Warambie, WA I nj u ri es Re c ord number C1S 510113 After locating some cattle for a muster ing party the pilot flew along a creek line at about 400 ft agl and 60 kt with 10 deg ree of f la p. To keep the ground party in sight the pilot commenced a left turn and the aircraft stalled. The p ilot was unab le to regain control of the aircraft before it hi t the ground . 26 Mar 1722 Cessna 210 B VH-DBU Canberra, ACT Non-commercial-pleasure Bathurst, NSW/Canberra, ACT C1N, P1N 210323 On takeoff a loud bang was heard when the landing gear was selected up. On arrival at his destination the pi lot attempted to l ower the l anding gear using both the normal and emergency systems. However, his ef f orts were in vain. As the airc raft touched down the main wheels collapsed and the aircraft came to a stop after sl i ding 140 m. 26 Mar 1045 Bell 206 B VH-BLP Lake Eildon , Vic. Commercial- ma pp i ng/photo/su rvey Ei ldon, Vic./Eildon, Vic. C1N , P1M, P2N 310093 During a low-level photograph ic flight , the pi lot made a shallow left turn at about 400 ft agl and a low fo rward speed. When he increased the rate of turn, the helicopter began a rapid turn to the right and the nose pitched up. The rotation continued fo r 3 to 4 turns duri ng wh i ch the nose pitched up and down. The pi lot had almost regained con trol when t he helicop ter s t ruck the g round heavily on its skids and rolled onto i ts r ight side. 27 Mar 1510 Pitts 82 A VH-WEB Wallacia , NSW Non-commercial-p leasure Wallacia, NSW/Wallaci a, NSW C1M 210333 After initial touchdown the aircraft bounced several t imes and the pilot initiated a go-around. During a very shal low climb away the aircraft struck a power cable and cartwheeled to the ground. 29 Mar Cessna 180 VH-BDN Non-commercial-pleasure C1 N 1442 Moorabbin, Vic. Goulburn, NSW/Moorabbin, Vic. 310103 The land ing was made on Runway 31C with a l ight surface wind from about 280 deg. The pilo t corre ct ed f or right dri ft on t he approach and the aircraft touched down on the main wheels. As the tai l settled d uring th e landing roll t here w as a sudden wind c h ange to 200 deg, gusting from 5 to 11 kt and the aircraft swung sharply to the left. The righ t wing con t acted the runway and t he aircraft nosed over onto its back. FINAL UPDATES Date Record number Pi l ot li cence Age Hour s total Hours on type Rat ing 02 Jan 210013 Private restricted 21 64 11 None The pilot had been required to divert due to a thunderstorm over his destination . He did not in it iate a go-around w hen circumstances indicated that this was the correct course of action. 03Jan 210033 Pr ivate 42 410 215 In st ru ment rating Class 4 The gear warning horn was serviceable, however, during the land ing approac h and flare the pilot had not reduced his t hro ttl e setting to the po i nt where the horn would be act ivated . 21 Feb Private 110143 35 viii I Aviation Safety Dig e st 11 7 650 Not known None Pda Reflections on an accident Recently a light twin -engine aircraft crashed while commencing a charter flight. Although the accident seemed fairly simple , many factors were involved. To help identify the causes of the accident and thus draw lessons affecting Company policy, the Chief Pilot wrote a report which was also submitted to the Bureau of Air Safety Investigation. This report - slightly amended by the author for publication - is printed below. D urin g the takeoff roll at a remote bush airstri p , the pilot lost con trol of a li ght twin operated by my Com pany. T he a i rc raft took off prematurely, stalled, en tered an inc ipie n t spin to the ri gh t and crashed . D am age to th e air cr aft was extens ive, although luckily ne ither th e pilot n or t he passe ngers suffer ed inj ury . M any fac tors w ere inv o lved in the accident a nd are n ot ed be lo w. The airstrip and conditions Th e a irst ri p is lo ca t ed on a slight rise; although there a re a few hills ne ar by, the approaches are good and m ost of the su rro und ing terrai n is low-l ying and level. T he nearest occu p ied s ettlement is a b out ten miles away by a ve ry rou gh track. Under m ost conditio ns the length and width of this part icular a irstrip are more than adequate for the Com pan y' s ai rc raft. The ma in problem is the surface dra i nage - whe n wet the grass becomes·· sl ippery and in pl aces the gro un d becom es boggy . As t he re is