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Occurrences & Incidents February - April 2022

All clubs and GFA members are urged to report all occurrences and incidents promptly, as and when they occur, using the GFA’s occurrence reporting portal at glidingaustralia.org/Log-In/log-in-soar.html. This is always best done while all details are fresh in everyone's mind.
You can read the full SOAR report at tinyurl.com/ltmko56

Reports noted 'Under investigation' are based on preliminary information received and may contain errors. Any errors in this summary will be corrected when the final report has been completed.

5-Feb-2022 VSA
Discus b
Aircraft Separation

What Happened
The pilot was competing in the Horsham Week competition and was one of the first group of gliders launched from RWY 35. After release, the pilot could not find lift and soon found himself at 1200ft AGL about 1km south (downwind) of the airstrip. The pilot was about to conduct a straight-in approach onto RWY 35 when the glider encountered a weak thermal. The pilot attempted to work the thermal, but this led to the glider drifting into the circuit area. At the time there were four tugs actively launching the remaining gliders. One of the tug pilots, upon joining base leg, spotted the glider in his path and radioed the glider pilot asking his intentions. The glider pilot stopped thermalling and conducted a straight-in approach and landing, while the tug pilot conducted a go-around. The Competition Safety Officer counselled the glider pilot and used this incident as the focus of his Safety presentation at briefing the following morning.

 

10-Feb-2022 NSWGA
DG-500 Elan Orion
Wheels up landing


What Happened
During a training flight the student pilot landed with the undercarriage retracted, a configuration that was not identified by the instructor.

Analysis
The student was landing at an unfamiliar airfield and was conducting a braked decent from height. The pilot lowered the undercarriage during descent but then raised the undercarriage when conducting the pre-landing checklist. The instructor did not recognise the student had retracted the undercarriage, and the aircraft landed on its belly suffering minor gelcoat abrasions. The instructor noted that the undercarriage position placard was obscured and that he was unfamiliar with the aircraft. The lack of consistency between gliders in the direction of landing gear activation was identified by the CFI as a casual factor, which can be a trap for instructors who are changing between glider types.

Safety Advice
This incident highlights the problem of using "checklists" as "to do lists”. Rather than checking that the gear was in the correct position during the pre-landing checklist, the student used the list as a prompt to action. OSB 01/14 'Circuit & Landing Advice' confirms that the pre-landing checklist is a 'check' and not an 'action' list. The undercarriage check should verify the undercarriage lever is matched to the lowered position on the placard.

19-Feb-2022 GQ
IS-30
Incorrect configuration

Under investigation
The pilot turned onto final high and deployed full airbrake to intersect the approach path to the aiming point. Identifying that an undershoot was starting to develop, the pilot partially retracted the airbrakes but the glider continued to undershoot. The pilot stated "instead of retracting the airbrakes some more I inexplicably pulled them out fully, believing that I had fully retracted them. I was aware that the undershoot had become serious enough that I would not have reached the runway, but because I believed the airbrakes were already fully retracted I attributed the situation to severe sink". Persons at the launch point observed the glider undershooting with full airbrakes deployed and alerted the pilot by radio. The pilot closed the airbrakes, just cleared the boundary fence and landed safely on the runway.

12-Mar-2022 GQ
Discus BT
Hard landing

Under investigation
On the return leg of a cross-country flight and about 15kms from the home airfield, the pilot found themselves low. The decision to break-of the flight was left very late, and when the engine failed to start during the downwind leg into a paddock, the pilot found themselves too low to properly align with the paddock direction. The final turn into wind across the side boundary fence was low and slow, and the glider stalled wings level from about 10ft just inside the boundary fence, and struck the ground heavily while drifting to the right. The aircraft suffered superficial damage, and the pilot suffered minor whiplash. The pilot stated the “possibility of making home no doubt influenced the poor judgement” and “in the final minutes of the flight I failed to divert all my attention to the landing.” The pilot also mentioned that, upon reflection, they were “not in a suitable frame of mind to fly this day due significant background stress from work- and business-related matters.”

19-Mar-2022 GQ
DG-1000S
Aircraft Loading

What Happened
On 19 March 2022 during a series of Air Experience Flights (AEFs), the glider was flown in an unapproved configuration (i.e. without the tail battery or 5.5kg of ballast weight installed) for 3 hours and 47 minutes. The glider had returned to the Club from routine maintenance undertaken at an Approved Maintenance Organisation (AMO) the day prior to the flight. It was rigged on the airfield (not at the hangar) on the following morning by two Club members who subsequently conducted the daily inspections and signed the Daily Inspection Record. The aircraft subsequently flew 8 sorites with several instructors and student combinations without incident. On the following morning during the daily inspection, it was identified that the tail battery was not installed. A replacement battery was installed, and the aircraft returned to service. An independent control check, which requires two consecutive independent signatures on the Daily Inspection Record after the controls have been disconnected and reconnected, was not completed.

