Desert Flower
20th May 2020, 06:25
https://www.atsb.gov.au/publications/investigation_reports/2018/aair/ao-2018-080/What happenedOn 8 December 2018, a Desert-Air Safaris Beech Aircraft Corporation B200, registered VH-ODI operated a charter flight from Adelaide Airport to Mount Gambier Airport, South Australia with a pilot and seven passengers on board. One of the passengers held a commercial pilot licence and acted in an observer role from the right flight deck seat, but was not a member of the flight crew.
During the landing at Mount Gambier, the aircraft touched down with the landing gear retracted, with the propellers contacting the runway twice before the pilot initiated a go‑around. During the go-around, the left engine failed. The aircraft then landed without further incident.
What the ATSB foundThe ATSB found that upon reaching the minimum descent altitude for an approach to Runway 18 at Mount Gambier, the pilot had not yet obtained visual reference with the runway. He therefore commenced a go-around and retracted the landing gear. After retracting the landing gear, the pilot sighted the runway and decided to continue the approach, but inadvertently did not re-extend the landing gear.
During the continued approach, the pilot likely did not detect the retracted landing gear due to an expectation that it was already extended. This was possibly also compounded by the now‑increased workload.
Further, the ATSB found that the pilot’s decision to conduct a go-around after the wheels-up landing stemmed from his misunderstanding of the situation, and an assessment that a runway overrun was imminent.
Safety messageThis accident highlights the hazards of spontaneous decision-making, particularly during a high‑workload phase of flight in a complex aircraft. The Civil Aviation Safety Authority Resource booklet and video Decision Making (https://www.casa.gov.au/safety-management/book-page/resource-booklet-7-decision-making-and-video) provides the following tips to improve the quality of decision making, mitigate the possibility of errors and ensure a considered approach in resolving issues or problems:
You cannot improvise a good decision, you must prepare for it. You will make a better and timelier final decision if you have considered all options in advance. This is why good briefings are important.
Use decision-making aids—operational checklists—to ensure you have not forgotten anything important.
Always have reserve capacity for reacting to unexpected events.
Delegate your load to other team members (if multi-crew) when time is critical.
Keep the big picture in mind rather than focusing on one aspect of a problem.
During the landing at Mount Gambier, the aircraft touched down with the landing gear retracted, with the propellers contacting the runway twice before the pilot initiated a go‑around. During the go-around, the left engine failed. The aircraft then landed without further incident.
What the ATSB foundThe ATSB found that upon reaching the minimum descent altitude for an approach to Runway 18 at Mount Gambier, the pilot had not yet obtained visual reference with the runway. He therefore commenced a go-around and retracted the landing gear. After retracting the landing gear, the pilot sighted the runway and decided to continue the approach, but inadvertently did not re-extend the landing gear.
During the continued approach, the pilot likely did not detect the retracted landing gear due to an expectation that it was already extended. This was possibly also compounded by the now‑increased workload.
Further, the ATSB found that the pilot’s decision to conduct a go-around after the wheels-up landing stemmed from his misunderstanding of the situation, and an assessment that a runway overrun was imminent.
Safety messageThis accident highlights the hazards of spontaneous decision-making, particularly during a high‑workload phase of flight in a complex aircraft. The Civil Aviation Safety Authority Resource booklet and video Decision Making (https://www.casa.gov.au/safety-management/book-page/resource-booklet-7-decision-making-and-video) provides the following tips to improve the quality of decision making, mitigate the possibility of errors and ensure a considered approach in resolving issues or problems:
You cannot improvise a good decision, you must prepare for it. You will make a better and timelier final decision if you have considered all options in advance. This is why good briefings are important.
Use decision-making aids—operational checklists—to ensure you have not forgotten anything important.
Always have reserve capacity for reacting to unexpected events.
Delegate your load to other team members (if multi-crew) when time is critical.
Keep the big picture in mind rather than focusing on one aspect of a problem.