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Occurences

All clubs and GFA members are urged to report all occurrences and incidents promptly, as and when they occur, using the GFA’s occurrence reporting portal at glidingaustralia.org/Log-In/log-in-soar.html. This is always best done while all details are fresh in everyone's mind.
You can read the full SOAR report at tinyurl.com/ltmko56
Reports noted 'Under investigation' are based on preliminary information received and may contain errors. Any errors in this summary will be corrected when the final report has been completed

1-Nov-2020 VSA
Grob G 103c Twin III SL - Piper PA-25-150
Rope/Rings Airframe Strike

What Happened
As the tow plane was taking-up the slack in the rope for an aerotow launch, the glider pilot observed the tow rope pass over the starboard wing. The glider pilot released the rope, but the rings caught in the aileron gap and the glider was pulled to a position 60-70 degrees off the runway heading before the tug was brought to a stop. An airworthiness inspection determined that the damage to the glider to be superficial and the glider returned to service.

Analysis
The incident occurred on the first flight of the day. The tow pilot taxied to the launch point on RWY 10 and parked adjacent to the runway leaving the tow rope across the runway. Subsequently, the glider was towed into the launch position a short distance downwind of the tug and ahead of the rope that was concealed in the grass. The glider pilot reported that during their pre-boarding checks she noticed the tow rope laterally about 2-3 meters and slightly behind the starboard wingtip. The pilot suspects she either considered the rope to be in an acceptable position or that there was more rope hidden in the grass that was not visible. The launch commenced shortly thereafter, and the tow pilot taxied to take up the slack. At this stage it was not apparent to either the glider pilot or ground crew that the tow rope was not properly positioned. As the slack was taken up the tow rope was drawn over the starboard wing which has downward curving wingtips. The wingman, who was holding the port wing, noticed the tow rope lying over the starboard wing and alerted the glider pilot. The glider pilot released the tow and radioed the tow pilot to stop. The tow pilot began to take-off and the glider pilot made another radio call to stop the launch. The tow pilot reported that he misinterpreted the first radio call as a signal to take off, as he had hesitated for some time while attempting to get a clear view of the wingman. The tow pilot applied power but a few seconds later he heard the glider pilot radio a second time to stop and brought the tow plane to a halt. However, before the tow plane could be stopped the tow rings caught in the starboard aileron slot and the glider was rotated about 60-70 degrees from runway heading.
Action Taken
The CFI interviewed the glider pilot, tow pilot and wingman on site immediately following the incident. The glider was inspected by the Technical Officer who determined the damage determined to be superficial and cleared the glider for flight. The club has since carried out the following actions to avoid a recurrence of this type of incident.
All pilots were reminded of the need to ensure that the tow rope is properly laid out forward of the glider before connecting the launch.
Tow pilots were reminded that radio calls should be regarded as unreliable and launches only commence based on standard ground crew signals.
All members were reminded of the importance of correct launch procedures and signals and particularly the procedure for stopping a launch.
Additional emphasis has been placed on the training of new members in ground crew duties.
A forward signaller is now employed for normal operations.

14-Nov-2020 NSWGA
Other Powerplant/Propulsion Issues
SZD-50-3 "Puchacz"- Piper PA-25
Under investigation. During the aerotow launch the tow plane accelerated slower than normal and once airborne the rate of climb was low.  At about 200' AGL the glider pilots noticed black smoke from the tow plane's exhaust, and at 250ft AGL the tow pilot signalled for the glider pilots to release. The glider pilots immediately released from tow and conducted and downwind landing on the reciprocal runway. The tow plane safely landed shortly afterwards. The tow pilot identified that he had conducted the launch with carburetor heat turned on. When flying in conditions that appear conducive to the development of carburettor ice, carburettor heat will be applied by the pilot at regular intervals as both a preventative measure against the formation of ice and a method to test whether or not carburettor ice is developing. If a normal drop in RPM or manifold pressure accompanies the application of carburettor heat, it is reasonably certain that ice is not forming in the carburettor. However, the use of carburettor heat will decrease engine performance by up to 15%, so pilots should beware of flying around with it continuously selected as the aircraft will use more fuel than planned for and this practice could potentially decrease the life of the engine due to an inappropriate mixture setting.

18-Nov-2020 VSA
Hard landing
SZD-50-3 "Puchacz"
Under investigation. During a flight review of a solo pilot, the instructor was too late to take control and prevent a heavy landing. The instructor conducted an inspection of the tail for damage and found none. The glider was then re-launched by aerotow, and during the ground roll the pilot under check dropped the right wing and took a while to get the wings level. At about 200ft AGL the flight crew identified they had no left aileron control. The command pilot informed the tow pilot of their difficulties and requested they be towed into position to conduct a right-hand circuit to the operational runway. The landing was completed without further incident and a post-flight inspection revealed nosewheel damage, a cracked front bulkhead with delamination from the skin, and interference with (and possible bending of) the aileron control circuit. This incident highlights the importance of always having an authorised inspector, who is familiar with the loads that the sailplane is likely to have been subjected to during a heavy landing, conduct a thorough inspection of all the likely damage points. For specific guidance on heavy landing inspections, refer to GFA Basic Sailplane Engineering, Chapter 25 https://tinyurl.com/yytzwo3d.

