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.
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.
