The soaring season is moving closer to the end and with that should be a reduction in the number of incidents reported in our SOAR system. Firstly, thank you for submitting SOAR reports. These reports are treated confidentially. They are investigated to confirm the facts, analyse what happened and most importantly devise safety outcomes that help us all going forward. Sue to the workload of Part 149 implementation our SOAR report investigation and documenting published reports is behind. I have engaged some assistance from experienced investigators and club CFIs are helping a lot. I am focusing on producing Occurrence Summaries for 2022/2023 and 2024. These are available on the Gliding Australia website. 2022 and 2023 are incomplete, at this stage but still valuable.
Dave Boulter
Executive Manager Operations
SOAR Report Number: S-2269
Title: Canopy Damage
Date: 18-Nov-2023
Region: WA
Aircraft Type: Schempp-Hirth Discus A
Classification Level 1: Operational
Classification Level 2: Airframe
Classification Level 3: Doors/Canopies
What Happened
The glider hit a patch of significant turbulence while cruising on final glide at 100kts. The pilot commenced re-tightening their shoulder harness and slowing down but immediately was hit by another strong vertical shear which caused their head to contact the canopy. Although it only seemed like a minor contact, it was clear from the noise level that the pilot’s head had punched a hole through the canopy. They estimated that their head went no more than 1 cm through the canopy. It was only the pilot’s second flight in the glider, and they found the seating position was a little tricky.
Analysis
The pilot was new to the glider type, and they had not found a comfortable seating position which resulted in their head being close to the canopy. Harnesses tend to become less tight during flight, so as the pilot started a high-speed final glide and hit turbulence, their head contacted and broke the canopy.
Safety Advice
When flying a new glider type, take the time to find a comfortable seating position and harness arrangement which also gives proper control access and maintains good head clearance from the canopy. Re-check harness tightness prior to commencing high-speed flight such as a final glide, particularly in turbulent conditions.
SOAR Report Number: S-2366
Title: Near Collision between Towplane and Glider
Date: 28-Apr-2024
Region: WA
Aircraft Type: Piper Pawnee PA25 and DG 1000S
Classification Level 1: Airspace
Classification Level 2: Aircraft Separation
Classification Level 3: Near Collision
What Happened
A near miss occurred between a glider and a towplane on the downwind leg of the circuit. The glider was approaching from the active side of the circuit and planning to join mid to late downwind or on base leg, as it was experiencing sink. At the same time the tug joined the circuit and called early downwind. Upon hearing the tug pilot’s transmission, the glider turned to the south in a position the pilot thought was outside the downwind circuit leg and was looking to their right so that they could turn behind the tug and follow downwind. Both aircraft were now head-to-head, with the tug slightly higher and slightly to the right of the glider. Both pilots spotted each other at the same time, and both turned to their left. The aircraft passed each other with a separation of around 200 feet horizontally and 50 feet vertically.
Analysis
The glider was a twin with the pilot flying in the rear seat, limiting their forward visibility. It was experiencing sink and planning a modified circuit entry. However, upon hearing the tug’s announced entry to the circuit, the glider pilot decided to try and follow the tug instead of joining the circuit immediately. This resulted in the glider flying in the opposite direction on the downwind leg. Although both tug and glider radios were fully operational, the tug pilot did not hear any radio calls from the glider and was unaware of its position.
Although both aircraft were fitted with FLARM, they did not activate. The tug FLARM was fully operational on the day. However, it was established that the glider FLARM was not powered on, as in this glider the FLARM is powered via the S100 Vario FLARM port, and the pilot had not switched on the S100 for this flight. It is evident that the pilot had not checked that the FLARM was functional during pre-takeoff checks.
A collision was narrowly averted by the immediate action of both pilots to turn when they saw each other at the last moment.
Safety Advice
It is preferable to commence the circuit in the early downwind position but, when necessary, gliders may need to join the circuit on any leg on both the active and non-active sides. Always manoeuvre to avoid being head-to-head with circuit traffic.
Good lookout is the primary method of maintaining situational awareness, alerted by correct radio calls, particularly around airfields. In a twin, brief the front passenger/student to report any traffic seen during the flight.
FLARM is an excellent enhancement to lookout but is only effective between aircraft fitted with functioning units. The effectiveness of FLARM installations should be tested and their operation always confirmed during pre-flight checks.
Soar Report: S-2381
Date: 7/7/2024
Region: NSWGA
Aircraft Type: DG1000S
Classification Level 2: Wildlife
What Happened
Whilst on short final, a Kangaroo hopped towards the glider on the runway at a range of approximately 500m. As the aircraft was landing, the kangaroo continued, and kept moving towards the aircraft. The kangaroo, still running at the plane did not change course, causing evasive action required by PIC, as the kangaroo avoided the wing, by a few metres.
Analysis
Wildlife hazards exist.
Safety Advice
When landing, expect the unexpected and alter the glide path as needed. Landing long and avoiding the kangaroo is the best option. Discuss in briefings as a hazard and possible actions to take.
Soar Report: S-2386
Date: 15/7/2024
Region: NSWGA
Aircraft Type: DG1000S
Classification Level 2: Flight Preparation/Navigation
What Happened
A Daily Inspection was completed on the glider in the hangar prior to taking it to the launch point. Before taking the glider to the launch point, the instructor of the first flight verbally confirmed with the member who completed the DI that the inspection had been completed.
The student on the first flight conducted the ABCD pre-flight inspection but did not check that the maintenance release for the glider had been signed. The instructor did not check the maintenance release, given the prior verbal confirmation. The aircraft completed the flight without incident.
On the second flight, the instructor conducted the ABCD pre-flight check and noticed the omission.
The instructor again confirmed with the person who conducted the daily inspection that the DI had been completed. That person said they had forgotten to sign the Maintenance Release. The Maintenance Release was subsequently signed, and operations continued.
Analysis
The incident highlights several failings and omissions. i.e. failure of the person carrying out the DI to sign the DI book, failure of the student to check the DI book, and failure of the instructor to ensure the student carried out the ABCD checks correctly. It could have resulted from complacency, time pressures, distractions or slips.
Safety Advice
Good safety outcomes rely on every person to diligently accept responsibility for their required duties and actions. A DI is an extremely important part of making flying safe. Conducting a DI is making sure the glider is safe for all persons who will fly the aircraft on that day and is therefore a big responsibility to do correctly, including the signoff.
Soar Report: S-1987
Date: 17/12/2021
Region: NSWGA
Aircraft Type: LS10-st
Classification Level 2: Runway Events
What Happened
The pilot was landing on the runway that has with a slope to the left. There were recently cut grass in piles on the runway, and the ground was soft and wet. Towards the end of the ground roll the right wing (being closer to the ground because of the slope) caught on grass resulting in a 150 degree ground loop to the right.
Analysis
Wind was not a factor as conditions were benign. The pilot was experienced and current on type. The LS10 is an 18m glider – combined with the grass piles and slope, the 18m wings would easily catch on the grass piles.
Safety Advice
Extra vigilance is required when landing longer wing gliders on slopes and with surfaces such as grass piles. Airfield maintenance needs to ensure hazards are minimised.
Soar Report: S-1990
Date: 13/1/2022
Region: NSWGA
Aircraft Type: Pilatus B4
Classification Level 2: Systems
What Happened
The pilot was having a short flight (7 minutes) in showery conditions with a cloudbase of 1200ft. A shower moved across the airstrip whilst the pilot was in circuit. On final, the pilot noticed that the airspeed indicator was showing a constant speed and not functioning correctly. Consequently, the last part of the final was slow, resulting in a higher than usual ‘dumped’ landing.
Analysis
It is likely that water from the rain showers entered the pitot system, causing the ASI to become faulty. Some days later the ASI was working correctly.
Safety Advice
Flying in poor conditions increases the risks associated with gliding. These include poor visibility, rain, affected instruments, degraded glider performance and sometimes extra decision-making. Pilots should evaluate risks before flying and consider whether a flight on days such as this are worth the increased risks.
Soar Report: S-2006
Date: 20/2/2022
Region: NSWGA
Aircraft Type: Standard Libelle 201 B
Classification Level 2: Terrain Collisions
What Happened
While landing downwind (and downhill), the glider overshot the runway and was substantially damaged when it ground-looped in long grass at the end of the strip.
Analysis
Low hours, low solo hours, current pilot flying a glider with relatively small airbrakes elected to land in what they thought was a headwind but had more tailwind component. Another glider had blocked another strip which may have affected decision making. As well, the wind on takeoff had been a headwind. The pilot initially selected a runway to do the circuit but did not check wind direction after that. Then believing they were landing in a headwind made a high final approach with a slight tailwind.
Safety Advice
The Libelle is not a very suitable glider for low hours pilots. Additionally, pilots must monitor wind direction in the circuit continually and make or change decisions on landing direction accordingly.
The soaring season is moving closer to the end and with that should be a reduction in the number of incidents reported in our SOAR system. Firstly, thank you for submitting SOAR reports. These reports are treated confidentially. They are investigated to confirm the facts, analyse what happened and most importantly devise safety outcomes that help us all going forward. Sue to the workload of Part 149 implementation our SOAR report investigation and documenting published reports is behind. I have engaged some assistance from experienced investigators and club CFIs are helping a lot. I am focusing on producing Occurrence Summaries for 2022/2023 and 2024. These are available on the Gliding Australia website. 2022 and 2023 are incomplete, at this stage but still valuable.
I have chosen three incidents to highlight.
Dave Boulter
Executive Manager Operations
Date: 24/6/2023 Region: QLD
Aircraft Type: Piper PA25-150 Auto Tug and Duo Discus
Classification Level 2: Miscellaneous
What Happened
During normal glider launch operations, an incident occurred on the 8th launch of the day involving the release of the tow rope from the tow plane. After towing a glider back to the launch point, the tow rope was reattached to the tow plane by the duty tug pilot. Despite multiple inspections and checks, the tow rope released itself from the tow plane twice during subsequent launch attempts.
Analysis
The incident was caused by the incorrect routing of the tow rope under the tailwheel steering arm of the tow plane. This routing allowed the rings to remain in place during manual test pulls but resulted in the release of the rope when rudder was applied, pulling the cable and release arm forward enough to release the rings. This highlights the importance of meticulous attention to detail during tow rope attachment to prevent such incidents. The incident also underscored a procedural oversight in the method of opening the TOST release mechanism. The focus on inserting the rings into the release at the correct position led to inadvertent routing of the cable under the tailwheel steering arm. This emphasizes the need for standardised procedures and thorough training for tow pilots to prevent similar incidents in the future. Following the incident, immediate actions were taken to rectify the root cause, including holding a meeting with all tug pilots to reinforce the correct method of opening the release mechanism. Effective communication and ongoing training are essential to ensure all personnel are aware of and adhere to established procedures for safe tow operations.