n o rmally no on e at the a irs trip to report on co nd it ion , th is in form at ion is usually obta in ed t hrou gh a er ial ins pe ction , combined with the pilot's (a nd the Co mp an y ' s) kn owledge of the strip and r ecent we at her. If the pilot decides to la n d, he/ she can then ca r ry o ut a fur the r insp ection to d eterm i ne wh e ther a tak e off woul d be sa fe , a nd if so what techn ique sho u ld be used . Thi s is ge n erally do ne w hi le tax ii ng after lan din g . If any doubt r emai ns an in sp ect ion on foot is m ade . A ppare ntly th is di d not h appe n ; the cho ice not to ta keo ff p roba bl y was n ot con si dere d , wh ile takeoff tec hni q ue also su ffered a si mi lar fate . At t he ti me of t he acc ident there were people working near the a ir st rip who could have been contacted prior to the fl ight , b ut a strip condi t ion report was neither re qu ested nor give n. We ather cond itions were an u nstab le ai r mass wi th u nste ady and gen e rally ligh t win ds. There had been considerable rain in the preceding period . Although st rong wi nd gusts w ere lat er cited by some unoffici al sources, this is u n li kely . In my op i nion' wind was not a de te rmi n in g factor in t he accident; rather it was brou g ht up afterwa rd s as a pl aus ible 'cause ' . I a lso dou bt tha t the boggy surface was the deter m in ing facto r - although it certainly was i mp o r tan t b oth in m a king directional control a little tr ick i er an d in reta rd ing acceleration . A takeoff from a su r face su ch as mud dy grass or loose sand which is soft and has poor traction is not easy - but nor need it be dangerous. It would seem to me that conditions were such on t he day of t he accident that for an experienced and careful pil ot usi ng the correct techn iques the operation could have been safely carried out. The aircraft The aircraft used was a fully serviceable IF R twin . This aircraft was not as suitable for bush work as, for example, a Cessna 206 or a B N-2 Islander . However , when a customer is prepared to pay for one's most expens i ve aircraft and one has financia l problems, one is not inclined to argue, much less pas s the job on to a competitor. As Chief P ilot , I considered that the opera t ion of t hat aircraft to the airstrip concerned was not unsafe - if it had been , the ALA R egister kept by the Company would ha ve noted restrictions on operati ons . I must state that in this Compan y the importance of operational requirements is recognised. Safety is of course far more important than a few dollars; it is better to go b1-o ke safely than to lose t he plane, pil ot and passengers in one eas y crash . The point is that the use of th at pa rt icular aircraft for that work and in those conditions was not unsafe in and of itself. But again, it did dictate careful handling and a high level of pilotage skill . The pilot T he request for t he chart er concerned came when the aircraft was on the return leg of another flight. T hus the pilot had already been fl y ing for most of the da y in an IF R environment from large sealed aerodromes with full condit ion information available, when without warning he was asked to proceed to the bush strip. The pilot had substantial experie nce flying twin - engine a ircraft in the ge ne ral r egion. However, at the time of the acci dent he d id not have a lot of recent experience operating into that strip. This, combined with the strip condit ion and pressure from the passengers (who were in a hurry to depart), prob ably induced a certain amoun t of anxiety in the pilot. The factors of lack of recent experience at that s trip , fatigue, unprep are dness and anxiety cannot be discounted in this accident. These are a ll valid r ea s ons Aviation Safety Digest 117 I 13 fo r a pilot to refuse a flight ; they s hould all - to th e g reatest ex t en t po ssible - be monitor ed by the Compan y as well . It is also possible that the pilot suffered from a cer t ain ov er- confidence, and consid ered that he could handle (almost) an y thin g . If you do not rec ognise y our limitation s, y ou tend not to be as careful as the situation dict at es. Such an outlook m e ans that o ne is relu c tant to admit that a s ituation is g etting outside one ' s control. P r ide is often hard to swallow, so o ne te nds to press on - outside on e' s capabilities. The