[Peetwo]

Popinjay to the rescue on mustering risk mitigation?? - 

Via PJ media minions:

Cessna 172 aerodynamically stalled during sheep mustering


A Cessna 172 aerodynamically stalled while climbing out of a dive during mustering at Mulgathing Station in central South Australia on 27 June 2024, an ATSB investigation report details.

The aircraft was observed diving towards a group of sheep before pulling out of the dive, rolling to the left, and descending towards and impacting the ground.

The pilot, the sole occupant, was fatally injured, and the aircraft was destroyed.

No evidence indicated any issues with the aircraft’s engine, control systems or fuel prior to the accident, and incapacitation was unlikely given the pilot’s age and medical history, the investigation report notes.

“Witness reports and the position and condition of the wreckage were consistent with the aircraft aerodynamically stalling and entering a left spin at an altitude too low for recovery,” ATSB Chief Commissioner Angus Mitchell said.

The ATSB report notes the pilot held a commercial pilot licence and was endorsed for low-level flying, but not aerial mustering.

“The operator did not require an aerial mustering endorsement as the role was intended to only involve aerial spotting of livestock, to assist staff on the ground with mustering activities,” Mr Mitchell explained.

Aerial spotting activities only require a low-level endorsement, but the aircraft was observed diving towards what was believed to be a flock of sheep prior to the stall, which would constitute aerial mustering.

“This accident demonstrates the importance of pilots staying within the boundaries of their training and qualifications, to ensure an adequate margin of safety,” Mr Mitchell noted.

“It also highlights to pilots the importance of managing airspeed and bank angle to minimise the risk of an aerodynamic stall, particularly close to the ground.”

Since the accident, the station operator (also the aircraft owner and operator) has initiated a third‑party safety audit, and implemented a pilot mentoring program.

The operator is also preparing a manual for pilots on safe aerial spotting, and is undertaking a review of its safety and training standards for pilots, and its operations to ensure compliance with Civil Aviation Safety Authority regulations.

Separately, while it was unlikely it would have improved survivability in this accident, the pilot was found to not have been wearing the upper torso restraint of the lap-sash seatbelt during the accident flight.

“While not the case here, several ATSB investigations have found injuries to aircraft occupants may have been avoided, or made less severe, through the appropriate use of multipoint harnesses,” Mr Mitchell observed.

The appropriate fitment and use of seatbelts is included in the ATSB’s SafetyWatch initiative, Reducing the severity of injuries in accidents involving small aircraft.

Read the final report: Collision with terrain involving Cessna 172N, VH-SQO, near Mulgathing, South Australia, on 27 June 2024

Image credit: David Tanner

Publication Date: 01/05/2025

Plus, from this week's DTS Stewie Macleod: 

Runway overrun highlights importance of being prepared to go-around



A GA8 Airvan operating a scenic flight in Queensland’s Whitsunday region overran the runway after the pilot did not initiate a go‑around when the aircraft was above profile with a high airspeed during approach, an ATSB investigation report details.

The aircraft, operated by Wave Air and with a pilot and seven passengers on board, was landing at Whitsunday Airport at Shute Harbour at the conclusion of a scenic flight on 2 November 2024.

After overrunning the runway, the Airvan travelled briefly across grass before entering marshy ground and coming to a stop in a ditch. While the aircraft was substantially damaged, the pilot and passengers were uninjured.

Multiple onboard passenger videos aided the ATSB investigation in determining the aircraft’s flightpath and speed during the approach and landing.

“The aircraft’s approach was above profile with a high airspeed,” Director Transport Safety Stuart Macleod explained.
“Subsequently, the landing was beyond the planned touchdown point.”

The report details that the aircraft passed over the displaced threshold of the runway at approximately 100 ft AGL. The pilot commenced the flare about 300 m beyond the displaced threshold, at an airspeed of approximately 90 kt. The aircraft then floated for about 640 m before touching down at a groundspeed of 65 kt with 370 m of runway remaining. “While landing beyond the planned touchdown point, there was adequate landing distance remaining, however the pilot did not apply sufficient braking to stop the aircraft departing the runway.”

The investigation determined the pilot had an incorrect understanding of the required approach speed. It also found that the pilot’s initial training was not fully completed, and that Wave Air’s training, supervision and checking flights did not identify the pilot’s approach speed was routinely excessive.