Safety Advice
The tow rope incident underscores the critical importance of meticulous attention to detail, standardised procedures, and continuous training in ensuring the safety of glider launch operations
Date: 18/10/2023 Region: WA
Aircraft Type: DG1000S and JS1
Classification Type 2: Aircraft Separation
What happened
Both aircraft involved were returning from a similar cross-country flight into the circuit area at the club’s airfield. The pilot of the JS1 was current, had recently achieved his GPC, and was making his second long cross country in his newly acquired glider. The crew of the DG1000 consisted of a current GPC pilot who was being coached by an experienced, current instructor/cross country pilot. The incident occurred with both aircraft completing a relatively long cross- country flight with thermals becoming more difficult on the last leg for the JS1. The JS1 started its engine approximately 50Km from YBEV and shut it down 15Kms out.
The JS1 was running a LX9080 navigation system with an integrated VHF. The pilot thought the VHF would automatically change to the CTAF and did not check that had occurred. He made the appropriate calls at 10 miles and downwind which were transmitted on the glider area freq.
Other gliders did call the aircraft to inform him he was on the wrong frequency, but these calls were not heard by the pilot.
The other glider DG1000 changed to the CTAF at 10 miles and due to the JS1 transmitting on the wrong frequency were unaware of his position.
Both aircraft joined downwind for runway 16 at approximately the same time with the DG in front and slightly further out. The DG turned base with the JS1 on the inside also on base.
The incident occurred when turning final, the front seat pilot of the DG during the turn sighted the JS1 to the left and slightly lower on a collision course. The instructor observed the JS1 approximately 1 second later (due to his position in the cockpit) and took evasive action. The DG turned right and completed an S turn before landing long. The pilot of the JS1 was unaware of the situation until after the flight.
Analysis
On review it was determined that not only was the JS1 radio on the incorrect frequency, but its FLARM was not working. This was due to a recent fitment of a “Power FLARM” that was interreacting with the standard Flarm fitted to the aircraft.
The JS1 pilot had not seen the DG and probably thought that as he had not heard any other aircraft in the circuit, he was not expecting to see any other traffic. He was probably concentrating on his checks and circuit patten in his new glider and not lookout.
The probable cause of this incident was due to the JS1 being on the wrong radio frequency, Its FLARM being unserviceable and being situated behind the DG1000, an ineffective lookout.
Safety Recommendations
The JS1 has been grounded and the aircraft taken to a maintenance base to fit an external VHF radio and to have its FLARM made operational. The pilot of the JS1 is fully aware of the situation in the debrief and aware of the failures in his lookout and situational awareness regarding the avionics. A safety bulletin has been published for the club members highlighting the use of radios and effective lookout.
Date: 14/2/2024 Region: WA
Aircraft Type: Discus
Classification Type 2: Miscellaneous
What happened
The Glider was climbing behind the tug at the start of a club cross country event in hot turbulent conditions. The pilot of the Discus was current, and an experienced L1 instructor. On the initial tow the tug was in a continuous left hand turn to minimise the exposure of out-landings when taking off on Runway 34. During this turn it was relatively turbulent and as the tug was levelling out after turning about 270 degrees the rope broke at around 900 AGL. The glider pilot elected to return to land followed by the tug.
Analysis
On examination of the rope, it was found to have failed approximately 7 meters from the TOST rings. The rope was rejected and replaced. The failed rope was then examined by a team to determine its breaking strain and was found to be well below the manufactures rating.
Safety advice
The cause of this incident was that the wear that appeared to be within limits failed well under the manufacture’s limits. On the same day approximately within an hour another rope failed (SOAR 2322). At this point all new ropes were used for the rest of the weekend while testing was carried out. As can been seen from the attached report the new rope was failing well below the manufactures claim of 1,000 kg. High temperatures were also a factor with the rope lying on hot bitumen which would also affect the property of the rope. The club has now dumped the 10mm and 11mm ropes and will operate with a new type of 12mm with a breaking strain of 2,700 kg. The team will monitor the wear and determine the minimum dimensions for safe operating.
The soaring season is moving closer to the end and with that should be a reduction in the number of incidents reported in our SOAR system. Firstly, thank you for submitting SOAR reports. These reports are treated confidentially. They are investigated to confirm the facts, analyse what happened and most importantly devise safety outcomes that help us all going forward. Sue to the workload of Part 149 implementation our SOAR report investigation and documenting published reports is behind. I have engaged some assistance from experienced investigators and club CFIs are helping a lot. I am focusing on producing Occurrence Summaries for 2022/2023 and 2024. These are available on the Gliding Australia website. 2022 and 2023 are incomplete, at this stage but still valuable.
For this season, there have been 98 reports since 1st October 2023.The main issues encountered were:
- Airspace infringement
- Incidents during landing: outlandings, heavy/hard landings
- Ground handling
I have chosen three 2023 incidents to highlight.
Dave Boulter
Executive Manager Operations
Date: 4/1/2023
Region: VSA
Classification Level 2: Ground Operations
What Happened:
After conducting the Daily Inspection, the wing dolly was re-installed to the glider and tied down to the cable run on the apron to attend the daily briefing. At the selected marshalling time the pilot loaded the glider with gear and hooked up the tail dolly and towing bar to the vehicle but forgot to untie the wing dolly. The aircraft suffered minor damage when the pilot attempted to tow the glider to the launch point.
Safety Advice:
Ground accidents are very common. Take your time. Rushing to the flight line usually results in forgetting something or worse damage to the glider.
Date: 8/1/2023
Region: QLD
Aircraft Type: ASW19 B
Classification Level 2: Aircraft Control
What Happened:
The pilot landed without lowering and locking the undercarriage on the third day of a mini-Grand Prix event at the club. In the three days of the event the pilot completed 12 hours of cross-country flying in hot weather conditions of about 30 degrees Celsius every day. On the day of the incident the pilot participated in a lead-and-follow coaching flight of 3-and-a-half-hour duration. Heights of 9000 Ft were achieved in strong thermals reaching +11Kts strength. After landing, the pilot discovered the undercarriage issue while disembarking. Fortunately, the glider sustained minimal damage as the landing occurred on a grass glider strip.
Analysis:
The pilot failed to follow standard circuit management procedures, specifically neglecting to conduct pre-landing checks before joining the circuit and during the circuit phase. The investigation highlighted the importance of considering human factors, especially in prolonged flying sessions in hot conditions. Factors such as dehydration, inadequate hydration during flight, sustenance, and cumulative fatigue from multiple days of flying may contribute to lapses in standard operating procedures. The pilot after taking time to reflect on what was discussed during the post flight debrief and subsequent investigation agreed that lack of hydration management, nil urination management used or in place, nil hypoxia management systems used or in place, and the cumulative effect of the above factors on the day, and also from the preceding two days contributed significantly to the onset of fatigue that led to non-standard management of the circuit resulting in landing wheel up.
Corrective Actions:
The pilot was asked to research hypoxia management and hydration management (including urination) prior to and during flight. Also, to read OSB 01_14 - Circuit and Landing advice and CASA Human Factors resource material. On going support was provided to the pilot around what things are being considered/implemented in preflight management to mitigate the risk of the same thing happening again. The pilot underwent a check flight to standard as part of remedial action.
Continuous education:
Clubs should promote continuous education on human factors, emphasizing the impact on pilot performance and the importance of preventive measures.
Date: 12/2/2024
Region: NSW
Aircraft Type: JS 3 with sustainer
Classification Level 2: Terrain Collisions
What Happened:
The Pilot outlanded in a paddock 2.3 km from the airfield while attempting to finish a cross-country competition task. The glider sustained minor damage to the undercarriage doors and the underside of the left wing. In an attempt to cross the finish line, the pilot flew into a non-manoeuvring area before attempting to start the sustainer jet engine at about 250ft AGL. The pilot reported: “At the 3 km finish point (approximately 250 feet AGL) it was obvious that to make the airfield, trees would need to be cleared and it was not possible to clear the trees due to lack of height AGL and lack of airspeed to gain height. I lowered the undercarriage, turned away from the trees (180 degrees) toward paddocks (that were not checked for out-landing), and turned on the jet sustainer. The aircraft was approximately 200 feet AGL. Whilst the jet sustainer engaged its startup procedure, the aircraft ran out of height and landed in a freshly ploughed paddock. There were fences in the paddock at close proximity and due to the fortunate circumstance of a freshly ploughed field and very quick stopping with the soft earth there was approximately 50 m of clearance to the fence. At the time of landing the jet was fully engaged (about 45 seconds had elapsed from time of turning away from trees and landing in the field).”
Analysis:
The pilot did not have a Low Level Finish endorsement. This endorsement provides training in energy management that must be considered for a safe approach and landing after a cross country or competition flight. Without that training, at a safer height, consideration to outland was warranted. The glider was equipped with a jet sustainer. The start sequence for this relatively easy and quick, compared to older sustaining systems. But there is a time lag between activation and the jet producing the power required. Due to the above there was no adherence to standard outlanding procedures. Paddocks were not assessed. On examination of the IGC trace, the height of turns into the paddock was concerning. The pilot's inability to manage energy effectively during the approach, resulted in a critical lack of altitude and airspeed necessary to clear obstacles and make a safe landing at the airfield. The delay in recognising the need to activate the jet sustainer further exacerbated the situation. Failure to conduct out-landing checks until the last moments reduced the pilot's situational awareness and limited the available options for a safe landing. The pilot is lucky the paddock was soft slowing the glider quickly.
Safety Advice:
Pilots must adhere to established procedures, including conducting out-landing checks well in advance of critical decision points. This ensures that safety margins are maintained, and adequate options are available in case of emergencies or unforeseen circumstances. Winning a competition or concluding a distance task is not worth the risk of damaging your glider or damage to yourself. The incident underscores the importance of adherence to procedures, effective energy management, and proactive risk assessment in mitigating the risk of outlanding incidents during cross-country flights. By prioritizing safety, maintaining situational awareness, and following established protocols, pilots can minimise the likelihood of similar incidents.
Date: 18/3/2023
Region: NSW
Aircraft Type: LS-8a and LS8-18
Classification Level 2: Aircraft Separation
Under investigation. During the second leg of a competition flight, the pilot of a glider established in a received a FLARM alert indicating an immediate threat. The pilot was unable to identify any reason for the FLARM warning and could not see any glider or any part of a glider while looking for signs of conflicting traffic. The FLARM alert was in response to another glider entering the thermal from directly behind and below and in the thermalling pilot’s blind spot. The entering glider then turned inside the other glider as its pilot opened the turn to sight the conflicting glider.
Date: 20/3/2023
Region: NSW
Aircraft Type: Mosquito and LS8
Classification Level 2: Aircraft Separation
Under investigation. Two gliders nearly collided while thermalling.
Date: 22/3/2023
Region: NSW
Aircraft Type: Discus B and LS8-18
Classification Level 2: Aircraft Separation
Under investigation. Two gliders nearly collided while thermalling.