19-Nov-2020 waga
Other Powerplant/Propulsion Issues
Stemme S10-VT
Under investigation. During a ferry flight from South Australia to Western Australia and while over the Nullarbor, the engine began to run roughly. The vibration caused by the rough-running engine dislodged the nose probe, which hit the propeller. The probe smashed one blade of the propeller, chipped the other blade, and made a small hole in the wing. Fortunately, the glider was over Loongana WA airstrip, where a safe landing was made.

21-Nov-2020 NSWGA
Doors/Canopies
SZD-48-1 Jantar Std 2
During aerotow launch the glider climbed through sharp and relatively severe turbulence. At about 2000ft AGL the pilot released from tow, at which point the glider’s canopy departed, missing the airframe entirely. The pilot observed the canopy tumbling towards the ground and then joined circuit and landed without further incident.
The pilot reported the glider was being flown for the first time with the seat back one notch further forward to allow reach of a newly installed instrument (LX100). When the canopy was put onto the glider the pilot found his head was touching the canopy. The pilot readjusted the seating to move it down and forward to allow adequate clearance. The pre take-off checks were then resumed and take-off initiated.
The pilot believes he locked the canopy when it was placed on the glider and thought it curious that the canopy stayed in place during the turbulence in the early part of the launch. The pilot suspects that either the locking mechanism was disturbed when he adjusted the seating position, or it may have gradually unlocked in the turbulence. The pilot stated that he did not recommence his pre take-off check after it was interrupted, so he could not state with certainty that the canopy was secured prior to launch. In hindsight, the pilot suspects his past incident free experience had led him to become complacent regarding his ‘checks’ when flying solo, and was perhaps combined with reduced currency due the COVID-19 pandemic.

21-Nov-2020 NSWGA
Wheels up landing
JS1 B
The pilot was flying "hors concourse" at the NSW State competition. On the last day of competition an assigned area task had been set with a 15km finish circle around the home airfield. After rounding the final turnpoint the pilot realised he would need to lose height in order to land off a straight-in approach, so flew the latter part of the approach at 80 knots with the airbrakes extended. On nearing the airfield, the pilot made his flap and rim adjustments but forgot to lower the undercarriage. The glider landed on the grass runway with the wheel retracted.
The glider suffered only minor abrasions to the lower fuselage. This is not an uncommon incident at competitions where straight-in approaches are encouraged to minimise circuit congestion and potential conflicts. Under normal flying operations a pilot will conduct at least three legs of a circuit and will conduct a pre-landing check during the downwind leg. However, a straight-in approach off a racing finish is a departure from normal operating procedures that requires the pilot to amend their normal routine, especially in the conduct of checklists.  
It is also a time of high workload that can cause a pilot to become overloaded and goal fixated. Concentrating on only one thing while flying, such as how the approach is to be conducted, can be dangerous, leading to loss of situational awareness and control. It is for these reasons that pilots conducting straight-in approaches at competitions must plan for the landing well in advance and ensure that once the finish line has been crossed that they make the transition to landing pilot and properly configure the aircraft while maintaining situational awareness.

 

25-Nov-2020 NSWGA
Wheels up landing
LS 6-c
What Happened
After arriving at the home aerodrome in turbulent conditions during a storm, the pilot forgot to conduct a pre-landing check and did not identify that he had not configured the aircraft for landing. The aircraft touched down with the undercarriage retracted.

Analysis 
The pilot was flying in the Narromine Cup and had returned to Narromine aerodrome after a 3½ hour flight where he found localised storms and quickly changing weather conditions. The pilot intended to land and flew towards the circuit area between the rain showers where he experienced significant turbulence and sink. The pilot stated: “I was concerned about the power of the falling rain and the associated wind. My focus was to avoid the rain cells and get the glider into the circuit as I was losing height rapidly.” The pilot made a radio call to the ground operations and requested wind direction and preferred runway. Over the next few minutes, he was advised of 2 different wind directions and 2 different preferred Runways as the wind direction was changing ever few minutes. The pilot elected to land on RWY22 Grass and found he had to modify his circuit due to the strong sink. The pilot made a successful landing in turbulent conditions but touched down with the undercarriage retracted.

Safety Advice
Pilot workload varies, even during routine flights, from low to high and will rise in the event of abnormal weather conditions or aircraft malfunctions. During high workload, pilots are especially vulnerable to error and psychological issues such as task fixation. In this case, abnormal weather conditions, high workload and an element of stress resulted in the pilot omitting to complete his prelanding checks that would have alerted him to the undercarriage being retracted. The risk of error is higher in single-pilot operations where there is no co-pilot to assist with resource management. The task of managing threats and errors is difficult in single-pilot operations but can be improved if pilots conduct a Situation Awareness review after a period of high workload. For more information, refer to the document ‘Gliding – Threat and Error Management’ available from the GFA Documents Library.

