Friday, January 20, 2017

Boeing 717, VH-NXN, and Fokker F28 MK 0100, VH-NHF, Paraburdoo Airport, Western Australia, on October 05, 2016 • • Cessna 210, VH-UPN, Broome Airport, Western Australia, on October 10, 2016

QantasLink accident a result of pilot error 

Pilot error caused a QantasLink aircraft to clip the tail of another plane in the parking bay at Para­burdoo airport in Western Australia, delaying by one day the return to Perth of more than 100 mine workers, according to an investigation.

The latest Australian Transport Safety Bureau safety bulletin outlines the cause of this incident along with 11 others that it investigated last year.

The incident in October occurred because the Qantas Boeing 717 “deviated” from the taxi line in the bay when trying to make room for an incoming company plane.

On board the Qantas flight operated by Cobham Aviation were five crew and 115 passengers, most of them mine workers.

As the Qantas B717 began taxiing an engineer noticed that it “deviated from the painted taxi line” and the engineer tried to warn the captain that he was approaching a parked Fokker F100.

As the B717 approached the F100 the engineer gave a thumbs up to indicate that the tails were not in contact, but he assumed the B717 would taxi towards the runway. Instead, the B717 continued towards the F100 until the engineer ran towards the front of the aircraft and waved to the captain to stop. The captain braked heavily. The plane’s passengers had to disembark and be bussed to another airport before flying to Perth the following day.

The report found that one of the contributing factors was that a wing walker was not in place to ­assist the crew as they taxied.

A Qantas spokesman said that immediately after the incident the company had reminded pilots that they were required to follow taxi line markings at all times, except when under the guidance of an aircraft marshaller.

Qantas is talking to several stakeholders to expand the parking bay area at Paraburdoo.

The ATSB also revealed that a pilot who crash-landed a Cessna aircraft with three passengers on board in October might have failed to lower the landing gear because the pre-landing checklist had been completed “mentally”. The pilot was used to flying aircraft with fixed landing gear, an investigation found.

The key reason for the Cessna incident at Broome airport appears to be the failure to properly carry out pre-landing procedures.

“The pilot may have only completed the pre-landing checklist mentally without actually performing the required actions,” the report says. “The pilot’s roster required them to operate both the fixed landing gear Cessna 206 and the retractable landing gear Cessna 210. They found this difficult and felt that this may have contributed to the landing gear not being selected down prior to ­landing.”

However, the extreme heat that day also may have been a factor. Before the departure from Fitzroy Crossing, the pilot had flown from Broome and then spent about 40 minutes in 41C heat while waiting for late-arriving passengers to board the flight.

The ATSB report did not name the charter company or the pilot. This is consistent with its policy of wanting to “reduce the risk of smaller operators not reporting transport safety matters to the ATSB to avoid negative public inferences”, a spokesman said.

This policy was being reviewed to make it consistent with International Civil Aviation Organisation practice, he added.

A Civil Aviation Safety Authority spokesman said CASA was “satisfied all appropriate steps had been taken by the air operator in relation to the accident”.


Taxiing collision involving Boeing 717, VH-NXN, and Fokker F28 MK 0100, VH-NHF, Paraburdoo Airport, Western Australia, on October 05, 2016

On October 05,  2016, at about 1600 Western Standard Time, a Boeing 717 (B717) aircraft, registered VH-NXN (NXN), was being operated by Cobham Aviation Services as QantasLink, on a scheduled passenger flight from Paraburdoo Airport to Perth, Western Australia. On board were the captain, first officer, three cabin crewmembers and 115 passengers.

As the aircraft commenced taxiing, the captain sighted a company B717 aircraft about to land on runway 06. The captain quickly assessed that due to limited apron space at Paraburdoo, they needed to taxi behind a Network Aviation Fokker F28 MK 0100 (F100) aircraft, registered VH-NHF (NHF), which was parked on Bay 1, to allow the inbound B717 room to pass and taxi to Bay 2, which they had just vacated.

An engineer for Network Aviation, who had been working on the F100, observed NXN taxiing and became concerned about the proximity of its left wingtip to the tail of the parked F100. The engineer checked the clearance between its wingtip and tail of the F100, and gave the captain the signal to indicate the aircraft was clear.  The captain assumed therefore that the aircraft was clear and continued taxiing around the back of the F100, and turned the aircraft sharply to the right to leave enough room for the inbound B717 to taxi past.

The engineer had expected NXN to taxi towards the runway rather than turning around the back of the F100. The engineer immediately assessed that the horizontal stabilisers of the two aircraft may collide, and tried to signal the captain to stop, but was near the wing of the aircraft and no longer in the captain’s sight. The engineer ran towards the front of the aircraft and waved to the captain to stop. The captain braked heavily but did not feel a collision. Some hours later, it was determined that the horizontal stabiliser of NXN had slid under that of NHF, scraping the surface, and both aircraft sustained minor damage. The passengers and crew of NXN were not injured and no one was on board NHF.

Investigation number AO-2016-129:

Wheels up landing involving Cessna 210, VH-UPN, Broome Airport, Western Australia, on October 10,  2016

At 1433 Western Standard Time, on October 10 2016, a Cessna 210N aircraft, registered VH-UPN, departed Fitzroy Crossing, Western Australia (WA), for a passenger charter flight to Broome Airport, WA. On board were a pilot and three passengers.

At 1545, the aircraft approached 5 NM from Broome Airport, the pilot reported they levelled the aircraft at 1,000 ft and conducted the pre-landing checklist in accordance with operator procedures. The pre-landing checklist included selecting the landing gear down and confirming that the landing gear was extended. At about 1547, an individual located under the approach path to runway 28, about 800 m from the runway 28 threshold, observed a Cessna 210 on approach with the landing gear retracted.

At 1548, the aircraft touched down on runway 28 with the undercarriage retracted. No persons were injured in the incident and the aircraft sustained minor damage.

This incident provides a good example of the importance of checklist vigilance. Checklists are designed to ensure that flight crew properly configure the aircraft for any given phase of flight. Regular routine flying can lead to checklists, which are regularly completed, being conducted mentally without the required actions being completed. Vigilance is required to ensure that each checklist is completed correctly and in full.

The Flight Safety Australia article Those who won’t: avoiding gear-up landings includes valuable information to assist pilots in avoiding gear up landings.

Investigation number AO-2016-134:

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