Analysis
Following routine maintenance, the glider was delivered in its trailer to the aerodrome, two pilots elected to tow the trailer to the operational runway (RWY 09) and rig the aircraft in situ. The two pilots who conducted the rigging then conducted separate daily inspections. A mandatory evaluation flight was then carried out by one of the two pilots who had previously conducted the rigging and inspection of the aircraft. On completion of the mandatory evaluation flight, no adverse flight characteristics were identified, and the Maintenance Release was completed. Across all the remaining eight flight, which were operated by five instructors, covering AEF, solo and instructor currency flights, no combination of student/instructor approached the forward CG limit. During the Daily Inspection on 20 March 2022, a pilot who had flown the aircraft on the previous day, identified that the tail battery was not installed following a failed the voltage test of the fin battery. A spare battery was located and fitted allowing for the aircraft to be deemed serviceable and returned to operations. The Daily Inspection Record ‘GFA Form 1’ was not signed off with two consecutive independent signatures as required after controls were disconnected and reconnected. A phone call was placed to the AMO to locate the missing fin battery, which identified that the fin battery was with the AMO.

Duplicate Inspection
GFA MOSP3 outlines the requirement for an independent duplicate check of an aircraft that has been reassembled and includes the need for the person undertaking the duplicate inspection to annotate the Daily Inspection record to this effect, such as by writing “duplicate inspection rigging/controls” alongside their signature. The need to remain vigilant and diligent is also highlighted in this section. The Sailplane Maintenance Release and Daily Inspection Record also highlights the requirement for two consecutive independent signatures following the disconnection and reconnection of flight controls, although it does not include the requirement to need to annotate the Daily Inspection record to this effect. The signed Maintenance Release on the incident aircraft did not include a note to reflect that a duplicate inspection of rigging/controls was conducted prior to the aircraft flying without the fin battery installed. Furthermore, following the installation of the fin battery, the requirement to have two consecutive independent signatures on the Daily Inspection Records was again not completed.

Fin Battery
The Flight Manual provides an exemption for the aircraft to be flown without the fin battery, but it either requires a ballast weight of 5.5kg to be installed in the battery box located in the fin, or it may be removed for an extremely light pilot flying solo as it reduced the minimum front cockpit load by 16KGs. In the case of this glider, the ballast weight was not installed in lieu of the fin battery. , and no pilots who flew the aircraft solo that day met the requirement to be considered an extremely light pilot. The Flight Manual also provides the direction to either install the battery or the ballast weight in the battery box of the fin while rigging the stabiliser.

Battery Checking
The battery voltage check is the critical control in ensuring that the fin battery is installed. The Daily Inspection Schedule in the Maintenance Release and Daily Inspection Record (GFA Form 1) carried in the aircraft makes reference to observing specific items shown in the Flight Manual. The schedule includes guidance to check Battery(s) installation and the instruments & radio. All pilots who were interviewed were unaware of the requirement to check battery voltages > 12 V during the pre-take-off checks. However, during the investigation several daily inspections being conducted were observed, and those few pilots directly referring to the ‘Daily Inspection Schedule’ in the Maintenance Release stated that it provided a useful prompt in conducting a deliberate inspection.

Safety Advice
Daily inspections are a crucial part of flight operations and are required prior to the first flight of the day. A properly performed daily inspection by a trained person follows a standard procedure and permits detection of conditions that render an aircraft un-airworthy. However, complacency and a lack of understanding of the standard procedure may prevent it from being totally effective among less experienced pilots. A daily inspection must be carried out using approved maintenance data (e.g the Aircraft Flight Manual or GFA Daily Inspection Schedule) and recorded in the Maintenance Release prior to the first flight of each day. Many factors influence the outcome of a daily inspection, such as level of training, weather, time pressures, stress, and fatigue. Awareness of their presence and actions to mitigate their effects are paramount to properly completing the procedure. A daily inspection may appear to be a simple task, but it is more than glancing at a checklist and wiggling flight controls. These inspections require an understanding of normal and abnormal conditions. For the flight, it is the start of the aeronautical decision-making process. If unsure of what a checklist item refers to or whether the item is airworthy or not, enlist the help of a Maintenance Authority Holder or instructor for assistance. 14-Mar-2022 saga

 

3-Apr-2022 WAGA
Piper PA-25-235 - Astir cs
Near collision

What Happened
A tow plane and glider nearly collided head-on in the circuit.


Analysis
It was not a busy day for the club and in this case, it was the last flight of the day with only the tug and glider airborne. Operations had been conducted on RWY 16 (left-hand circuit direction), but as the wind was changing the duty instructor informed the low hours glider pilot to land on RWY 34 (right-hand circuit direction) after release. Unfortunately, this information was not passed onto the tow pilot, who positioned land on RWY 16. The two aircraft joined their respective downwind legs from the same side of the runway, which placed them head-on to each other. The tow pilot advised that his descent back to the circuit took him downwind to RWY 16 where at this point, he saw the glider coming towards him. The tug’s FLARM activated, and the tow pilot turned to the right to avoid the glider. The glider pilot advised that he released from tow and turned right, which placed the glider into wind in a good position for the downwind leg for RWY 34. The flight was shorter than planned as the aircraft was in sink. The glider pilot advised that he never saw the tug, nor does he recall his FLARM activating. The glider pilot did not make a downwind call but made a call on base leg.
The CFI noted the following Contributing Factors:
* The tug pilot was unaware that the duty runway had changed (The Club will review its procedures to ensure all parties are notified of a runway change).
* The tug pilot did not expect to see the glider at that height at that point on his downwind leg.
* The circuit direction for RWY 34 is right-hand, and for RWY 16 it is left hand. This placed both downwind legs on the same side of the aerodrome.
* The glider pilot experienced sink from the point of release, which shortened the into wind leg.
* Both aircraft were descending at about the same rate.
* The Glider pilot did not make a downwind call.