“For pilots, this accident should demonstrate the importance of accurate knowledge of your aircraft’s reference speeds, and always being prepared to promptly execute a go‑around if an approach for landing does not proceed as expected,” Mr Macleod noted.

“In addition, routinely practicing go‑arounds will ensure the manoeuvre can be performed safely when needed.”

While not determined to have contributed to the accident, the investigation also found Wave Air’s weight and balance system used an incorrect figure to calculate the aircraft’s centre of gravity, and passengers were not weighed in accordance with the operator’s procedures.

Additionally, it was found the operator’s stabilised approach criteria included a decision height which was too low.

Since the accident Wave Air has taken several safety actions including updating its training and checking manual, appointing a new head of training and checking, updating pilot training, reviewing procedures and errors in the weight and balance system, and revising its stabilised approach criteria.

Read the final report: Runway excursion involving GippsAero GA8, VH-IDM, Whitsunday Airport (Shute Harbour), Queensland on 2 November 2024

Publication Date: 07/05/2025

Finally, back to PJ the Oz aviation safety guru... 

A330 engine malfunction incident detailed in ATSB preliminary report



The ATSB has released a preliminary report detailing an engine malfunction incident during a Qantas A330 passenger flight between Los Angeles and Brisbane on 4 December 2024.

The preliminary report summarises evidence gathered so far in the ATSB’s ongoing investigation. It does not contain analysis or findings, which will be published at the conclusion of the investigation.

The preliminary report notes that, while the Airbus A330‑200 was cruising at about 34,000 ft after departing Los Angeles, the flight crew received a passenger report of sparks emanating from the right engine observed during the climb.

After conducting a number of checks and considering alternate airports, the flight crew opted for a return to Los Angeles, and descended the aircraft to 31,000 ft to reduce load on the engine.

By the time the aircraft reached this altitude, the intermittent sparks were observed to have stopped. 

“Later, as the aircraft was descending to land in Los Angeles, three loud bangs were heard, and there was a right engine compressor stall indication,” ATSB Chief Commissioner Angus Mitchell said.

“In response, the flight crew operated the engine at idle for the rest of the descent and landing.”

A post-flight inspection of the right engine identified a missing high-pressure compressor blade that had separated at its root, another high-pressure compressor blade fractured about half-way up, and damage to the tips of several other blades. 

A variable stator vane was also found to be out of alignment, and there was metal debris in the engine’s exhaust.
The aircraft was subsequently grounded, and the right engine replaced.

The preliminary report details that, on the aircraft’s previous flight into Los Angeles, the flight crew had observed a high N2* vibration advisory. 

During the turnaround in Los Angeles, two maintenance engineers troubleshooted the N2 vibration issue, during which they observed particles in the right engine exhaust.

“The ATSB’s ongoing investigation is considering the communications between involved personnel during this troubleshooting, including communications between staff in Los Angeles and at the Qantas maintenance operation centre in Sydney,” Mr Mitchell said.

The troubleshooting culminated in the aircraft being released to service with its N2 vibration sensor inoperative in line with minimum equipment list (MEL) requirements, meaning N2 vibration readings were not available to the flight crew on the incident flight.

“Flight crew for the incident flight told the ATSB they were not aware that particles had been observed during the examination prior to their flight,” Mr Mitchell noted.

As well as the communications and maintenance during the turnaround in Los Angeles, the ATSB’s ongoing investigation will examine the recorded data, maintenance procedures and records, and the outcomes of the material failure analysis being conducted by GE Aerospace on relevant components of the engine.

A final report will be released at the conclusion of the investigation, including findings, and any identified safety issues.

“Should a critical safety issue be identified during the course of the investigation, the ATSB will notify relevant parties immediately so appropriate and timely safety action can be taken,” Mr Mitchell concluded.

* N2 refers to the rotational speed of a jet engine’s high-speed spool, which consists of the high-pressure compressor and the high‑pressure turbine connected by a concentric shaft.

Read the preliminary report: Engine malfunction involving Airbus A330‑202, VH‑EBQ, 1,370 km west-south-west of Los Angeles International Airport, United States of America, on 4 December 2024

Publication Date: 08/05/2025

MTF...P2