Date: 18/3/2023
Region: NSW
Aircraft Type: Mosquito and LS4
Classification Level 2: Aircraft Separation
Under investigation. Two gliders nearly collided while thermalling. Approximately six gliders in the same thermal.
Date: 2/4/2023
Region: QLD
Aircraft Type: Standard Libelle 201 B
Classification Level 2: Wildlife
While thermalling near the Bunya Mountains a wedge tailed Eagle dived from above with legs extended and collided with the port wing of the glider. Inspection the left wing identified delamination of subsurface materials, chipped gelcoat and cracking in several areas extending over an area approximately 30cm diameter. Although birds and glider pilots often share the same thermal and can operate near each other with relative safety, birds can and do occasionally encounter a glider. While it is uncommon that a bird strike causes any harm to aircraft crew, many result in damage to aircraft. Wedge-tailed eagles are territorial and are known to defend around their nest sites from other wedge-tailed eagles and the occasional model airplane, hang glider, glider, fixed-wing aircraft or helicopter.
Date: 6/4/2023
Region: QLD
Aircraft Type: Jantar Standard 3
Classification Level 2: Terrain Collisions
Under investigation. On the return leg of a competition task conditions deteriorated, and the pilot conducted an outlanding into a cultivated paddock. During the flare, the pilot noticed a picket and wire fence across the landing run. The pilot conducted a ground loop to avoid contact with the fence.
Date: 6/4/2023
Region: QLD
Aircraft Type: Nimbus-2C
Classification Level 2: Miscellaneous
An inexperienced launch crew hooked the glider on for an aerotow launch but did not properly engage the rings in the release. At 150ft AGL the rings pulled free, and the glider was safely landed in a paddock. The glider was being launched from the CG release, as a nose release was not fitted, and the crew was unfamiliar with its operation.
Date: 6/5/2023
Region: QLD
Aircraft Type: LS8-18 and ASW20B
Under investigation. On the day of the accident, 10 gliders were competing in a local Grand Prix event and flying around a 150 km task. The task was a polygon with 5 turn points. The collision occurred in a thermal just after several gliders rounded the third turn point. The thermal was occupied by six gliders flying at similar heights. An LS 8-18 glider was the last to enter and, about halfway around its first turn, collided with an ASW 20B glider. Investigation is ongoing, but a review of the flight traces suggests the pilot of the LS 8-18 entered the thermal slightly below and possibly in a double-blind position with respect to the ASW 20B and stayed in this position until the moment of impact. If the pilots of both aircraft were in a position such that they could see the other, they did not, and this was possibly because they were looking at one or other glider in the thermal at the time. The pilot of the ASW 20B eventually noticed the other glider in close proximity, and the collision occurred when he took evasive action by rolling out of the turn. The gliders suffered no structural damage. The port aileron of glider the ASW 20B suffered a 150mm abrasion to the trailing edge, and the leading edge of the port wingtip of LS 8-18 suffered minor paint abrasion. Unfortunately, this is a known hazard in gliding competitions and Airprox events continue to occur despite pilots being trained in risk management for flying in proximity to other gliders. Since the introduction of Flarm, the incidence of actual collisions has dropped significantly. However, see-and-avoid remains the primary defence.
There is a theme in this month’s SOAR reporting. Flying near other gliders requires great care and concentration. Start gaggles, near airports, and turn points, are places where gliders congregate. Flying along cloud streets can create potential head on situations. As mentioned above, see-and-avoid is our primary defence. Clearing both left and right and above and below during entering of turns and exit of turns is very important.
Date: 3/2/2023
Region: NSWGA
Aircraft Type: ASW 27-18
Classification Level 2: Ground Operations
Under investigation. While towing the glider to the hangar, a wind gust (possibly a thermal) struck the glider causing it to dislodge from the tow equipment. The starboard wing impacted a runaway marker and the glider hit the tow vehicle. Significant damage was cause to the starboard control surface, the port flap, and vertical fin assembly.
Date: 5/2/2023
Region: VSA
Aircraft Type: ASW 28
Classification Level 2: Systems
What Happened
At the top of a competition launch, the pilot was unable to release the tow rope.
Analysis
The pilot chose to make a radio call to the tow pilot advising of the failure to release but did not use the tug callsign. After a few radio calls, the tow pilot eventually became aware of the situation and towed the glider back towards the aerodrome. After numerous attempts to release the tow rope, it did release. The pilot landed back on the aerodrome and inspected the release, but the release tested OK and the pilot was unable to determine the cause of the failure. The pilot took a relaunch and the released worked when used.
Safety Advice
As with all radio communications, broadcasts must identify the callsign of the station being called as well as the station calling. In this case the glider pilot did not know the tug callsign, so there was some initial confusion as to which of the four tugs was involved. Had the pilot conducted the standard release failure procedure and flown out to the left of the tow plane in accordance with standard procedures, they may have got the tow pilots attention earlier.
Date: 26/2/2023
Region: NSWGA
Aircraft Type: ASW 28
Classification Level 2: Systems
What Happened
At the top of the launch, the pilot was unable to release the tow rope and, following several unsuccessful attempts by the glider pilot, the tow pilot released the rope from the tow plane. The pilot landed safely.
Analysis
The pilot reported that the release had also failed during an aerotow a few weeks earlier (Refer to report S-2163), so a more thorough inspection was considered warranted. The release mechanism was removed from the sailplane and the inspector found a small stone lying loose in the nose under the release mechanism. As the stone was mobile, the inspector considered it was most likely that it would occasionally move into a position that prevented the release from being actuated. The stone was removed and there have been no further problems.
Date: 28/2/2023
Region: NSWGA
Aircraft Type: ASK21
Classification Level 2: Terrain Collisions
What Happened
Shortly after becoming airborne on an aerotow launch and at a height of about 80ft, the glider flew through turbulence causing the student pilot to hit his head on the canopy and inadvertently release the tow cable. The pilot reflexively lowered the nose and opened the airbrakes to conduct a short landing and contacted the ground hard. The glider rebounded into the air and again struck the ground hard in a nose down attitude. The pilot was uninjured, but the glider was extensively damaged around the nose wheel and forward of the rear instrument panel.
Analysis
The student pilot had planned to fly a solo soaring flight of one hour to qualify for the issue of a ?C? certificate qualification. The wind was north westerly at about 8 knots, gusting to 15 knots. The pilot had intended to fly the Club?s PW5, in which he had flown 27 flights. However, the supervising instructor suggested the K21 was more suited to the conditions, as it provided a more stable platform and was the aircraft in which the student had completed most of their training. The CFI reported that the student had flown 151 flights prior to the incident and had gone solo after 71 flights. The student had flown 36 solo flights before the incident, of which 27 flights were in the PW5. The student had trained with four instructors over 12 months, and usually flew about once a month for a week at a time. The student's current instructor regards him as a thorough and disciplined pilot who conducts comprehensive prefight checks with appropriate attention to options. He is very comfortable in the air, and flies in a safe and well considered manner. The investigation identified the crosswind from the left, and mild gusting as contributing factors. The groin strap was loose, but the lap and shoulder straps were tight. The student had their hand close to the release knob and was not holding it, but the sudden bump may have caused the pilot to grasp it. The CFI concluded that the incident was not the result of a PIO, but a reflexive response to aggressive but short-lived turbulence. The student?s action was inappropriate for a low-level launch failure, and the student acknowledged that they should have taken a second or two to assess the situation before reacting. The duty instructor supervising the launch stated that it appeared to be normal up until the point of turbulence, whereupon the glider was seen to sharply nose down and disappear below the line of sight on the sloping runway, and appear again, probably after the first contact with the ground and a bounce. The student will undergo further training, with the emphasis on decision making rather than an instinctive response in various emergency scenarios.
Safety Advice
Aerotow launch emergencies are not uncommon and form part of a pilot?s training. During launch the pilot must have a plan to address any emergency that may occur. Indeed, the pre-take-off checklist requires a pilot to consider their actions in the event of an emergency. In the case of a rope break or premature release from tow, the priority for the pilot is to lower the glider?s nose and adopt safe speed. The next action is to assess landing options and conduct a safe landing. Sudden and aggressive control movements in pitch must be avoided, especially when close to the ground. Coarse elevator control inputs are inconsistent with a safe transition from a stabilised approach into the flare and landing and will often result in a sudden and unrecoverable steep dive into the ground.
Date: 5/3/2023
Region: SAGA
Aircraft Type: ASK21
Classification Level 2: Ground Operations
What Happened
While towing the ASK-21 glider back to the hangar, the driver received a stop signal and applied the vehicle brakes. Unbeknown to the driver, the rigid towing bar had bent and was now rubbing on the glider?s rudder. Upon arriving at the hanger, the driver noticed the rudder had suffered some minor scratching from the bent towing bar.
Analysis
The rigid tow bar became bent when the towing combination, which was travelling above normal speed, was abruptly braked when the vehicle driver received a signal from the duty instructor to stop. The compressive force of deceleration resulted in the tow bar deforming. The cause of the incident was largely the result of a deterioration in judgment caused by prolonged exposure to a very hot day with multiple incidences of time in the sun repairing cables breaks. In addition, the tow vehicle driver was under some pressure to depart the airfield for a meeting in town and was in a hurry. Despite no significant damage resulting from this incident, there was a high probability that major damage could have resulted. The day?s operation was not unusual but was conducted in high temperatures common in that location at this time of year. During the day there were multiple launch stoppages due to cable breaks, with winch drivers remaining in the sun for prolonged periods. Both the glider pilot and the tow vehicle driver had driven the winch during the day. At completion of flying, the two gliders on the airstrip were to be moved to the hanger connected to vehicles via rigid towbars. The ASK-21 was towed at speed towards the hangar and was about to overtake the other glider when the Duty Instructor signalled stop to allow the other glider to enter the hangar first. The vehicle towing the ASK-21 stopped with enough force to cause the tow bar to deform while decelerating the glider. There was a brief exchange between the duty instructor and passenger of the tow vehicle, where it was resolved that the ASK-21 would be towed beyond the hangar to make room for the other glider. The driver then departed with the damaged tow bar causing an oscillation of the glider?s tail that was noticed by the Duty Instructor. The Duty Instructor again signalled the vehicle driver to stop but the driver did not see the signal and continued on their way. On arriving at the hangar the ASK-21 was unhooked and the driver and vehicle left the field immediately without further communication. After exiting the vehicle, the passenger noticed the deformation in the tow bar and conducted an inspection of the glider with the duty instructor. Apart from some abrasion, the glider did not suffer further damage. The CFI interviewed the persons involved and identified several failures: The winch drivers lacked self-awareness of their fatigued state. The vehicle driver was in a hurry to leave and drove too fast. The passenger in the vehicle towing the ASK-21, being similarly fatigued, did not identify the glider was being towed too fast. Neither the vehicle driver nor passenger maintained adequate situational awareness during the tow. It is not normal practice to overtake another glider under vehicle tow. Despite the investigation showing no significant damage had occurred to the glider, this incident could have easily resulted in substantial damage had there been greater contact between the rudder or tail plane and the vehicle or tow bar. Additionally, had the glider in question had a more ridged tow bar it may have transferred additional braking forces to the airframe of the glider.