other side of the same c oin is the 'I never make silly mis t ake s' or 'I alw ays make it' mentalit y . It is this s ame attitude which often makes pilots continue a lousy approa ch , land at an uns afe airs trip , fl y VFR in ghas tly weather, not take ice seriou sly when IFR , take off without checking fuel quantity and qualit y, and so on. Why did the aircraft lose directional control? The first fa ctor involv ed in losing control of the aircraft's direction was tha t t he pilot forgot to release the park brake when commenc ing to taxi. That this was not a part of the pre - take-off c he cks indi c ate s a certain weakness in th e che cklisl - understand ably caused be cause usuall y a set par k brake become s clearl y obviou s when taxiing. In this instance it did not becau se of th e s lipp ery surface co ndi tions. But th e re are other major control s at the pi lot 's di s po s al to maint a in direction al control: the no se wheel stee rin g, the rudd e r, as ymmetri c p o wer. In this c ase the nose wh eel wa s co ns ciously lifted from the airstrip early to li g ht en the load on th e main whe els a nd to pr ev ent it from becomin g bo gged in a soft patch . The idea is to redu ce to tal drag , increase acceleration a nd re du ce the tak eo ff roll - the well-known soft-field take off tec hnique . Of course when the nosewheel le ft the g round it be ca me useless as an aid to maint a inin g dir ectional c ontrol. In s ingle-engine air craft the p ropeller slipstream flo ws ov er th e tail s urfaces, pro v idin g in creas ed rudd e r effectiveness at low airspe eds . But on twins the slips trea m g enerally does not go an y where ne ar th e ru dd er - c on s equ e ntl y the rudder is no t mu ch help until the air speed has built up . E sp ec ially wh en o ne is op e rating in m arg in al condition s, t here is a cer t ain and justifiable relucta nce to co mpromise pe rformance by usin g a sy mme tri c po wer . Bu t this is a co ntrol which may be us ed w hen n ec essar y - and was not us ed in this case. The corr ect take off tec hniqu e fo r a lig ht tw in o n a soft a nd slipper y surface is to mainta in ju st sufficient pre s sur e on th e no sewheel to p ro vid e po sitive steering - but not so mu ch that it ca n s ink into soft patches . When air speed is such th at directional co ntrol c an be mainta in ed with rudd e r alone , the nose should be lifted such that the n osewlieel is no long er on th e strip. If the aircraft be g in s to wander , the nosewheel should be pl aced b ac k on the s trip , carefu l use made of brake a nd if n ece ssary a sy mm etr ic pow er , and the take off ab a ndon ed if con s id ered a dvi sa ble. Of cou rse th e t echnique o utlin ed will not necessarily r es ult in a very sho rt take off roll; it will s imply be as sho rt as safety a nd the c onditi on s di cta te. T hi s m us t be taken int o account wh en d ete rminin g lo ad or s trip len g th re quirem e nt s. 14 I Aviation Safety Digest 117 In the air briefly W hen th e pilot saw his a ircraft career i ng off to one si d e of the st rip , toward t he b u sh, a h ut a nd a s mall h ill , he de c ided th a t ra th er t han go thr o ugh he wou ld try to go ov er those ob stacles. So the a irc r aft t ook off at an ex tr emely low air spe ed - it was fl yi ng in g rou nd effect , on th e back side of the powe r curve, a nd ac cordi ng to the passeng er s with a ho rn ( pres um ably stall wa rn in g) soundin g. I t is sig nificant that the pilot did n ot h ear any stall warn ing , n or d id he reco gn ise the si tua tion t hat the airc raft was in . The a irc ra ft 'c ra wled ' up the s ide of t he hill, an d there at a he igh t o f p robably a bo ut 100 fe et th ings changed for the worse. Up to this poin t, it w ould appear t ha t th e ai rcraft could ha ve been flo wn ou t of its p re d icame n t, usin g the high power-wei gh t ra tio, tr ad in g h eight for spe ed , and flying downh ill to w ards a low clear area. Bu t whe n the ground is near and all y ou wa n t to do is gai n altit ude and irra tionally lea ve th e probl em behind , ther e is a c ertain reluctance to low er the n ose ev en though this is necess ary . The pilot ke pt th e nose hi gh, th e air craft stalled and dropped the r igh t wi ng. Hi s r eac t ion WflS to ap ply fu ll left aileron wh ich was re ta ined until the airc r aft hi t