Safety Advice
This incident highlights the risks when operating at aerodromes with non-standard circuit directions and the importance of good communication, both on the ground before flight and in the air. When communicating a change in runway, all relevant persons need to be informed by whatever means is appropriate. It is also strongly recommended that pilots of radio-equipped aircraft use the ‘standard’ traffic circuit and radio broadcast procedures at all non-controlled aerodromes. These procedures are outlined in sections 7 and 8 of CASA Advisory Circular (AC) 91-10 ‘Operations in the vicinity of non-controlled aerodromes’. In areas outside controlled airspace, and especially in the circuit, it is the pilot’s responsibility to maintain separation with other aircraft. For this, it is important that pilots use both alerted and un-alerted see-and-avoid principles.

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9-Apr-2022 VSA
DG-500 M
Other Runway Events

What Happened
The pilot of a locally-based self-launching sailplane commenced its take-off roll while the runway ahead was occupied by gliders awaiting launch.

Analysis
Gliding operations were being conducted at this uncertified aerodrome from on the grass verge to the left of the bitumen runway within the runway strip approximately 60 meters behind (downwind of) the displaced threshold in accordance with local procedures. The ERSA entry for this aerodrome advises:
c. Gliders and tugs operate from the grass on side of RWY short of the displaced threshold. Other ACFT must not make low/shallow approaches and must land beyond the displaced threshold.
d. All powered ACFT take-offs shall commence from the displaced threshold unless operationally required. When the runway strip is occupied by a tug aircraft or glider, the runway is deemed to be occupied. Aircraft using the runway may, however, commence their take-off run from a position ahead of a stationary glider or tug aircraft (Refer Chapter 3 of the CASA Visual Flight Rules Guide and AIP ENR 5.5-2, paragraph 1.2.4). Safety Advice
Taking off behind other aircraft and persons is potentially dangerous, as a loss of control during the take-off roll could result in a collision with the other aircraft or associated personnel. Regulation CASR 91.375 requires, among other things, that “When operating on the manoeuvring area, or in the vicinity of a non-controlled aerodrome you must: keep a lookout for other aircraft to avoid a collision; (and) ensure that your aircraft does not endanger other aircraft.” CASR 91.410 requires a pilot to only take off or land if it can be done so safely considering all the circumstances, including the prevailing weather conditions. ‘Considering all the circumstances’ should include consideration of the risk posed to persons on the ground (refer CASR Part 91 Plain English Guide, Version 2.0).

 

12-Apr-2022  GQ
HK 36 TTS
Fire Fumes and Smoke

What Happened
Under investigation
Just after take-off a witness observed white smoke streaming from the glider and called emergency services. The command pilot reported the smell of oil coming from the air vent and decided to return to the aerodrome for an engine-off landing. After exiting the glider the command pilot reported seeing oil on RH undercarriage leg below the oil reservoir overflow.

25-Apr-2022 NSWGA
ASW 27-18 E
uncommanded release

What Happened
An Alexander Schleicher ASG 29 (ASW 27-18) fitted with a TOST E 22 release suffered an uncommanded release on hook up prior to launch. The TOST rings literally fell out of the closed release when the rope was rattled.

Analysis
The investigation revealed a fully functional release system and release. The release showed little wear, was in good condition and deemed serviceable. The sailplane had logged 388 launches. The TOST rings used in this case measured 4.66mm. New TOST rings measure 6.7-7.0 mm. It was also noted that the E 22 beak when fully closed was about 3mm short of the casing slot. This was confirmed to be normal as per the TOST design. Subsequent tests carried out on the release using the same worn rings with 4.66mm diameter showed that with only slight upward angle of the tow rope, the curve of the rings would slip under the closed beak. The following is an extract from correspondence received from TOST: “The release E22 was designed and certified to be only operated with the connecting ring pair according to LN 65091. According to the aerospace norm LN 65091 the circular link (the small ring) needs to have a diameter of 7 mm (tolerance: +0,0 mm and -0,3mm). A diameter of 5,1 mm is way too far from any allowable tolerance. Please do not use connecting rings with a diameter of 5 mm with our releases, that’s very dangerous.” Sailplanes fitted with a E 22 release, if not using rings meeting new or close to new dimensions, have an increased risk of an uncommanded release.

Safety Advice
The GFA currently have no standalone guidance material on the TOST E 22 release and permitted TOST ring wear tolerances. The GFA recommends following manufacturers guidelines. Following this incident, the GFA Airworthiness Department issued ‘AIRWORTHINESS ALERT 2022-1 - TOST E22 Aerotow Release’.

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