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The Boeing B747 was under radar control by Sydney Approach (North). The aircraft had descended to 2000 feet and intercepted the Runway 16 localizer in preparation for an ILS approach to Sydney (Kingsford Smith) International Airport. The Piper PA28 was engaged in a solo navigation exercise from Bankstown Airport which is 16 km west of Sydney International. The exercise required the Piper to depart Bankstown tracking in a northerly direction along the Lane of Entry (LOE) outside controlled airspace (OCTA) while remaining below 2000 feet. The LOE abutts the western boundary of the Sydney Control Zone (CTR) and the Sydney Control Area (CTA).

The surface wind in the Sydney and Bankstown areas was light and variable the cloud base 3500 to 4000 feet and the visibility 10 km or more. The PA28 departed Runway 29 at Bankstown and the pilot identified and flew over the first aeronautical ground strobe light (at Clyde) marking the departure track in the LOE but was unable to sight the second light (at Carlingford). The pilot did not make good the required track of 007 degrees magnetic to follow the LOE but allowed the aircraft to fly on into the Sydney CTR on a north-easterly heading. The pilot subsequently recognised Macquarie University and then changed course to depart the Sydney CTR.

As the B747 was intercepting the glideslope at 2000 feet the Second Officer saw a light aircraft ahead at the same level. It was in the 12 30 relative position tracking generally towards the B747 and crossing from right to left. The Captain and First Officer of the B747 also sighted the light aircraft as it passed abeam to the left at an estimated 200 feet horizontally and at the same altitude. The B747 crew identified the aircraft as a PA28 but did not observe the rotating beacon on the PA28. The PA28 pilot first sighted the B747 as it passed abeam to the left. The Sydney Approach (North) controller first noticed a faint primary paint radar contact very close to the B747 at about the same time as the B747 crew reported the near miss. The radar return became stronger and recognisable as the aircraft turned to the North. At the time of the incident the PA28 pilot had a total of 110 hours flying experience. The pilot had flown northbound in the LOE on three previous occasions; twice dual and once solo. The last time being some 10 weeks before the incident. Prior to boarding the aircraft the pilot's flight plan was checked by an instructor but formal briefing on the particular navigation exercise or the LOE was not provided.

The procedure in place at the relevant flying organisation relied on the student to find an available instructor to provide flight plan checking and exercise briefings. No self-briefing aid eg video was available at the Bankstown Pilot Briefing Office for pilots to familiarise themselves with the features of the LOE. The PA28 pilot stated that after take-off on Runway 29 Centre at Bankstown the aircraft was climbed straight ahead to 1000 feet before commencing a right turn. The pilot then identified the Rosehill refinery and the first ground strobe light. The aircraft was then on a heading of about 013 degrees magnetic from Bankstown. After passing over the first ground strobe light the pilot was unable to find the next strobe light at Carlingford. Attempts to find the second light were made without reference to the aircraft heading and the pilot then became directionally disoriented. The position of the Carlingford light was correctly depicted on the current Visual Terminal Chart being used by the pilot. Eyewitness evidence indicates that the Carlingford strobe light was operating.

The PA28 was flown on headings well to the right of that required to maintain correct track from the first ground strobe light to the second one. This led to a penetration of the Sydney CTR and conflict with the inbound B747. Sydney Approach (North) was not able to detect the impending conflict as the PA28 was not transponding. It was not required to have an active transponder and there were no primary radar returns which was probably due to tangential fading. The PA28 was not displayed until the B747 and the PA28 were in close proximity and the PA28 changed heading. Sydney Approach Control (North) is not able to identify monitor or readily communicate directly with aircraft which stray into the Sydney CTR from the LOE. The rotating beacon of the PA28 was ineffective in giving the B747 crew early warning of conflicting traffic. The PA28 was sighted against a background of suburban housing presenting a nearly head-on aspect. None of the B747 crew recalled observing the PA28's rotating beacon. The B747 crew considered that the PA28 was sighted in sufficient time for avoiding action to have been taken had it have been warranted. Neither aircraft took avoiding action. The performance of the Sydney air traffic control radar was not a factor.


For CAA Central and NSW Offices.

Consideration should be given to the following

a. Establishment of facilities whereby ATC can identify monitor and communicate directly with all aircraft which enter the Sydney CTR and CTA from the Bankstown LOE without authorisation.

b. Revising the inbound and outbound tracks in the LOE so as to minimise the risk of traffic penetrating the Sydney CTR and CTA.

c. Installing a more effective visual guidance system in the Bankstown LOE then the present aeronautical ground strobe light facilities.

d. Amending the Sydney VTC so as to accurately show the relative positions of aeronautical ground lights and other significant land marks.

e. Ensuring that all unserviceable aeronautical ground lights are repaired within hours of the notification of failure.

f. Establishing a procedure which enables Sydney ATC to identify aircraft intentionally operating in R409 A&B.

g. Providing self-briefing facilities at the Bankstown pilot briefing office as a matter of urgency for pilots to study prior to operations through the LOE.

h. Considers a requirement for all Australian registered general aviation aircraft to be fitted with multiple rapid flashing omnidirectional white strobe lights.

i. Taking action to ensure that pilots undergoing navigation training are properly supervised and maintain a satisfactory level of proficiency in negotiating the Bankstown LOE.

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General details
Date: 08 January 1989 Investigation status: Completed 
Time: 10:54 CST  
 Investigation type: Occurrence Investigation 
 Occurrence type: Loss of separation 
Release date: 08 February 1989 Occurrence class: Airspace 
Report status: Final Occurrence category: Incident 
Aircraft 1 details
Aircraft manufacturer: Piper Aircraft Corp 
Aircraft model: PA-28-151 
Aircraft registration: VH-FZW 
Sector: Piston 
Damage to aircraft: Nil 
Departure point:BANKSTOWN NSW
Aircraft 2 details
Aircraft manufacturer: The Boeing Company 
Aircraft model: 747-238B 
Aircraft registration: VH-EBM 
Sector: Jet 
Damage to aircraft: Nil 
Departure point:PAPEETE,TAHITI
Destination:SYDNEY NSW
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Last update 21 March 2016