6 Dec -2020 gq
Other Crew and Cabin Safety Issues
DG-1000S
What Happened
A training flight was being conducted with the student, following pre take off checks, take-off commenced uneventfully.  At approximately 200 ft AGL the instructor in the rear seat noticed the right-hand shoulder strap of the front seat harness was hanging loosely over the student’s shoulder. The instructor took control of the glider while the student fastened their harness.

Analysis
The instructor and student boarded the glider for the student’s second training flight on the day. The instructor listened to the student correctly verbalise his pre- and post- boarding checks in preparation for the aerotow launch. During the launch the instructor noticed the loose shoulder harness and asked the student to check if his harness was secure at which point the student found the harness was not secured at all. The student fastened the harness while the instructor had control of the aircraft.

Findings
The student did not secure the harness on entry to the glider. The student conducted the pre- and post-boarding components of their pre take-off checks but failed to physically confirm that his harness was secured. The harness type in this glider is four point with a central buckle which is turned to release. The instructor confirmed that there was no noticeable distraction while they prepared for the launch. The student had flown in this particular aircraft on approximately ten previous occasions.

Causal factors 
The student stated that he must have checked the parachute harness and not his seat harness while conducting the pre take-off check. The instructor cannot visually see that the harness has been secured from the rear seat. The student had only completed 10 training flights at the time of the incident and is relatively inexperienced and still getting familiar with boarding and pre-launch procedures.  

Safety Advice
On boarding a glider, the crew should always secure their harness as a first priority. Instructors might consider visually checking the security of the student’s harness before boarding during initial training flights until the student has developed this habit. When checking the ‘Harness’ during the post-boarding component of the pre take-off checks, the pilot must visually look at the harness buckle and apply pressure against the straps to confirm it is tight and secure. This incident serves as a reminder to all pilots of the importance of completing checklists in a thorough and methodical.

11 Dec -2020 VSA
Aircraft Separation
Pik-20 - Piper PA-28-161

Occurences 1
What Happened
The pilot of a Piper PA-28 reported passing close to a glider approximately 35NM WSW of Wagga Wagga at 6000ft in Class G airspace while flying on a converging heading. 
What Happened
The pilot of a Piper PA-28 reported passing close to a glider approximately 35NM WSW of Wagga Wagga at 6000ft in Class G airspace while flying on a converging heading. 

 

Analysis
The Piper PA-28 crew were on a closed-circuit training flight from Wagga Wagga, with waypoints being Albury and Narrandera. The glider pilot was flying a 340km closed-circuit task originating from Tocumwal, with turn points being Corowa and The Rock. At about 14:58 local time the Piper PA-28, on a heading to Narrandera, and glider, on a heading to Tocumwal, passed within proximity of each other. Flight data logs for both aircraft were made available for review. The glider pilot carried a ‘NANO’ flight recorder that features an integrated 66-channel GPS receiver, built-in antenna and built-in battery. Flight data, such as GPS derived time, position and altitude, are stored directly in IGC format and are downloadable through a USB connection. The unit was set to record data points at two-second intervals. The track from the PA-28 was derived from Flight Radar 24. Altitude was derived from the ADS-B unit that was set to standard pressure (1013.2 HPa). The Area QNH pressure difference on the day was about 9Hpa, or about 270ft. At the time of the Airprox event, the glider was flying in the cruise at about 70 knots on a heading of 247 degrees at about 5,800ft, having been in the glide and slowly descending from 6,000ft. The PA 28 was in the cruise at about 98 knots on a heading of about 345 degrees at about 6,000ft. Analysis of the flight logs, coupled with the statements from the pilots, revealed the glider passed right to left of the PA-28 about 200ft below and 0.45NMs to the left of PA-28. The glider pilot stated that he did not see the PA-28 approaching from the left and said that at that time his focus was likely to be on threats in front, above and below, and at least 60 degrees either side. He further stated: “I would like to think that I try to keep a good lookout at all times, however it is impossible to be looking everywhere at every second of a flight.” The PA-28 command pilot stated that the glider passed within an estimated few hundred feet under his aircraft, and that the crew had not seen the glider coming. He stated, “The glider passed under the right wing to the left and continued west. We were maintaining A060. We contacted Melbourne Centre to report the glider.”
Safety Advice
In this case CAR 162 requires that when two aircraft are on converging headings at approximately the same height, the aircraft that has the other on its right (i.e the PA-28) must give way. In addition, power-driven heavier-than-air aircraft must give way to gliders. However, this rule relies on the principle of see-and-avoid. By itself, the concept of ‘see-and-avoid’ is far from reliable. It is important that pilots apply the principles of ‘see-and-avoid’ in conjunction with an active listening watch. Research has shown the effectiveness of a search for other traffic is eight times greater under alerted circumstances than when un-alerted. However, pilots should be mindful that transmission of information by radio does not guarantee receipt and complete understanding of the information. Without understanding and confirmation of the transmitted information, the potential for alerted see-and-avoid is reduced to the less safe situation of un-alerted see-and-avoid. Although glider pilots are not required to monitor the Area Frequency in Class G airspace, if a radio with dual frequency monitoring is fitted the pilot should monitor the area frequency to enhance situational awareness. The following publications provide some useful information on the see-and-avoid principles:
ATSB publication - Limitations of the see-and-avoid principle (1991)
ATSB publication - Safety in the vicinity of non-towered aerodromes (2010) AR-2008-044(2)
Civil Aviation Advisory Publication – CAAP 166-01 Operations in the vicinity of non-controlled aerodromes
Civil Aviation Regulations 1988, CAR 166 – Radio broadcasting by pilots overflying non-designated, non-controlled aerodromes
Civil Aviation Advisory Publication – CAAP 166-2 Pilots’ responsibility for collision avoidance in the vicinity of non-towered (non-controlled) aerodromes
Be heard, be seen, be safe - Radio procedures in non-controlled airspace
GFA Operational Safety Bulletin (OSB) 02/12 - Lookout for Glider Pilots
GFA Operational Safety Bulletin (OSB) 02/14 - See and Avoid for Glider Pilots
.

