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.
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.