Safety Advice
Fatigue High levels of fatigue cause reduced performance and productivity and increases the risk of accidents and injuries. Fatigue affects the ability to think clearly. As a result, people who are fatigued are unable to gauge their own level of impairment and are unaware that they are not functioning as well or as safely as they would be if they were not fatigued. People working in a fatigued state may place themselves and others at risk. Fatigue management is a shared responsibility between Clubs and their members. Clubs have an obligation under their Safety Management System to minimise the risk of fatigue, so far as is reasonably practicable. Individual members have a duty to take reasonable care for their own safety and health, and make sure their acts or omissions don?t adversely affect the health or safety of others. For further information on fatigue, refer to the Human Factors in Gliding publication. Towing with a Vehicle Drivers using a rigid bar must never tow at faster than walking pace and should always use the tow-out equipment designed for use with the glider. When towing gliders, never brake heavily and always allow a greater distance to slow or stop than the distance you would allow with only the car. Drivers and their passengers should always situationally aware and maintain a scanning technique.
Date: 5/3/2023
Region: VSA
Aircraft Type: DG1000
Classification Level 2: Weather
What Happened
While taking off from RWY 01 in a strong crosswind with a glider under tow, a strong gust from the left struck the combination just prior to the tug was becoming airborne. With the aircraft weight being mostly carried by the wings, the tug skidded sideways across the ground and then became airborne. The tug and glider proceeded to drift to the right and crossed the right-hand boundary fence at about 50ft. The combination climbed rapidly, and the glider released at 3000ft AGL about four minutes later.
Analysis
The towing combination comprised a DG-1000 glider being flown by a pre-solo student pilot under instruction and a Pawnee tow plane flown by a low hour?s tow pilot. A tow pilot who observed the take-off advised that the wind was 15kts, and probably gusting to 20 kts. The drift started just when the tug got light on the undercarriage, and about 5-10 seconds later the combination was climbing over the boundary fence. At that time, other gliders were landing on RWY 27, which was more into wind. As the tug started drifting to the right, the gliding instructor took control but elected to stay on tow as the as the combination had gained sufficient height and speed to clear the fence, and the instructor was concerned that had he released the rope may have struck the fence and potentially caused difficulties for the tow pilot. In hindsight, the instructor recognised that the flight should not have proceeded in the prevailing conditions, and that once the tug started to drift, he should have released and allowed the tug to safely climb away while landing the glider straight ahead on the runway. The Club CFI noted that the cause of this incident was most likely the result of a strong gust combined with incorrect inputs by the tow pilot, and it highlights why gliding duty crews must manage flight risks by moving operations to the most into wind runway in a timely manner.
Safety Advice
Like most clichés there is truth behind the statement that landings are mandatory, but take-offs are optional. Operations in crosswind conditions require strict adherence to applicable crosswind limitations or maximum recommended crosswind values, operational recommendations, and handling techniques. Most aeroplanes have a maximum demonstrated crosswind component. This is not a limitation?it is merely the greatest that was demonstrated during certification. If the pilot is very proficient, they may be able to take off (and land) with a greater crosswind. Also, while the aeroplane may be able to handle it?it?s the pilot that most often cannot. Pilots must therefore decide whether to attempt a crosswind take-off based on their recent experience and not some figure in the pilot?s operating handbook. In the case of an aerotow, it is the tow pilot that has this responsibility as pilot in command of the combination.
7-November-2022 SAGA
Discus-2cT
Airspace Infringement
What Happened
While thermalling to gain height before embarking on a cross country flight, the pilot allowed the glider to drift into restricted airspace. The pilot had launched into a thermal north of the airfield and drifted south due to northerly wind. While conscious of the glider’s proximity to the airspace boundary to the south of the airfield, the pilot became focussed on finding the core of the thermal and did not realise the glider had penetrated restricted airspace by 1NM. Upon reaching 6000 ft, the pilot proceeded on the planned Cross-Country flight and only identified the airspace breach upon reviewing the flight trace at the end of the flight. The pilot immediately reported the infraction.
Analysis
The aerodrome from which the pilot was operating is situated beneath Class C airspace (LL4500), and within and between several areas of restricted military airspace and Danger Areas. The Club has access to some restricted airspace by arrangement with the RAAF. The Club CFI advised that the pilot has a good understanding of Airspace and is normally very diligent not to infringe airspace. However, on this occasion the pilot lost situational awareness of the glider’s proximity to the restricted airspace while focused on finding the core of the thermal. As a result, it didn’t take long before the glider drifted across the boundary. The CFI noted that the boundary is not well defined by ground features, and an analysis of the Club’s database of airspace infringements has identified this boundary as being a common area for airspace infringements. The club has increased pilot awareness of the issue and runs regular airspace workshops that are well attended.
Safety Advice
To avoid airspace infringements pilots should apply Threat and Error Management in their flight planning and flying (e.g., identify the threats such as airspace, weather and equipment). Pilots must also consider the errors they are likely to make, such as in navigation, and address them early. Particular attention should be paid to vertical limits of controlled airspace, and pilots should plan to remain 200’ below the base of controlled airspace and/or 1nm from the edge whenever possible. An approved and up-to-date moving map display in the field of vision is useful, and ensure you carry a backup, whether a current paper chart with the route drawn on or a second moving map display. It is also important that pilots understand the role of distraction before and during flight and how it can lead to inadvertent infringement of controlled airspace. Pilots should consciously recognise distractions including those from passengers, unfamiliar equipment or its malfunction, aircraft problems or weather as well as personal problems or stress. Pilots should ensure they positively shift attention from them back to flying, operating, and navigating the aircraft. If weather is becoming a factor, change your plans early and carefully. Importantly, look outside the cockpit with
9-Nov-2022 GQ
Astir CS
Aircraft Separation
Under investigation
A powered aircraft listed with RAAus and an Astir CS glider were involved in a mid-air collision appoximately 2NMs South-West of Gympie aerodrome at a height of about 2,500ft. Both aircraft spiralled to the ground and their pilots were fatally injured. The accident is being investigated by the Qld Police and Coroner.
19-Nov-2022 GQ
Piper PA-25-235
Aircraft Separation
What Happened
A glider and tug combination on departure from the aerodrome and climbing out in a left-hand turn towards the north-west came within 800 metres horizontally and 200ft vertically of a recently solo and low hours pilot flying to the south-west upwind of the operational runway.
Analysis
This incident occurred on a busy day, with the club conducting training and aerobatics for aviation students from the Griffith University Soaring Society using three two-seat gliders and two tow planes. There was also some cross-country flying being conducted by experienced pilots. Just after midday, the recently solo pilot was launched by aerotow in the DG1000 for a local flight. Shortly afterwards, the Duo Discus was launched for an aerobatic flight, and the tow pilot was flying to the designated aerobatic area. The pilot of the tug towing the DG1000 positioned the combination over directly over the runway instead of upwind, and the glider pilot released at 2000ft in the general area where the aerobatic flights were being conducted. The pilot of the second tow plane TOWING THE Duo Discus reported that “There were lots of gliders in the air and there was a lot of cumulus cloud, so whilst visibility generally was good, gliders were hard to pick up against the very white sky. All aircraft have Flarms.” The second tow pilot conducted a standard departure and while climbing through 2000ft towards the aerobatic area, the command pilot in the Duo Discus sighted the DG1000 flying directly towards the towing combination from about 30 degrees to the right. The tug pilot did not see the glider. The pilot of the Duo Discus immediately released and made a radio call “turn left, turn left, turn left”. The tow pilot recognised the glider pilot’s voice and at the same time saw the glider release in the mirror. The tow pilot immediately turned left and descended. The pilot of the DG1000 saw the two aircraft in front at this time and simultaneously the aircraft FLARM alerted. Neither the tug pilot nor the pilot of the Duo Discus recalled receiving a FLARM alert. All aircraft separated, but the solo pilot was unsure of what to do and appeared to have continued straight flight ahead.
Safety Action
Following the flight, the CFI, who was also the pilot of the second tug, conducted a debriefing with all parties involved. The following causal factors were identified:
l Ability to spot aircraft was impaired by significant cloud.
l The solo pilot lacked experience operating in a complex and dynamic airspace.
l There was a general lack of understanding about where the aerobatic manoeuvres were being conducted.
l The Flarms in the Duo discus and Tow Plane may not have been serviceable.
l The collision beacon in the nose of the DG1000 was not turned on.
The club has since taken the following remedial action:
l A safety presentation emphasising lookout was presented to members.
l Procedure were implemented for coordinated operations during training programs, including supervision of early solo pilots in this environment.
l Formal procedures were established for the conduct of aerobatic flights to avoid conflict with gliders and transiting powered aircraft.
l The nose beacon in the DG1000 is required to be turned on in flight to increase visibility.
l All Flarms were checked for serviceability.
27-Nov-2022 VSA
EON Olympia Mk 2b
Terrain Collisions
What Happened
The pilot released from tow at about 2000ft AGL and found strong sink. The pilot turned back towards the aerodrome but rapidly ran out of height. The pilot elected to make a straight-in approach to a paddock about 1 km from the aerodrome but on late finals observed a powerline ahead. The pilot turned right to land in another paddock, but the glider's wing hit the ground during the turn and the glider struck the ground while travelling sideways. The forward fuselage suffered substantial damage and the tailskid was torn off. The pilot was uninjured and was driven back to the aerodrome by the farmer.
Analysis
The elderly pilot had about 500 hours aeronautical experience, of which 300 hours and 150 flights were in sailplanes. He had not flown for more than 12 months and completed six flights with the CFI as part of his Flight Review in the week preceding the accident. On the accident flight the pilot was flying a vintage Olympia sailplane that he had owned for several years and recently sold. The pilot’s experience on type was not provided. The pilot reported that after releasing from tow the glider encountered heavy sink and despite heading straight back to the aerodrome the glider did not fly into any lift. The pilot believed paddocks around the aerodrome were landable, so he continued to push on rather than select a closer paddock and conduct a circuit. On late final the pilot observed a powerline across the approach, and while manoeuvring at low level to land in another paddock the glider’s wing struck the ground. The glider slewed sideways and landed heavily and was substantially damage. The pilot was uninjured. The reason for the high sink rate was not established, and the glider’s airbrakes may have been extended for the flight.
Safety Advice - Outlanding
Accidents during outlanding are often due to not having enough time to thoroughly inspect and choose a field and plan the landing. The trap is when you keep hoping that you will find a thermal so you delay making the decision to land. Unlike landing at the home airfield where the runway layout, ground features and hazards are usually well known, when landing in a strange paddock the pilot is faced with the unknown. Such a situation demands the pilot take additional precautions to ensure a proper survey is undertaken of the landing area so as to identify all hazards and ensure a safe approach and landing can be accomplished. Pilots must adhere to their training, which requires the conduct of a proper circuit of the landing area to review for suitability.