 

 

Occurrences & Incidents August - October 2020

 

GFA Occurrence Reports 2 Nov 2020 2

GFA Occurrence Reports 2 Nov 2020 3

 

All clubs and GFA members are urged to report all occurrences and incidents promptly, as and when they occur, using the GFA’s occurrence reporting portal at glidingaustralia.org/Log-In/log-in-soar.html. This is always best done while all details are fresh in everyone's mind.
You can read the full SOAR report Here
Reports noted 'Under investigation' are based on preliminary information received and may contain errors. Any errors in this summary will be corrected when the final report has been completed.

16-Aug-2020 GQ
Twin Astir
Flight controls
What Happened
During an Air Experience Flight, the Instructor noticed the rear control stick was progressively developing a loose feeling as though it was not properly connected to the control surfaces. The Instructor abandoned the flight and made a safe landing back on the aerodrome.
Analysis
The rear control column in the Twin Astir is detachable and held in place by a retaining nut. Inspection revealed the retaining nut had come loose. The glider had been returned to service two days previously having had an extensive refurbishment and Form 2 carried out at an approved maintenance facility.

 

Occurence 1

 

 

 

4-Sep-2020 GQ
Near collision
DG-1000S - Piper PA-25
What Happened
While on the downwind leg and Just prior to turning onto the base leg, the instructor in a DG1000 sailplane observed a Pawnee tow plane in a 45 degree right-hand bank and steep descent, approaching head on slightly below. The tow plane passed rapidly under the left-wing mid span. Vertical separation was estimated at less than 100ft when first sighted. 

Occurence 2

Analysis
Both aircraft carried data loggers and the data files were analysed. The flight traces disclosed the tow pilot joined a long descending non-standard right base for runway 05 immediately after the glider being towed released at 2000ft AGL south of the field. The DG-1000 sailplane was mid-downwind on a standard left-hand circuit for the operational runway 34. This placed the tow plane and sailplane on reciprocal headings with high closing speeds. As the sailplane passed abeam the landing area the tug descended below and between the airplane and runway with approximately 200m horizontal separation in a right-hand turn onto final for runway 05.
Findings
The tow pilot was unaware of this conflict, which was not brought to his attention until the incident was reported some 28 days after the incident. Therefore, his recollection of the actual sequence of events was not clear. The tow pilot could not recall if there was a particular reason for making a non-standard right-hand circuit onto runway 05 at the time and stated that his normal recovery preferences were to conform to the runway in use by the gliders; or to use the cross strip in the normal circuit direction where the wind favoured this runway. The tow pilot could not recall hearing a downwind call from the glider, nor did he recall seeing the sailplane in close proximity during the base to final turn; although he stated that his focus at that time would have been on his landing area. Both aircraft were fitted with flarm, but neither pilot can recall a collision alert at the time of the incident.
Causal Factors
l The tow pilot conducted a non-standard circuit onto the cross strip causing a conflict with traffic on downwind for the operational runway. 
l The launch prior to the incident was number 3 for a total of 27 launches all conducted by the same tow pilot, there may have been some perceived pressure on the tow pilot to expedite the recovery for the next launch
l The gliding instructor was distracted by managing the student radio calls and monitoring the student’s handling of the glider in the circuit. This may have contributed to missing the tow pilot’s circuit call and reducing the time spent visually scanning for other traffic.
Corrective action
The CFI and deputy CFI discussed with the tow pilot the importance of being predictable in the circuit and to use standard approaches unless there is an operational safety requirement to do otherwise, regardless of the workload pressures presented on the day. To reduce the workload on the tow pilot the Club has added to the morning briefing an assessment of the expected workload and where necessary a second tow pilot/tow plane is to be requested. Where a second pilot/tow plane is not available, delays in launching are to be expected.
Safety Advice
By itself, the concept of ‘see-and-avoid’ is far from reliable. It is important that pilots apply the principles of ‘see-and-avoid’ in conjunction with an active listening watch, and that pilots act predictably in the circuit. The following publications provide some useful information on the see-and-avoid principles and guidnace for pilots operating in the vicinity of non-controlled aerodromes:
l Limitations of the see-and-avoid principle (1991), available from the ATSB’s website at: 
l Safety in the vicinity of non-towered aerodromes (2010) AR-2008-044(2), available from the ATSB website.
l Operations in the vicinity of non-towered aerodromes (Civil Aviation Advisory Publication CAAP 166-1) available from the Civil Aviation Safety Authority website. 
l Pilots responsibility for collision avoidance in the vicinity of non-towered (non-controlled) aerodromes using the ‘see-and-avoid’ (Civil Aviation Advisory Publication CAAP 166-2), available from the Civil Aviation Safety Authority website.