the ground. But this in correc t re actio n p rob a bly did n ot mak e a lot of differe nce for from th at h eight it is n ot po ssible to recov er from an incipi en t sp in . Miscellaneous factors Two o ther fa cto rs sho uld be men t ion ed . Th e first is t hat th e pas sen ge rs' eq ui p me nt was n ot tied d own . Luckily all the imp act force s we re do wnward an d the eq uip m en t s ta yed on th e fl o or. Had acceler at ion s bee n in othe r direc tion s, s er ious inj ury co uld h ave res ul ted. Secondl y, althou gh eq u ip ped w ith a serviceable ·a nd reliable HF rad io, an d des pit e possible V HF communi cation wit h over fl y in g air c raft , th e pilot did not re po rt to Flig ht Ser vice w hen tax iin g. There was, there fo r e, no SARWATCH o n t he aircraft - indeed , no one out s ide th e air cr aft even kn ew tha t it was t ax iin g to ta ke off. A ga in luc kily th ere were n o injuries:• for had the pilot and / or r ad io be en di s able d no o ne would h av e kn own of the acc ident a nd help wou ld n ot h ave been forthco m in g until th e next d ay. Conclusions Te chni cally on e could s im ply call it a ll ' pilot er ror ' , and le av e it at th a t - c ert a in ly up to th e po int of the stall the pilot could ha ve prevented the acc iden t. But th e wa y a pilot fl ies a nd t he decisions he /she make s are v ery lar gely the r es u lt of tra inin g and Company policy . With r es pect to the fo rm er , it w ou ld a ppear that th e p ilot ha d not be en a dequ a tely tau g ht seve ral item s - mo st impo rta ntly in rel a tion to operations from bush a i rst rips and also stall/ in c ipient spin re co gniti o n , pr ev ention a nd r ecover y. Pe rhaps th e mos t c ru cial les so n which h ad n ot b een tau gh t was the im por tance of recognisin g r eali ty and a ctin g accordi ngly . Fly in g safely m ea ns c ri tically no tin g wh at is really h ap pe nin g even if it s eems unli kely - a nd n ot believ in g wh at on e wo uld m erely like to see. Fl ying safely also mea ns real ising that conditions are always chan gin g, as is t he pilot's view of what is happening. De cisive co rr ective action should be t aken immediately u nless t he re is clea rly no urgency - and modified as soon as one ev en suspects that th e correction was not en ou gh/was too m u ch/w as incorrect. This princ iple, wh ich is so i mp or tan t and which has its application th rough a ll ph ases of flight, is rarely consciously tau g ht. W i th res pe ct to C ompany policy, several points sh ou ld be men ti on ed . Fi rst , there was inadequate pr eparat ion for t he fl ight - strip condition should have be en che ck ed , t he pilot questioned a bout whether he was com pletely happ y to make the flight, con side rat ion giv en to cargo , and so on. Secon dl y, pilot check flights we re too lax - although they were ca rri ed o ut , th e re was too much em ph asis on no rmal ma n oeu v re s a nd not enough on 'bush' te c hn iq ue s, l ow -sp eed work a nd the like. A large section of t he ch eck would often be the Chief P ilot riding as check pilot on a ch arte r fl ight, w he n of course emergen cy manoe uv re s could not be practised. Also th e re wa s a t en den cy to regard the D epartmental in st rum en t ra ti ng re ne wal test as an adequat e pilot ch eck . T h ir dly, lon g-term C ompany records of pilot rece ncy (e. g . in b ush o per at ions), str ip condition, and so on, would appe ar to h ave be en both inad e quat e and in ade quately u sed . F ou r th ly, C om pany procedures should hav e insisted on a full SAR W ATC H from before takeoff until after to uch- dow n wh en ever practicable. Use could also be made of th e ETD for SAR proced ur es. In som e ways t he c ir cu it operat ions at the beginning and end of a fl igh t ar e th e most cr itica l phases of that flight - thus it is im porta nt th at a SARWATC H be maintained over these op erat ion s. The time between an accident and rescue action can be critical; witho ut a SARWATCH it can be fatally long . Some of these Compan y policy factors w ere affected by fina ncial considerations - how much mo ne y can be spen t checking and working on a pilot's possible weak points on the off-chance that one day he / she'will encounter a certain condition? (Clearly the scope of the checks in my C ompan y was inadequate - but ho w far do you go?) O ther