Currency and Aging
It is well known that flight experience can compensate to some degree for age-related declines in cognitive function and that overlearned complex tasks such as piloting are less susceptible to age-related deterioration than abilities to perform in novel situations. Notwithstanding, recency of experience can have a dramatic effect on overall airmanship, regardless of age. It is known that older pilots who have long breaks between flying take longer to regain their proficiency. Older pilots should fly regularly and participate more frequently in recurrent training. Unfortunately in this case, the recent flight review was not sufficient to prevent this accident from happening.
29-Nov-2022 VSA
Piper PA-25-235/A1
Aircraft Control
What Happened
During the third aerotow for the day and at approximately 50ft AGL, the tug commenced an uncommanded rapid roll to the right resulting in the tug turning sharply to the right. The tug pilot released the tow rope and initiated an unusual attitude recovery. The glider pilot simultaneously released the tow rope and landed straight ahead. The tow pilot flew a modified circuit and landed.
Analysis
The launch was being conducted without the assistance of a wingtip runner, so the glider was taking off from a wing down position. The slack in the rope was taken up uneventfully and the combination became airborne. The tow pilot reported that shortly after becoming airborne and at a height of about 50ft, the tug “…went from straight and level to nearly 90 degrees within less than a second”. The pilot attempted to reduce power but inadvertently pulled the mixture control. Observing the glider passing on the left, the tow pilot pulled the release, and then applied full power to climb away. The glider pilot also released from tow and landed heavily straight ahead. The tow pilot completed a modified circuit and landed safely. The tug was inspected by a LAME and no issues or defects were identified. The glider was undamaged. The trace from the tug’s Flarm unit verified the pilot had sufficient airspeed at the time of the upset. The Club Tugmaster believes the occurrence was consistent with the tug having been caught by a thermal gust.
2-Dec-2022 NSWGA
DG-808 C
Aircraft Separation
Under investigation
Two gliders nearly collided in the circuit while landing on different runways. A DG 800 was on final approach to RWY 18 and a SZD 55 was in a left-hand circuit to RWY 09. The SZD 55 passed directly underneath the DG 800 with abut 60 feet vertical separation. The pilot of the SZD 55 did not see the DG 808 and was unaware of the incident until debriefed afterwards. The pilot of the DG 800 observed the SZD 55 low on the left and passing underneath and had no time to take avoiding action. Analysis of the flight traces revealed that both gliders had passed in opposing directions about 1 minute earlier when the DG 800 was on base leg to RWY18 and the SZD 55 was positioning to join downwind to RWY 09 in left-hand turn. At that time the gliders passed within 130 metres horizontal separation and 151 feet vertical separation. Neither pilot could recall receiving a Flarm alert of the near collision. Both pilots heard each other’s circuit calls, but the pilot of the SZD 55 was confused by the DG 800 pilot’s circuit call due to the expectation they would be landing on the common runway being used for landing on the day. The pilot of the SZD 55 was undertaking their first flight in type.
8-Dec-2022 NSWGA
Sparrow Hawk
Terrain Collisions
Under investigation
During the initial stages of an aerotow launch, and shortly after the glider became airborne, witnesses observed the glider move into the high tow position and, when at a height of about 50ft AGL, the glider was observed to suddenly pitch up steeply to the right, and then the left wing and nose dropped. One witness observed the tow rope was still attached as the glider pitched down but believed the pilot must have activated the tow release because the tow plane climbed away while the glider departed controlled flight. As the glider’s left wing dropped, the wingtip struck the ground followed by the fuselage striking the ground in a nose down attitude while pivoting around the wingtip. The glider was substantially damaged, and the pilot suffered serious injury. Police and emergency services attended, and the pilot was transported to hospital by ambulance. The pilot has no recollection of the launch or accident.
15-Dec-2022 NSWGA
Standard Cirrus
Aircraft Control
What Happened
During a competition flight the pilot conducted a straight-in approach from the control point approximately 10km from the finish circle. The pilot omitted to configure the aircraft for landing by lowering the undercarriage and did not complete the pre-landing checklist before landing.
Analysis
The pilot stated that he had earlier recovered from two potential outlandings and he may have been fatigued. Additionally, the pilot did not carry sufficient drinking water for the flight and may have also been dehydrated. The pilot also noted the undercarriage lever on the aircraft being flown acted opposite to what he was accustomed. Discussion with the CFI highlighted the importance of maintaining appropriate consideration of human factors in relation to the effects of dehydration, appropriate infight hydration, sustenance, urination, the cumulative effects of fatigue following multiple days of flying, including in hot conditions.
Safety Advice
Straight-in approaches are now commonly used to simplify the final approach under competition conditions. While they require more experience and energy management, they avoid complexity and exposure to collision risk. However, the chances of identifying an error while flying a normal, standard circuit is significantly higher than when on final glide for a straight-in approach. The absence of a base leg (particularly) but also of a downwind leg also reduces the opportunity to examine the landing area and final approach. Notwithstanding, none of this does more than add to workload and this procedure is, on balance, safer for experienced pilots. Despite this, landing mishaps still occur during a straight-in approach due to poor workload management, so pilots must take care to ensure that the pre-landing checklist is carried out. For further information, refer to OSB 01/14 'Circuit and Landing
17-Dec-2022 GQ
Cessna 150G
Aircraft Control
Under investigation
As the glider/tow aircraft combination was passing about 1500 feet, the tow aircraft received a drastic load pulling the tail to the left. The tow pilot checked the rear vision mirror and noted the glider in a position well to the left of the tow aircraft. As the tow pilot watched, the glider commenced a correctional turn to the right but at such a speed that the tow pilot became alarmed and decided to release the tow rope from the tow aircraft.
17-Dec-2022 WAGA
SZD-48-1 Jantar Standard 2
Preparation/Navigation
What Happened
During an aerotow launch, the glider pilot noticed a vibration at approximately 300 feet AGL and observed that the airbrakes were open. He promptly closed them and the flight continued.
Analysis
The pilot is very experienced and was carrying out his third flight for the season. At the time he thought he had an adequate time to conduct all his checks as the tug had just taken off. However, he did not realise that the second tug had started and was positioning in front ready for the tow, which caused him to rush through his checks to avoid holding up others awaiting to fly. Although he thought he had checked the airbrake, they were not locked. On review there did not seem to be a safety issue regarding the climb as the tug pilot did not notice any decrease in performance.
Safety Advice
Pilots must remain alert to the risks of rushing through checklists, as vital procedures can easily be missed. Checklists enhance flight safety and enable the pilot to confirm safety critical systems and controls are correctly and consistently configured for a phase of flight. Distractions, interruptions, and haste result in a disruption of the sequential flow of the checklist. One technique to counter distractions and interruptions is to repeat the entire checklist (starting from the beginning) during these situations. Unfortunately, if the pilot is in a hurry, this will likely not be done.
17-Dec-2022 VSA
Twin Astir
Aircraft Separation
What Happened
A winch launch was abandoned just before the launch commands were given as a powered aircraft flew over the runway at a height where conflict was likely. No radio calls were heard from the aircraft, that had departed a nearby certified aerodrome.
Analysis
A two-seat glider was about to be launched on a training flight when the launch crewman heard and then saw an aeroplane about to overfly the duty runway at a height that would likely conflict with the launch. The ground crewman immediately called “stop, stop, stop” to the member in the control van, who relayed the message to the winch driver. The launch did not proceed. Neither the ground nor flight crew heard a radio call from the aircraft to indicate a possible overfly of the glider field. The ground crewman made a broadcast to the aircraft overflying to the effect that it was overflying an active winch launching glider field but did not receive a response. The identity of the overflying aircraft could not be ascertained.
Safety Advice
The potential for conflict with transiting aircraft overflying operational winch sites is real, and there have been several close calls over recent years. It will be obvious to all that it is essential for pilots preparing to launch to be aware of any airspace activities in their vicinity and the threat, if any, posed by the presence of other aircraft. Lookout is the principal method for implementing see-and-avoid. Effective lookout means seeing what is 'out there' and assessing the information that is received before making an appropriate decision. The primary tool of alerted see-and-avoid that is common across aviation is the radio. Radio allows for the communication of information to the pilot from the ground or from other aircraft. Radio is also useful for the wing runner, to aid in situational awareness or monitoring of gliders or aircraft that might affect the launch operation. A radio announcement prior to each and every launch is a standard operating procedure at all gliding sites and is expected by other operators. With winch launching operations, Gliding Australia now requires all launch commands, including the ‘take-up slack’ and ‘all out’ commands, be given on the CTAF or local aerodrome frequency. These additional calls improve situational awareness for pilots flying in the area and are known to have been responsible for reducing conflict with transiting powered traffic at, at least, two winch sites in Australia. In this case the above requirements for ensuring the airspace was clear for launch was clearly understood by duty crew on the day, and their alertness prevented a potential accident.
26-Dec-2022 NSWGA
Discus-2b
Terrain Collisions
Under investigation
During a cross-country flight the pilot flew across unlandable terrain in search of lift marked by clouds. When the pilot arrived under the clouds, he was unable to find lift, and the glider became too low to fly to suitable landing areas. While attempting to land on a highway, the glider undershot and crash into scrubland. The glider was substantially damaged but the pilot was uninjured.
21-August-2022 waga
DG-500 Elan Orion
SZD-50-3 Puchacz
What Happened
Under investigation. During a dual tow endorsement exercise and at about 250ft AGL, the rope weak link connecting the two tow ropes to the tug failed. Both gliders under tow landed safely. During the prelaunch check the link was inspected and appeared to be in serviceable condition. However, it was evident after the event that the weak link had degraded over time.
3-Sep-2022 Saga
ASK21
Runway Events
What Happened
Under investigation. The winch launch crew gave the "Take-up slack" signal to launch a glider on a training flight when another glider was on short final. Fortunately, the winch driver was aware of the landing glider and reported this to the launch point. Launch commands were being given on the UHF, contrary to GFA recommendations.
8-May-2022 SAga
DG-500 Elan Orion
Aircraft Control
What Happened
The touring motor glider pilot had flown to a remote aerodrome in company with another motor glider. The forecast winds were light from the Southwest, so the pilot planned to land on RWY 24. Upon arrival at the aerodrome the pilot joined circuit for RWY 24 midfield at about 1,000ft AGL to assess wind direction from the primary and secondary windsocks. Both windsocks were hanging limp, indicating little to no wind on the ground.