7-Oct-2020 GQ
Terrain Collisions
Discus B
What Happened
While outlanding in a paddock near a farmhouse and at a height of about 30 ft, the starboard wing of the glider struck a power line that was strung between two poles over the fence-line of the paddock. The aircraft yawed to the right and descended quickly, touching down while skidding sideways. The aircraft came to rest facing approximately 70 degrees to the right of its original track. The pilot was uninjured, but the aircraft suffered damage to the leading edge of the right wing.

Occurence 3
Analysis
The pilot was competing in a Grand Prix event organised by the local club. On the final leg of the task and about 45kms from home, the pilot found himself below final glide and struggling to find lift. The pilot flew into an area of landable terrain with which he was familiar and arrived at about 1300ft AGL. The pilot identified a suitable outlanding paddock running north-south next to a farmhouse, and then used the available height to search for lift while remaining within reach of the identified paddock. The pilot spent the next 5 minutes maintaining or slowly losing height in weak lift to the West (downwind) of the paddock before breaking-off the flight for landing. The pilot descended upwind of the paddock and joined circuit on a left-hand base leg at about 500ft AGL (refer graphic 1).  The pilot joined final at about 400ft AGL and set an aiming point about one-third the way into the paddock, where the plough furrows were better aligned for landing.
As the glider crossed the boundary fence, and at a height of about 30ft AGL, the pilot noticed a wire pass over the canopy. The starboard wing then struck the wire, identified as a ‘Single Wire Earth Return’ powerline, that was strung between two poles about 40 metres inside and parallel to the paddock fence line (refer graphic 2 and photograph 1). Witness marks identify the wire struck the starboard wing about mid-span and slid down the leading edge until it cleared the wingtip. The impact caused the glider to yaw severely to the right and skid partially sideways onto the ground. Upon touchdown, the aircraft skidded sideways in the paddock and came to rest approximately 70 degrees to the right of its flight path. The pilot reported: “As to why it (the powerline) caught one wing, I can't say with certainty. I was toward the left-hand side of the paddock, as I'd assessed that had a better landing surface; the paddock was ploughed in a race-track pattern and that side seemed to have smoother furrows in the correct direction, which would mean that the bow of the wire would be higher to my left and lower to my right. But I may have had some small angle of bank on making a last second correction.” The glider was subsequently inspected for structural damage at an Approved Maintenance Organization and found to have only minor abrasions to the starboard wing leading edge and a cracked winglet.
Causal Factors
l The pilot did not identify the single wire crossing the paddock during the initial overflight or during the final approach.
l The single power cable was difficult to see and the supporting posts were obscured by trees or blended with the background. 
l The pilot did not conduct a downwind leg that may have provided an opportunity to identify the posts and wire.
l The pilot’s workload while landing in an unfamiliar place was high and likely increased stress levels.
Safety Advice 
Wire strikes are associated with low-level flight, and usually occur to gliders during landing. Operating in the low-level environment is inherently dangerous as there are a greater number of obstacles to avoid, there is significantly less time to regain control of an emergency situation, and there is a higher workload as pilots must negotiate the hazardous environment in addition to their normal workload.  In some cases the consequences of a wire-strike will be minor, as in the case of this accident. In less forgiving circumstances the wire may snare the aircraft, resulting in an accident that could cause the destruction of the aircraft and possible injury or death of the occupants. It is therefore vital that pilots who are operating into an unfamiliar landing area should remain vigilant and ensure that all the necessary precautions, such as flying a proper circuit while maintaining a good lookout for obstacles, are taken to reduce the risks associated with operating within the low level environment. However, despite reconnaissance of the proposed landing area and a constant lookout during flight, wires are often difficult to detect. The likelihood of a pilot seeing wires is determined by a number of factors including the number of wires, type of support structure, length of wire span, the environment and the background against which the pilot is viewing the wires. Remember also that SWER lines do not necessarily follow fence lines. They may cut the corners off paddocks, stretch across at some intermediate distance into the paddock or wander off completely at random. The best guidance is that, if you can see a homestead, assume that there will be a SWER line leading to it. You MUST find it before you attempt a landing. To identify powerline locations, visit the lookupandlive.com.au website. This site provides an interactive geospatial map that has been developed to display the Energex, Ergon Energy, Endeavour Energy, Essential Energy and Powerlink electricity networks, including sourced third-party information. 