factors were affected by pilo t s' well- known dislike of paperwork, and still others by simple lack of orga ni sation. Th e key to all this is professionalism. We need to educate ourselves to be always professional in our approach . As always, man y were the factors involved in the making of the a ccident . We can consider ourselves lucky that this time lessons can be learnt at the cost of only the aircraft, not hu man lives. * * Aviation Safety Digest would like to t hank this pilot for his comments on this acc ident . T he sole aim of the Digest is to p romote flight safety, and one of the best ways of doing so is by recounting th e experiences of others. Clearl y the message derived from aircraft incidents or accidents can fall between two extremes , dep e nding on whether the occurrence was self-i nduced and handled poorly, or beyond the pilot's control and handled well, or a combination of these facto rs. I t is most important to note that an incident does not have to have been handled perfectly to convey a safety message; indeed, the reverse is often the case. T his is why the Digest on occasions presents articles in which individuals' actions may be questionable. Ar ticles are never presented with any intention of denigrat i ng anyone, but rath er only in the hope that we can all learn from the experiences of others • "That's th e Macken zi e spread - bloody hypochondriacs~' (Courtesy of The Bulletin) Aviation Safety Digest 117 I 15 Modifications to aircraft can be approved by either Department of Aviation officers or Departmentally authorised persons. While the great majority of approved modifications enhance the overall operational effectiveness of the aircraft to which they are fitted , the odd exception does sneak through the system. A case in point was highlight ed by an incident involving a Cessna 177RG. The pilot had carried ou t his pr estart, afterstart a nd taxi checks using a card check list carr ied in the aerop lane. After obtai nin g takeoff clearance he lined up and co mmenced the takeoff roll. At abo ut 60 knot s the a ircraft's nose dipped perceptibly and this was accompanied by a sligh t noise. The pilot rotated the aircraft and short ly after establishing it in the cl imb he n ot iced that the landing gear selector was in the UP po siti on, although he had not at that stage completed the after-takcoff checks. H e selected the landi ng gear dow n a nd obta i ned the cor rect indication ; th en selected it up and ob tain ed a n or mal up and locked indi ca tion. The pilot had int ended carry ing out a touch-and-go land ing but, because of the abnormal occurrence dur in g the takeoff, wisely opted for a full stop lan d i ng which was un eventful. Po st fli g ht inspection revealed tha t the prop e ll er was abraded on its tip s . 16 I Aviation Safety Digest 117 A technical examinat ion of the aircraft, and the landing gear in particular , showed all systems to be functioning no rm a ll y. The LAME ca rrying out the inspect ion did, however, notice th at a non-standard (n ot a fac tor y fi t) C B rad io microphone had been in sta ll ed immediately below the landing gear selector. Furthermore , the select or knob was loose and could rotate t hrou gh 90 degrees, in wh ich position the knob presen ted a larger than usual area in the horizontal plane ; the signifi ca n ce of this was that it made the selec tor knob more susceptible to an in advertent knock from som eone r eachin g for th e CB m icro phone. A word is necessary here on the C 177 R G la nding gea r syst em. The C l 77 RG in co rporat es a nose ge ar sq uat switch , which is actuated by the nose oleo extens ion, and wh ich electricall y prevents in adve rt ent gear re tract ion whenever the nose gear s trut is GYRO HORIZON CDI CDI AIRSPEED ALTIMETER CLOCK TURN DIRECTION GYRO OOO OOO 0 ° 00000000000° VERTICAL SPEED INDICATOR TACHOMETER ADF ~ ~ LANDING GEAR ~ ==1LEVER CB MIKE e ~ VHF MIKE ~ compressed by the weight of the aircraft. G ive n th ese c ir cums tances, investi gators po s tulated the following seq uence of events: • T he pilot, in r eac hing for the microphone aft er start up, had accidentally bumped the undercarriage sele ctor knob to the UP position. • Beca use th e a ircraft 's weight was acting on the l and ing gear , the nose gear s quat switch pr evented the gear from retracting. • As lift developed during the