The pilot reported “A lefthand circuit was initiated and during the circuit whilst flying over the dried dark brown clay lakebed to the South of the airfield, some turbulence was felt. Turbulence was also felt on the base leg, but this reduced once over the green fields whilst turning onto finals.” The approach was conducted with the engine idling and the propellor in fine pitch. The pilot stated the aircraft touched down mid runway and he noted the ground speed was very high. Due to the high speed, the pilot had difficulty maintaining directional control. The pilot reported “…Full main wheel brake was applied with full backstick to try and maintain control with the tail wheel. The aircraft veered to the right off the runway and the right undercarriage fibreglass wheel fairing contacted a white cone shaped fibreglass light marker.” As the glider slowed, the pilot was able to steer the glider back onto the runway. While taxying to the parking area at the end of RWY 24, the pilot observed the primary windsock was now indicating a strong East-North-Easterly wind, confirming the aircraft had landed downwind with a slight crosswind component. The secondary windsock was noted to be still hanging limp and may not have been serviceable. Discussion with other pilots revealed the lakes and surrounding terrain often generate a microclimate different to that in the surrounding areas. The aircraft was inspected by authorised inspector, who conformed the damage was isolated to the fibreglass wheel fairing.
24-Sep-2022 wAga
Ground Operations
Astir CS
What Happened
As the glider was being stowed following outlanding and derigging, the fuselage was pushed too far forward into the trailer which resulted in damage to the canopy. The pilot was conducting outlanding training into a local paddock. The pilot had flown with the CFI on an earlier flight where a successful outlanding was conducted. The pilot then embarked on a second outlanding in a single seat glider but misidentified the surface vegetation and landed in a crop. A trailer retrieve was conducted and, although a team of competent pilots went out, none were familiar with the trailer. The CFI advised that he had run a course on glider trailers the week prior using two different types but not this particular trailer. As a consequence of this incident, the CFI ran another course covering all trailers that are in common use at the club.
25-Sep-2022 GQ
Grob G103A Twin II Acro
Low Circuit
What Happened
A post-solo pilot had arranged with their instructor to fly from the rear seat of the club’s Twin Astir and practice take-off and landing. As there was insufficient crew, the glider was launched by winch with the wing on the ground. At around 200ft AGL the pilot lowered the nose of the glider and released the cable. The pilot flying then conducted a low-level turn onto downwind, following which the turn steepened and continued until the runway heading had been achieved. The final turn was flown at very low height and less than 50 metres from trees on the side of the runway.
Analysis
The CFI reported that they had arrived at the flight line to observe the instructor sitting in the front seat of the glider in the process of conducting a wing-down winch launch on RWY 12 into a south-westerly crosswind. After the aircraft landed, the CFI approached the instructor for an explanation of what had happened. The CFI was informed that the pilot flying had lowered the nose due to the airspeed being low and made the decision that there is a winch failure and released immediately. It was the instructor who directed the pilot to turn onto downwind, and then when the instructor realised the turn was low and flat, they took over. The instructor lowered the nose of the glider and performed a steep turn completing a 360 degree turn and then landed the aircraft safely. The CFI expressed concern that a launch would be conducted without a wingman, and that a landing straight ahead was not considered even though there was ample runway ahead. The CFI suspended the instructor’s flying privileges for four weeks.
Safety Advice
Wing down take-off
There is no provision in GFA winch operations for gliders to be launched wing-down. While wing down take-offs can be conducted using aerotow launch, albeit with some risk, acceleration under a winch launch happens much more quickly and exacerbates the risk. With the wing on the ground the resultant drag is likely to cause the glider to commence a ground loop that will become a cartwheel. Once this process has commenced it can be so rapid that safe recovery is impossible even if the release is activated immediately. The result of the cartwheel on winch launch will almost inevitably be the glider rolling toward inverted and impacting the ground. Always use a wing runner to hold the wings level, and if the wing drops to the ground release immediately.
Too Slow
For safety reasons there is no signal for “too slow”. If the launch speed starts to fall off, reduce the angle of climb. If there is no response and the speed continues to fall toward minimum safe speed of 1.3Vs, treat it as a launch failure and release the cable. Adopt ‘safe speed near the ground’ before manoeuvring and land straight ahead whenever possible.
Launch failure when airborne
The definition of the launch failure is the inability to maintain the minimum winch speed on the launch during the climb, regardless of the reason. After a launch failure in flight you must maintain control of the aircraft and return it to a safe landing by performing the following actions:
Action 1. Regain and maintain the safe speed near the ground (1.5VS).
Action 2. Operate the cable release mechanism twice.
Action 3. Land ahead unless there is insufficient space to land safely.
30-Sep-2022 GQ
Nimbus 3T
Aircraft Control
What Happened
Under investigation. The pilot reported that after climbing to just over 5,000 ft, he did a normal engine test run of the sustainer engine. After about 40 seconds the pilot conducted a standard shut-down procedure, but the engine did not retract. The pilot stated:
“I tried resetting switches with no success, then I tried reaching under the panel to move wires etc. with no joy. The next decision was whether to go direct to land however, I decided that stopping the prop would be a good idea while I still had height. I tried reducing the airspeed however the prop kept turning. I then brought the speed right back while flying straight and level. The prop was still turning even when a mild stall started. The stall was recovered without major speed build-up. About a minute after this at around 60 Kts, the Glider entered a shallow left spiral with rapidly increasing speed. Attempts with rudder and stick did not help. With some back stick the spiral developed into a spin. Full opposite rudder and stick forward had no effect to slow the spin. Several resets and repeats were tried with no effect to the spin. With the ground coming up fast the decision to bail was made. Pull both canopy handles, canopy flew off whacking my head on the way. As the hands went to the canopy handles the Glider started to invert leaving me hanging by the straps, evacuation was easy as I fell out as soon as the buckle was turned. Free fall was brief with the chute opening quickly after pulling the handle. Parachute ride was gentle, but quite a bit of effort was required to avoid landing in a dam. The Glider landed upside down about 300 metres upwind.”
12-Oct-2022 WAGA
LAK12
Ground Operations
While towing the fully ballasted glider to the launch point at walking pace, the wing dolly struck an obstacle, causing the tail of the glider to turn towards the vehicle. The horizontal stabiliser struck the vehicle and was substantially damaged.
Analysis
During the morning briefing the pilot received a phone call from work and had to excuse himself. The phone call lasted for some time, which delayed his preparation for flight. By the time the pilot was ready to tow out, most of the fleet was lined up and he did not want to be last. In his haste to get to the flight line, the pilot did not observe a small, forked branch from a tree was lying in the path of the wing dolly. The wing dolly struck the branch, which lodged in the spokes of the wing dolly wheel causing the wheel to stop turning. The moment arm from the long wing and short tow bar resulted in the glider’s tail swinging towards the vehicle. The tail plane struck the rear of the vehicle and suffered substantial crush damage to the stabiliser and elevator, and the aluminium spar was bent. The main contributing factors in this incident was stress leading to the pilot’s haste and a reduction in situational awareness.
Safety Advice
When dealing with stressful situations, one tends to focus on a particular concern to the detriment of situational awareness. Situational awareness means looking at your surroundings and assessing risks. In this case, in the pilot’s haste to avoid being last on the grid led a failure to ensure the glider was being towed clear of obstacles. Doing things at haste also risks forgetting or missing vital actions that could compromise the safety of the aircraft and its occupants.
12-Oct-2022 nswga
Speed Astir II B
Runway Events
What Happened
Shortly after touchdown the glider’s port wingtip contacted high grass and proceeded to ground loop to the left. The pilot stated that he had recently conducted several wing-down crosswind landings in an ultralight aircraft, and this may have led him to subconsciously land with the port wing slightly low. The glider was undamaged. The CFI reported that there is some exuberant Patterson's Curse on the runway which stands above the pasture. In addition, the glider has a very low wing so is more at risk than most gliders. The glider was on an extended rollout to finish near the relevant hangar, and the event occurred at low speed during the rollout. It is common practice at this site for gliders to finish with an extended rollout for convenience, but the CFI noted that this does increase the risk of "taxiing" incidents and the matter will be discussed at the next instructors' panel meeting. The Club’s summer mowing program is proceeding at best pace..
31-Oct-2022 SAGA
ASK 21
Miscellaneous
What Happened
The CFI identified a club member had been flying gliders, including solo, up to two months after their GFA membership expired. GFA Operational Regulation 3.1.1 states: "An aircraft to which these Regulations apply must not be operated except by an individual who is a member of the GFA.” Paragraph 8.1(a) of Civil Aviation Order 95.4 states that a relevant sailplane must not be operated except in accordance with the (Operations) manual of the relevant sport aviation body. With Regulatory breaches, CASA expects GFA to deal with the matter and achieve a suitable outcome in the first instance. Where GFA is unable to achieve a suitable outcome, the matter must be referred to CASA. In this case the person immediately renewed their membership, which was backdated to the expiry date, and was counselled by the CFI. Members are solely responsible for ensuring their membership is current before flight, and the GFA membership system sends at least two email reminders in the month leading up to the expiry date.
1-May-2022 waga
DG-500 Elan Orion
Preparation/Navigation
What Happened
During an aerotow launch the tow pilot noticed that the combination was not climbing normally. After checking the tow plane, and at approximately 2,000 ft AGL, the tow pilot gave a ‘rudder waggle’ signal to alert the glider pilot to the poor climb rate. When the glider pilot did not respond to the signal, the tow pilot check is rear-view mirror and observed sunlight reflecting off the open [aluminium] dive brake panels. The tow pilot then called the glider pilot on the CTAF frequency and informed the pilot the glider’s airbrakes were open, and after several seconds of inaction the tow pilot made another call. The glider pilot then closed and locked the airbrakes and replied to the tow pilot over the radio. The launch and release proceeded normally thereafter.
Analysis
The glider pilot had conducted nine flights since the beginning of 2022, four of which were in his own glider (Hornet), and three of were private passenger flights in the club's Puchaczs. The pilot had not flown the DG505 since September 2021. The CFI spoke to the pilot about the occurrence and it was determined that the pilot did not correctly lock the dive brake prior to the launch. It was not determined why the glider pilot did not notice the wing waggle or hear the intial radio calls. The pilot stated they had cycled through opening and closing the airbrakes during the pr-take-off checks, and when challenged by the launch crew the pilot stated they “touched the dive brake handle to ensure it was fully forward and checked the handle was flush with the cockpit wall and said ‘dive brakes locked and away’. The pilot noted that unfamiliarity on type may have contributed: “the airbrake handle on the DG 505 is apparently in the ‘locked position’ the handle is flush with the wall of the cockpit when the brakes are not locked”, whereas on “other gliders I fly the airbrake handle is not flush with the cockpit wall until it is locked away.” The glider pilot agreed to attend additional training with one of the club's Level 3 instructors before flying the DG505 again. The CFI wrote an article for the club's monthly newsletter, reminding pilots to physically check that the dive brakes are properly locked when performing the pre-take-off checks.
Safety Advice
Unfamiliarity with type is most likely to cause problems during high workload situations. It is therefore importance that pilots understand that ‘new’ gliders take time to get to know. Sometimes differences can be minor, and familiarity comes easily. However, even simple processes, like locking the airbrakes, can be different between types. It is therefore important that pilots take the time to know and fully understand the function and location of all the controls and systems.