 

Occurrences & Incidents March - July 2020

All clubs and GFA members are urged to report all occurrences and incidents promptly, as and when they occur, using the GFA’s occurrence reporting portal at glidingaustralia.org/Log-In/log-in-soar.html. This is always best done while all details are fresh in everyone's mind.
You can read the full SOAR report at tinyurl.com/ltmko56
Reports noted 'Under investigation' are based on preliminary information received and may contain errors. Any errors in this summary will be corrected when the final report has been completed.

8-Mar-2020 VSA
Aircraft Control - Hard landing
DG-500 Elan Orion

What Happened
At the end of a soaring flight the inexperienced pilot elected to land long to stop in front of the airfield access gate to the glider hangar. The pilot mishandled the airbrakes during the flare resulting in the gliderballooning, and the aircraft bounced a few times due to misapplication of the controls. The pilot deployed full airbrake to prevent the bounces, which caused the glider to strike the ground heavily on the nose and tailwheel simultaneously. The nosewheel fairing was damaged.
Analysis
The pilot attempted to extend to flight in order to land long by reducing the airbrake setting during the holdoff stage. The pilot did not conduct a minimum energy landing but allowed the glider to touch down while still at flying speed, and this resulted in the aircraft rebounding into the air. The pilot over corrected with elevator. i.e. pitched too far forward, and the aircraft struck the ground several more times before the glider came to rest.
Safety Advice
When small amounts of airbrake are used during the float, and the glider is allowed to touch down at speed,the pilot mut ensure that elevator control inputs are small. This is because the faster and cleaner the aircraft, the greater the pitch sensitivity. Recovery from a bounce should not be thought of in terms of 'control movements', but by reference to the glider's attitude and its position in relation to the ground. In other words, the pilot needs to recover by selecting an attitude which prevents any further climb. Bounces can be avoided by the pilot establishing the glider on the approach at the correct airspeed for the conditions using half or more airbrake. Pilots must endeavour to maintain the approach speed to roundout and aim to touch-down with low energy on the main-wheel and tailwheel simultaneously.

14-Mar-2020 GQ
Fuel Related - Exhaustion
Piper PA-25-235

Fuel Starvation

WHAT HAPPENED
During an aerotow, at around 1200ft AGL, the tow plane's engine stopped. The tow pilot waived-off the glider, which climbed away in a thermal, and landed the tow plane safely on the reciprocal runway at the aerodrome.
ANALYSIS
The tow pilot arrived at the field as the rostered tug pilot and found towing was already in progress. There was a large group of students for training, as well as single-seat aircraft needing launches. The tow pilot was not involved in the initial Daily Inspection but performed their own individual inspection prior to taking over the aircraft. The tow pilot assumed the aircraft had started the day with a full tank of fuel, and this belief was reinforced by the fuel gauge reading full and the flight record showing only one launch had been conducted.
LESSONS LEARNED
The tow pilot stated “The Pilot In Command has the sole responsibility to ensure there is no possibility of fuel starvation. I used methods to calculate remaining fuel that are inaccurate and unreliable, and ignored my feeling that the fuel must be low ... How do we stop it from happening again?. The human part will always be there, but the only way I believe to reduce the risk to the barest minimum is a proper fuel calculation, and write the tacho number down on the tug sheet as a ‘go or no go’ in your pre take-off check. Every tug pilot does one before each tow, even if it is abbreviated, and that check definitely includes fuel. It would also be a safety advantage for the club to install an accurate fuel meter on the bowser. I do not believe the complication of more rules or procedures will help, because those things are already in place, and I simply flew in ignorance.”
SAFETY MESSAGE
Fuel exhaustion is a situation where there is no more fuel onboard. Unlike Fuel Starvation there is nothing to be done about re-establishing the flow of fuel. Most of these occurrences lead to a forced landing. Nevertheless, an ATSB study from 2015 (see Further Reading) showed that fuel exhaustion results in fewer fatalities than fuel starvation. A possible reason for this could be that the pilots involved in fuel starvation scenarios consider more options than just a forced landing, sometimes leading to inappropriate choices and fatal outcomes. Exhaustion occurrences are normally either the result of a gross error in the fuelling of an aircraft before flight, or the result of a number of seemingly minor aspects of fuel planning and management during the flight.