takeoff ro ll , the a ir cra ft 's weight sta rted to come off th e no se gear a nd so the s quat switch o pened and a ll owed the l andi n g gear to r et r ac t. • Hence, the no se dipped and the prope ll er s tru ck the gro und . At this stage, howe ver, the a ir craft became a irborne , preventing further damage, and the pilot found him self in the climb with the gear up a nd locked, wi thout consciou sly h aving mo ved the sele ctor knob to the up position . Subsequent discussion with the pilot confirmed that this was ind eed the probable sequence of events. The pilot discounted any possibility of his having initi ated a pre mature retraction. H e did, ho wever, re call that he h ad in adver te ntly pi cked up th e CB mi cropho ne wh en he went to give hi s fir st R/T call of the sor ti e. Because he wa s unfami liar with the a ir craft, a nd because the CB microphone was m ounted between the VHF mic rophone and the landing gear selector, he had initially mistaken it for the VHF microphone. In picking up the CB microphone he probab ly knocked the gear selector knob to the UP po sition. Th is inc id en t should provide food for thought for all those in the modifica tion development and app ro val cha in , Departmental or otherwise. While the pilot's un fa m ili ar ity with th e part ic ular aircraft un do ubt edly co ntributed to the incident, the posit ionin g of a mi cro phone imme diately adj acent to a cr itical systems control switch was unwi se. T h ere ca n be few General Aviation pilots who h ave not at some stage fumbled, witho ut looking, for a hand-op e rated mi crop hone while primar il y en gaged in another more press in g aspect of flight. It is most import ant th at such cont ingencies a re taken into account wh en cockpit modifications are proposed. Considerat ion must be given, not ju st to finding a space for an item, but to the who le quest i on of cockpit ergonom ics - the 'sc ientific st ud y of efficiency in a wor kin g env ironm e nt ' . An apprec iation of this need mu st be manifested, first, by the en gineers who implem e nt modifi ca tions and, seco nd , by any pilot whose opinion r egard i ng a proposed modification is sought. As this in cident s how ed, modifications which are not pl anned in th e co ntex t of cockpit ergonomics can be a fli g ht safety ha zard • Aviation Safety Digest 117 I 17 ~eade-i Fuel tank water drain checks 'After conducting an investigation for a Major Defect Report following the discovery of water in the fuel tank of a sophisticated General Aviation twin I thought an article on the importance of conducting water checks might be appropriate for Aviation Safety Digest.' The aircraft was undergoing a 100-hourly insp ection when a large amount of water and fungus-like contamination was found in the right -hand main and nacelle fuel tank s. All endeavours to trace the so urce of the co nt am inated fuel were unsuccessful. The investigation si milarl y failed to determine wh en the last fuel tank water drain check was carried out. It could well be that the aircraft had been carrying the water for over two weeks. I t had reached the engine firewall and fuel filter, and the conditions were ripe for an engine failure. While a single engine failure in itself ma y not have been too dramatic , the scene was set for the left engine to fail also: the pilot ne e ded only to select fuel cross fe ed from the right tanks and the left engine would have drawn water from the contamin ated right nacelle tank as well. Discussions generated by the inv es tigation of this discovery brought to light extreme cases of fuel quality contro l neglect: pilots admitted that t he y had not carri ed out a fuel tank wat er drain check in years of operating turbin e- pow ered a ir craft. Fu el quality co ntrol in Australia is of a hi gh standard and it is possible that this is the very reason for the neglect of pro c edures once th e fu el is in th e a ir craft tank s. But remember that water can come from several sources, for example: in co rrectly stored drum stock; co ntami nate<) ho ses and pumpin g equipment; rainwa ter (through poorly fitted tan k ca ps or defective cap seals); condensation fr om part ially filled tanks; and dissolved water released from the fuel by a loweri ng of the fuel temperature - s uch as will occur in fl ig ht. Th~ probl ems of the presence of water in jet f