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.
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.