14-Mar-2020 GQ
Flight controls
Astir CS Jeans

Hotelier

What Happened
During the Daily Inspection (DI) one of the aileron’s L'Hotellier coupling safety pins was incorrectly fitted and not securing the fitting as required. The DI was being conducted by a pilot undertaking their first inspection on type. Although the pilot had been briefed on the DI, they choose to seek confirmation of the L'Hotellier coupling system from an airworthiness inspector, as they found the connections for the ailerons and the airbrakes used two differing types of safety locking pins. The inspector confirmed that there were two different types of safety locking pins being used but noticed that the left aileron safety locking pin had been incorrectly fitted and was not in safety. They found the safety pin had not been inserted through the small hole at the top-rear of the locking tab as the designer intended but had been forced around the L'Hotellier coupling and merely clipped together. The safety pin was removed and found to have been bent out of shape. The safety pin was fixed and fitted through the small ‘locking’ hole, and its safety was independently confirmed. Following an independent control check, the maintenance release was signed, and the aircraft returned to service. The Club CFI noted that it was likely that the safety locking clip has been connected this way for a considerable length of time and that the aircraft had been flown in this configuration on several occasions. The CFI found that the aircraft had been signed out by several daily inspectors, which suggested a gap in their knowledge and training. The CFI sent an email to all members alerting them to this problem and some remedial training was conducted.
Safety Advice
The Daily Inspection is required to establish that the glider is fit for flight for that day’s flying operations and certify that in the Maintenance Release. A thorough Daily Inspection is essential to avoid incidents and accidents by finding faults with the glider before it flies. A person holding Daily Inspector authorisation therefore plays a frontline role in incident and accident prevention, and in continuing to keep the glider airworthy... Another good reference is the ‘Daily Inspector's Handbook’ that is available from the GFA Documents Library.overloaded.

 

15-Mar-2020 VSA
Rope/Rings Airframe Strike
ASK-21

Wheel rope
As the slack was being taken-up in the rope for an aerotow launch, the rope caught around a tuft of grass to the side of the runway. When the rope became taut, while still caught in the grass, the wing runner gave the “all out” command. As the tow plane accelerated the rope disengaged from the tuft of grass and became instantly slack. The glider over-ran the slack rope, which then got entangled with the nose wheel. The command pilot in the glider pulled the release but because the rope was wrapped around the front wheel and still connected to the tow plane, the glider continued forward. The command pilot applied the glider’s brake, which alerted the tow pilot to there being a problem and the launch was abandoned. The command pilot reported this “All happened VERY quickly”. This incident highlights the potential hazard of a rope overrun and highlights why a launch should not proceed if the tow rope becomes fouled. The Club’s CFI has raised awareness of this incident and aksed the instructors to ensure wing runners do not allow a launch to proceed if the rope is hindered or fouled.

21-Mar-2020 GQ
Collision with terrain
Ventus-3M

While on a cross-country flight an outlanding became inevitable and the pilot elected to conduct a selfretrieve. The engine failed to start, and during the subsequent outlanding the glider’s port wing contacted long grass causing the glider to ground loop.
Factual Information
The pilot was flying a cross-country sortie in his self-launching glider when conditions deteriorated and an outlanding was likely. At an estimated 1000ft AGL the pilot decided to start the engine to self-retrieve. The pilot reported the engine appeared to raise slower the usual and stated, “I may have been influenced in this feeling by the flashing battery light on the engine controller.” When the pilot tried to start the engine, it only clicked and did not turn over. The pilot then attempted to air start the engine by diving, even though this is not a procedure in the flight manual, but this was unsuccessful as the propeller failed to rotate. During this action the pilot did not have time to fully assess the suitability of paddocks for landing, and the paddock selected had a significant slope. While landing across the slope, and upon flaring for touch down in a wings level attitude, the uphill (port) wingtip caught in grass and the glider turned through 180 degrees.
Analysis
The aircraft is fitted with three LiFePO4 batteries – an engine battery in the nose, a battery in the tail and a battery behind the pilot’s seat. All batteries can power the avionics but only the engine battery will power the engine. The pilot reported that the low-battery light had been illuminating intermittently for some time, even though the battery voltage normally checked at over 13V, and he had already made arrangements to return the avionics controller (the prototype Sn1) to the manufacturer for checking and a software update...
Safety Advice
Batteries - LiFePO4 batteries feature a high discharging current, have a long cycle life and their voltage remains almost unchanged down to about an 80% discharged state. However, when the battery starts running out it drops rapidly. Pilots flying aircraft with these types of batteries need to be aware that a satisfactory voltage check does not guarantee there will be sufficient charge available during flight. Outlanding Incidents - A common reason for powered sailplane outlandings going awry is the pilot’s mindset of expecting the engine to start first time and not having any other plan. GFA training requires pilots to remain within glide range of suitable landing options, and to make the decision to break-off the flight at a sensible height above ground. For pilots of powered sailplanes, including sustainer types, the decision to break off the flight will usually be higher than that for pure gliders. The actual height will be governed by the complexity of the engine starting process and availability of suitable landing options should the engine fail to start. This then allows the pilot sufficient height and time to conduct a safe outlanding should things go