1-May-2022 WAGA
DG-500 Elan Orion
Aircraft Control
What Happened
The pilot was conducting a local private passenger flight, and had returned to the circuit after a flight of about 2 hours duration. During the final approach the pilot flared early, and the glider stalled onto the runway from about 1 metre. The tailwheel struck the runway first and just ahead of the mainwheel. The landing was observed by the Duty Instructor and several other pilots, who described the landing as being "heavy". The duty instructor, who is also Airworthiness inspector, noted that the glider ran out of energy while the main wheel was approximately one metre above the ground but it did not sustain any damage. The pilot believed they had too much airbrake applied after the flare, but the duty instructor was of the view that the round-out was started too high. The CFI has briefed one of the club's Level 3 instructors, who has agreed to spend some time with the pilot to assist with improving their landing technique and other aspects of their flying. It was noted by the CFI that while the pilot was current, they had only a few flights on type and had not flown this aircraft for several months.
8-May-2022 SAGA
DG-500 Elan Orion
Aircraft Control
What Happened
During the initial ground roll of an aerotow launch being flown by the student pilot, the starboard wing dropped to the ground. The flight crew heard a noticeable ‘bang’ as the wingtip struck the edge of a taxiway. The student then experienced problems controlling the aircraft, so the instructor assumed control. The flight continued with no further issues, but after landing the instructor noticed damage to, and excessive movement in, the winglet. The glider was grounded pending a detailed structural inspection.
Analysis
At this regional aerodrome it is usual for gliders to launch from the right-hand side of runway 31 on the 4m wide bitumen edge of the main unsealed runway. During launch the glider’s right wing overhangs the edge of the runway, and the take-off path crosses a taxiway to the north of RWY 05/23. The CFI reported that the soil around the bitumen moves due to changing moisture content, and at the time of this incident the soil was about a 20 to 30mm below the level of the bitumen. When the wing dropped to the ground, the wingtip wheel holder struck the edge of the bitumen and compressed against the wheel, and the shock caused the wingtip to flex that damaged the wingtip retaining pin. The bent retaining pin prevented the wing tip extension from easily being removed, but upon inspection it was revealed that the alignment pins and stub spar were undamaged. The level change along the edge of the runway and taxiways is a known issue, and the airfield maintenance team are constantly filling the areas and rolling the surface to keep the level change as small as possible. The CFI stated: “The key learning from this issue is the damage to the wingtip extension, was not obvious at first glance. The fact the force of the impact was sufficient to bend the wingtip wheel mounting frame indicated that further investigation was needed before returning the aircraft to the flight line.”
Safety Advice
A damaged wingtip security mechanism can lead to the winglet dislodging in flight, as SOAR report S-1600 attests. On 15 November 2019 at about 2000ft AGL, the wingtip securing mechanism of a Lak 17 sailplane failed, allowing the winglet to move forward and dislodge from the alignment pins. The winglet twisted in the airflow causing the aircraft to enter a spin that was not recoverable. The pilot only just managed to escape by parachute. Any significant wingtip strike during launch in an aircraft with detachable winglets should be treated seriously and whenever possible the flight should be abandoned. The aircraft should be thoroughly inspected by an approved inspector before being returned to service.
8-May-2022 NSWGA
FK Lightplanes FK9 Mk IV ELA
Runway Events
What Happened
A powered aircraft entered the runway and took off while the runway was occupied by a glider and tug preparing to launch.
Analysis
Operations at this regional aerodrome have been limited to a single runway (runway 05/23) for several months while runway 18/36 is reconstructed. The reconstruction has also closed the cross runway 09/27. Runway 05/23 is an asphalt surface 30 metres wide and 2040 metres long. When conditions are suitable, glider operations from taxiway B on runway 05/23 are common practice given that taxiway B is midway along the runway. Operating in this manner minimises the duration of runway occupation with the glider next to launch able to prepare outside of the runway strip, and the tow plane is able to land short and, where no aircraft are wishing to use the runway, roll through to conduct the next launch with minimal delay and impact on other users. Taxiway B has clear visibility to both the 05 and 23 thresholds and vice versa. On the day of the incident, and prior to the powered aircraft entering the runway, the glider ground crew made an entering runway call on the CTAF for an imminent glider launch. The glider was then pushed from the holding point at the runway strip edge onto runway 23 at taxiway B (mid runway taxiway). As the glider was turned and aligned on the runway centreline a powered aircraft called on the CTAF that it was also entering runway 23. The glider ground crew called the powered aircraft and confirmed that the glider was on the runway and would be launching in approximately 2 minutes. The powered aircraft was visible at the runway threshold from the glider launch point. The powered aircraft acknowledged and responded that it would be “out of the way”. As the ground crew removed the glider tail dolly and prepared the aerotow rope, the powered aircraft took off and overflew the glider/tug combination by an estimated 100-150 feet. During the subsequent investigation, the pilot of the powered aircraft stated that he knew the gliders were operating from about the mid length of runway 23. He advised that after broadcasting he was entering the operational runway from the threshold, about 1,000 metres behind the glider operation), he received a radio call from the gliding operation advising they would be taking off in about three minutes. The pilot of the powered aircraft could see the tug and glider, but due to the distance he believed they were positioned outside the runway and that he could take-off and be out of the way without interfering with the glider launch. As his aircraft is a taildragger the pilot did not see the gliding combination over the nose until he was airborne, at which point he judged the safest course was to continue the take-off. The pilot of the powered aircraft was surprised to see the glider was on the runway and not the grass. The gliding CFI advised that the position of the gliding operation was agreed by the aerodrome operations panel and local operators are aware. However, consideration will be given to including an entry in ERSA or issuing a NOTAM for the period the runway works are in progress.
Safety Advice
This incident highlights the hazard of non-standard operations, i.e. gliders operating from mid runway and at some distance from the threshold, and the critical importance of communications, especially what you say and how you say it. For further information on good communication, refer to the fourth booklet in the revised 'Safety behaviours: human factors for pilots’ kit available from the CASA website: https://bit.ly/3gCsl0U
NOTE: When the runway strip is occupied by a glider tug 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 (Chapter 3 of the CASA Visual Flight Rules Guide and AIP ENR 5.5-2, paragraph 1.2.4 refer). Also, Pilots must comply with CASR 91.055 – ‘(Aircraft not to be operated in manner that creates a hazard’.
21-May-2022 NSWGA
Astir CS
Landing
gear/Indication
What Happened
Following a winch launch to about 1600ft AGL, the pilot retracted the undercarriage and flew towards a nearby ridge. After several minutes ridge soaring, the pilot returned to the circuit. While configuring the aircraft for landing the pilot found the undercarriage handle was jammed and could not be moved despite several attempts. The pilot made a radio call informing the ground crew of the problem and conducted a safe landing with the undercarriage retracted. The aircraft suffered only minor abrasions to the bottom of the fuselage. Inspection identified the rear edge of the mudguard (which is part of the undercarriage system) had latched onto a lapped joint in the wheel bay liner. This is a known issue with this type and is usually the result of the pilot raising the undercarriage with excessive force. The proposed solution is to add about 10mm to the leading edge of the aft section of liner to ensure the overlap is always maintained.
22-May-2022 SAGA
ask21
Aircraft Control
What Happened
The elderly pilot, who had been driving the winch all day, decided the fly the glider back to the hangar at the end of flying operations. During final approach the pilot increased airspeed to 80 knots and flew along the length of the runway at between 10 to 15 feet. Towards the end of the strip run and while the glider was still flying at 70 knots, the plot opened the airbrakes slightly. While the pilot was prepared for a change in pitch, the glider immediately dropped, and the mainwheel struck the runway at speed. The glider rebounded, touched down again and the pilot held the glider in the flare attitude. The glider then touched down heavily and rolled to a stop within about 70 meters. The glider was withdrawn from service pending a hard landing inspection.
Analysis
The CFI found that mishandled recovery from the initial bounce led to pilot-induced oscillations, with around 4-5 touchdowns occurring. The Club’s Instructors’ Panel observed that the pilot’s skill set is gradually declining with age, and that the pilot was well behind the action during the bounced landing. The pilot has accepted this observation and will participate in some remedial training and more frequent check flights. It is unlikely the pilot will attempt another ground-effect run.
Safety Advice
As we grow older our body has a tendency to "slow down" in reaction time, and our cognitive abilities also decline with aging of brain cells and their billions of complex interconnections. Every day we perform hundreds of cognitive tasks but are mostly unaware of the effort involved. Cognitive deficiencies are insidious, have a substantial negative impact on performance and are hardest to identify when the pilot is performing routine activities. One reason symptoms go unnoticed is that with practice and routine, the brain adjusts to mild to moderate cognitive impairment. In other words, normal activities can mask the severity of the deficiency. However, if the pilot’s routine is interrupted by an urgent or stressful situation, then the extent of cognitive impairment may become more evident. It is well known that flight experience can compensate to some degree for age-related declines in cognitive function and that overlearned complex tasks such as piloting are less susceptible to age-related deterioration than abilities to perform in novel situations. Notwithstanding, recency of experience can have a dramatic effect on overall airmanship, regardless of age. It is known that older pilots who have long breaks between flying take longer to regain their proficiency. Older pilots should fly regularly and participate more frequently in recurrent training (e.g., flight reviews). However, when physical deterioration outstrips piloting skills - it's time to quit!
12-Jun-2022 GQ
SZD-50-3 Puchacz
Terrain Collisions
What Happened
During the final approach the student mishandled the flare and recovery, and the instructor was too late in taking over and could not prevent the left wing from contacting the ground heavily and then impacting a runway light. The glider’s port wingtip was substantially damaged.
Analysis
The pre-solo student was undertaking the first of four planned pre-solo assessment flights. The student performed well during the launch and brief soaring flight and flew a normal circuit. The student established the glider on a stabilised final approach using a half-airbrake setting. In response to overshooting the aiming point the student opened the air brakes further, which resulted in a high rate of descent. The student over rotated into the flare and the glider ballooned. The student corrected by closing the airbrakes and pitching forward on the stick, and then opened the airbrakes again. The instructor called taking over but this was not heard by the student who remained on the controls. The instructor found the controls were difficult to move and could not prevent the left wing striking the ground heavily and then colliding with a runway light. The student had not flown for two months and the instructor, with hindsight, recognised that they should have given the student more time to refamiliarise themselves before introducing the pressure of an assessment flight.
Safety Advice
The most common instructing accident is 'instructor failed to take-over in time'. These accidents usually involve the trainee responding in an unforeseen way or failing to respond at all (e.g. not rounding out). Given that the overall idea is to let the trainee do as much as possible within their level of skill the instructor should never wait until the last moment - which can rapidly become too late before responding to a situation that is going awry. This is particularly true of any manoeuvres close to the ground. Instructors also need to guard themselves against unexpected reactions during the critical stages of flight by adopting a defensive posture, i.e. having their hands and feet ready to take control.
23-Jun-2022 NSWGA
HK 36 R
Runway incursion
What Happened
While a motor glider was on final approach to RWY 36, the Duty Instructor observed two persons walking down the middle of the runway towards the launch point. The Duty Instructor made a radio call to inform the motor glider pilot of the runway incursion and suggested he land on RWY 35. The motor glider pilot diverted onto runway 35 and landed without further incident.
Analysis
The motor glider pilot was flying a glider approach and not under power. The pedestrians were a visiting level 2 instructor and former club member, and an ab-initio student. The instructor had landed earlier after a very brief solo flight and decided to walk back to the launch point after leaving the aircraft at the hanger complex. The Duty Instructor noted the pedestrians when difficult to see in the late afternoon lighting conditions as their clothing blended into the surrounding grass and trees. The motor glider pilot stated that he did not see the pedestrians during the approach for the same reasons, and that he may not have seen them at all had the Duty instructor not made the radio call. The motor glider pilot stated the pedestrians were directly in his approach path and he very easily could have hit them. The visiting instructor admitted he was not paying attention and did not consider the dangers of walking down the middle of an active runway, nor the issue of visibility late in the afternoon. The ab-initio student stated he was unaware of the approaching motor glider, that he was following the lead of the instructor, and had not thought of the dangers of walking in the middle of an active runway. The pedestrians were counselled and all personnel on the airfield were reminded of the dangers of being on an active runway, and of the expectation that all personnel returning to the launch point must use the adjacent dirt road.
Safety Advice
A runway incursion happens when an aircraft comes close to collision with another aircraft, vehicle, or person within the take-off and landing area. In most cases, runway incursions happen due to human errors. In this case, the pedestrians’ lack of situational awareness and failure to recognise the risks of walking down the middle of an operational runway were the key causal factors. Situational awareness is the understanding of your environment, which involves information processing and sound decision-making. No one has perfect situational awareness, but it is vital that one thinks ahead, and monitors, detects and recognises those factors that pose a risk. Above all, avoid complacency.
10-Jul-2022 NSWGA
ASK 21 Mi
Birdstrike
What Happened
At about 500 ft on climb out, the pilot of the glider under tow observed an eagle fly straight towards the tug. The tug pilot saw the bird approaching and made a sharp left turn. The bird passed the tug but was caught in the slipstream. The glider pilot reported “an uncontrolled rotating ball of feathers came straight at the glider hitting the port wing about five feet out from the fuselage. I requested a right turn back towards the airfield and released for a straight in landing on RWY 03”. After landing a maintenance inspector examined the port wing and found the bird had struck the top of the leading edge and slid over the wing leaving scratches and slight residue, but there was no structural damage, and the aircraft was returned to service.
4-Sep-2021 GQ
Piper PA-25-235
weak link
What Happened
The tow pilot identified that the TOST weak link fitted to the tow rope had been incorrectly assembled and was double the rated strength.
Analysis
The tow pilot was inspecting the weak link and tow rope for serviceability as part of the Daily Inspection before the day’s operation when he noticed there were two equal link inserts fitted to the weak link. Both inserts had round holes rather than one having an elongated hole, which effectively doubled the breaking load (see photograph). There were no records of when the weak link had been changed, but it is believed many aerotows had been performed in this configuration. The tow pilot replaced the weak link and ensured the correct inserts were fitted.
Safety Advice
The TOST weak link system is an engineered and approved system which prevents aircraft overloading in winch, autotow and aerotow operations. By using this system, the operator is assured of maintaining the manufacturer's airworthiness requirements for protection of both tow plane and sailplane. The GFA recommends clubs and operators use the TOST reserve insert and sleeved weak link system. This uses two weak links in parallel protected by a steel sleeve. Both weak links have attachment holes at each end and are 8 mm in length. The reserve has oval attachment holes and carries no load in normal operations. If the load exceeds the rating, the weak link will fail and the reserve link will take up the load. If the load is more than a momentary jolt both weak links will fail. For further information, refer to Operations Advice Notice (OAN) 01/13 ‘Weak Links – Selection, Application, Safety and Testing of Glider Weak Links’.
10-Sep-2021 SAGA
ASK21
terrain collision
What Happened
Under investigation. While landing with a crosswind and during the final approach, the glider drifted off the runway centreline. The instructor prompted the student to regain the centreline by turning slightly into wind, but the aircraft touched down near the side of the runway with the port wing over the ungraded verge. The port wing contacted the ground and tall grass caused the glider to rotate to the left through 130 degrees and skid to a stop about 3 metres off the runway. The glider suffered substantial damage to the port wing.
16-Sep-2021 SAGA
Ventus 2cxM
terrain collision
What Happened
Under investigation. The pilot conducted a low-level finish manoeuvre upon returning to the circuit from a cross-country flight but did not change his planned approach when it became obvious a modified circuit may be appropriate. As a consequence, the pilot conducted a very low turn onto final approach, following which a severe ground loop occurred. The glider was substantially damaged.
26-Sep-2021 SAGA
DG-1000S
technical
What Happened
Under investigation. One of the port airbrake panel mounting bolts was found to be not in safety. The aircraft had been subject of 29 Daily inspections since the last annual inspection.
9-Oct-2021 GQ
Standard Cirrus
Aircraft control
What Happened
The pilot left the decision to break off the flight late to search for thermals in the vicinity of the aerodrome before entering circuit and did not configure the aircraft for landing. Once in circuit, the pilot became distracted by radio calls and adjusting for lift and forgot to conduct the pre-landing checklist.
Analysis
The pilot advised that while planning to land he decided to see if there was any lift at a known location near the circuit joining area. He considered lowing the undercarriage at that point but decided to wait until joining the circuit to minimise drag. When arriving at the location he could not find any lift and joined circuit at the normal height. During the downwind leg the glider flew into lift while the pilot was responding to a radio call from another glider pilot about likely thermal sources. The pilot considered taking a climb in this lift but chose not to because of possible conflict with other circuit traffic and instead modified his circuit to account for the increase I height. The radio call and modification to the circuit led to the pilot omitting to conduct the pre-landing checklist, and the glider subsequently landed safely, albeit with the undercarriage retracted.
Safety Advice
Landing mishaps commonly occur to pilots who lack the discipline to break off the flight at an early stage, and who become overloaded in the circuit. Workload management can be eased by proper flight management, which includes attending to pre-landing tasks, like lowering the undercarriage, early rather than later in the circuit (OSB 01/14 'Circuit and Landing Advice' refers). Many similar accidents have had their genesis in pilots choosing not to lower the undercarriage until late in the flight in the mistaken belief that to do so would significantly reduce the glider’s performance by increasing the drag. While a lowered undercarriage adds to profile (or parasitic) drag, such drag increases with the square of the airspeed – so in most sailplanes the drag penalty of the lowered undercarriage is negligible up to normal cruising speeds.
20-Oct-2021 GQ
Standard Cirrus
terrain collision
What Happened
Under investigation. While outlanding, the pilot crowded their circuit and overshot the intended landing area. The glider touched down heavily in the following paddock that was upward sloping, and passed through a barbed wire fence before striking the hills hoist and coming to rest near the farmhouse.
23-Oct-2021 NSWGA
DG-1000S
Launch
What Happened
While demonstrating a double hook-up manoeuvre at approximately 1700' AGL, a bow developed in the rope and the weak link broke while manoeuvring to take-up the slack. The rope recoiled over the canopy and left wing, and the weak link struck and penetrated the left wing (see photograph below). The pilot under review flew a normal circuit and landed safely with the tow rope still tangled over the canopy and left wing.
Analysis
The sortie was the second flight of an instructor Flight Review, and the pilot under review had not flown since July 2021 due to the Covid-19 pandemic lockdown. On this flight the pilot under review was demonstrating a pre-planned double hook-up manoeuvre at approximately 1700' AGL. During the procedure the pilot positioned the glider approximately 45° to the left of and below the tug, whereupon he paused in this position awaiting acknowledgement from the tug pilot. No acknowledgement was forthcoming, so the pilot positioned the glider slightly further out. On this occasion the tug pilot gave the appropriate acknowledgement, and the glider was then manoeuvred back to the normal towing position. During this manoeuvre a bow developed in the rope that curled back level with the glider’s starboard wing leading edge. While the pilot was attempting to take out the slack, the rope suddenly became taught and the weak link at the tug end broke. The tow rope recoiled towards the glider and draped over the canopy and port wing, and a section of the weak link assembly struck and penetrated the port wing. The instructor under review released the rope but it did not fall away, so a gentle descent was made to circuit height. Following a normal circuit, a safe landing was made with the rope still draped over the glider.
Safety Advice
It is not uncommon for slack to develop in the rope during out-of-station manoeuvres and for the weak link to break when the rope comes back under tension. In situations involving a large bow in the rope it is recommended that pilots release the rope just before the slack is fully taken up to prevent breaking the weak link, and also to avoid potential control difficulties should the rope wrap itself around a control surface.
24-oct -2021 vsa
DG-1000S
technical
What Happened
Under investigation. The sortie was the post annual maintenance test flight. During the take-off behind the tug, and just after becoming airborne, the pilot flying heard a loud cracking noise from behind. The pilot released from tow and conducted a safe landing straight ahead on the runway. Upon exiting the glider the flight crew observed the wings "had a huge dihedral" (see photograph).
3-Nov -2021 nswga
js1 b
Terrain Collisions
What Happened
The sortie was the second flight after the annual inspection 2 inspection. For the first flight on the previous day the glider was unballasted. The pilot conducting a 350km cross country flight, and commenced final glide at 5050 ft QFE approximately 46 kms from the home airfield. The pilot reported encountering extensive sink, and opened the water ballast dump valves with about 25kms to run. At about 10kms inbound the pilot was on a crosswind leg at 600 ft AGL for the chosen outlanding paddock. The pilot deployed and attempted to start the sustainer jet engine, but it failed to start. The pilot then commenced a right-hand turn onto late downwind, intending to continue the turn onto final approach. The pilot lowered the undercarriage and selected landing flap but noticed the rate of descent was higher than normal. When approximately 100 metres from the boundary of the selected paddock, the pilot identified the glider was undershooting and, determined not to risk rolling through the wire fence, he steered the glider to the left.
During this manoeuvre the left winglet caught the ground, causing the glider to rotate through 180 degrees and travel backward to rest and retarded by the natural scrub vegetation which was about 2ft high. The pilot contacted the airfield to organise a retrieve crew, and then prepared for the de-rig. It was at this time the pilot noticed that the left wing was still full of water, and upon checking under the wing he found the drainage port was covered by a transparent adhesive patch, presumably applied during the annual inspection. The pilot stated that he had not noticed the patch during his daily inspection. The pilot believes that he may have been flying slightly cross-controlled due to the asymmetrical ballast configuration and that this resulted in a higher-than-normal rate of descent.
Occurrences & Incidents August - October 2020