30-Apr-2020 GQ
Powerplant/Propulsion
PIK-20 E

Under investigation. Returning to Mareeba airport from cross country, the pilot started the engine to selfretrieve. The glider was climbed to 6,000ft, which was about 2,000ft above that needed for final glide. While reducing power to cool the engine before retracting the pilot felt a jolt through the airframe and noticed in the rear vision mirror that the propeller tips were broken. The pilot shut down the engine but was unable to open the engine bay doors to apply the propeller brake. With the propeller windmilling, the glide ratio deteriorated markedly and the aircraft rapidly lost height. Eventually the propeller stopped but the engine could not be retracted, and as the glider was pushing into wind it became obvious to the pilot that an outlanding would be needed. The pilot selected a grassed paddock and configured the glider for a landing with the engine extended. The aircraft touched down safely, but during the initial landing roll it struck a rock hidden in the grass and the undercarriage collapsed. The right wing then got caught on the grass and the glider performed a ground loop and came to rest 90 degrees to the direction of travel. The pilot was uninjured, but the glider suffered substantial damage including a broken tail boom. Upon exiting the glider, the pilot inspected the engine and found the mechanism for raising and retracting the engine had detached at the top pivot point where the bolt had fallen out. The pilot found the bolt retaining nut in the engine bay. When the bolt let go the engine pylon moved forward, allowing the propeller tips to contact the small hinged door cover. When the engine stopped, the airflow pushed the pylon back into the engine bay doors and prevented them from opening. The pilot reported that he found the bolt to be in the normal position during the Daily Inspection, but he did not check whether the nut was secure. The incident is being investigated by the Airworthiness Department.

10-Jul-2020 GQ
Other Weather Events
ASK 21 B


What happened
The Club was running an ab-initio training course and the weather bureau was predicating strong crosswinds in the afternoon that would have made it unsuitable for the training being conducted. A decision was made to commence operations at 06:30 to provide a window for training before conditions deteriorated. The first aerotow launch commenced on time and shortly after the glider became airborne the canopy began to fog over. The student, who was flying the glider, lost sight of the tow plane and inadvertently kited through its slipstream. The instructor took control at about 200ft AGL, released from tow and lowered the nose to attain safe speed near the ground. The instructor stated: “I had seen the windsock at the end of the strip go past and knew there was not enough strip to land ahead without going into the paddock at the end of the strip. A tractor had been seen in that paddock before launch so, unsure of its position, and not being able to see in front, only out the clear view, I made the decision to do a 180 degree turn and land in the paddock next to the strip. I commenced a shallow (no more than 20-degree bank) to the left and levelled out preparing to land in the paddock, when the student said she could see the club house. I then got a visual of the clubhouse and moved approximately 30 metres to the left and proceeded to land on runway 30 using the wheel brake to stop very short as I could still not see the other aircraft on the strip.” Following this flight, the instructor halted operations for an hour to allow the air to warm. The instructor noted the temperature of the air at the time was close to the dew point and there was fog about 10kms away.
Comment
A cold canopy that is exposed to slightly warmer or moist air can ‘fog up’. It is likely that the glider moved between different temperature layers as it climbed, and this may have led to a combination of temperatures suitable to allow fog.
Safety Advice
Whilst the above flight successfully turned through more than 180 degrees to land back on the airfield, such turns are not recommended below a height of 300 feet due to the risk of mishandling and low-level loss of control. Although it may be inconvenient, at low level it is safer to minimise the amount of manoeuvring by landing as straight ahead as possible unless terrain features dictate otherwise.g

 
26-Jul-2020 VSA
Aircraft Control
Piper PA-25 - Twin Astir

Aerotow


Under Investigation. During the aerotow launch and at a height of about 1500ft AGL the student
commenced an exercise to ‘box’ the tow plane’s wake (slipstream). The exercise had been pre-briefed with both the student and tow pilot. The student commenced the exercise from the low tow position and moved the glider quite quickly to the right. As the student began to transition into the high tow position while still out to the right of the slipstream, the tow pilot made a radio call to the crew in the glider advising the glider was displaced too far to the right and that he was having control difficulties – specifically that he was being pulled into a roll to the left. The instructor directed the student to return the glider to the normal low tow
position but in so doing the student allowed a significant bow to develop in the tow rope. The instructor took control of the glider but was unable to prevent the rope from quickly becoming taught, at which point the weak link broke. As the towrope was re-tensioned, the tow pilot reported that this caused an excessive yawing moment and the tow plane commenced an uncommanded roll to the left that he managed to counteract before it became too severe. Upon the weak link breaking, the rope sprang back and draped over the glider’s starboard wing. The student operated the glider’s release and the rope slip off the wing and fell to the ground. Both the tow plane and glider landed safely back on the airfield.