Aviation safety investigations & reports

Beech Aircraft Corp B200C, VH-AMB

Investigation number:
199804984
Status: Completed
Investigation completed

Summary

A Beech 200 was conducting an instrument flight rules (IFR) flight from Lismore to Glen Innes. The pilot gave a departure report to the Brisbane Sector 2 radar controller, and reported climbing through 3,500 ft. The controller advised that there were no other aircraft observed on the radar display. That departure report was also heard by the crew of an IFR Saab SF-340 that had just departed Casino on a flight to Williamtown, via Point Lookout. The Saab was climbing through 2,700 ft when the crew became aware that both aircraft were approximately 5 NM south-west of Lismore. The Saab crew descended to 2,500 ft, in order to establish 1,000 ft vertical separation from the Beech. The Saab crew subsequently saw the Beech pass from left to right, about 1 NM in front of their aircraft, as the Beech climbed through patches of cloud just under the main cloud base of 4,000 ft. The Beech pilot also saw the Saab pass below his aircraft.

Due to their proximity to each other, Lismore, Ballina and Casino aerodromes were encompassed by a non-standard Mandatory Broadcast Zone (MBZ), and used a common radio frequency of 124.2 MHz. The MBZ was approximately 60 NM long and 30 NM wide, and extended from the ground to 5,000 ft above ground level. The intent of the common frequency was to enable pilots operating at any of those aerodromes to hear transmissions from other pilots, so that they could coordinate operations in order to minimise the risk of conflict. Pilots were required to monitor the MBZ frequency when operating within the MBZ. They were also required to broadcast flight details when inbound to, taxiing at, and departing from an aerodrome within the MBZ.

The pilots of both aircraft had made the required broadcasts; however, neither received a response from any other aircraft. While taxiing at Lismore, the Beech pilot had monitored a transmission on the MBZ frequency from another pilot, but disregarded it as that aircraft was operating in the Ballina area. A recording device was installed at Lismore aerodrome to monitor aircraft using that facility. The majority of recorded transmissions from aircraft operating at Lismore were clear. Transmissions recorded from aircraft operating at Ballina and Casino were generally clipped or garbled, and more difficult to understand. The Saab crew later reported that pilots of aircraft on the ground at Lismore were unlikely to hear radio transmissions from aircraft on the ground at Casino, and vice versa.

At the time of the occurrence, both aircraft were operating in non-controlled Class G demonstration airspace. As part of that demonstration, modified procedures had been introduced, including the removal of the directed traffic information service previously provided by flight service, and the introduction of a radar information service provided by air traffic control. The provision of that service to pilots was dependent upon their aircraft being radar-identified. The secondary surveillance radar code from the Beech was not detected by the air traffic control radar system until it had climbed through an altitude of 3,300 ft. The Saab was not detected until it had climbed through approximately 3,000 ft.

Prior to the commencement of the demonstration, pilots of IFR aircraft were provided with traffic information on other IFR aircraft, in accordance with guidelines detailed in the Manual of Air Traffic Services and the Aeronautical Information Publication. Pilots operating an IFR flight from a non-controlled aerodrome were required to contact flight service by radio when taxiing. A flight service officer would then provide traffic information to pilots of conflicting aircraft that were not on the MBZ frequency. Based on that procedure, the Saab crew and Beech pilot would not have been provided with mutual traffic information, as they were both operating on the MBZ frequency at about the same time. However, traffic information was required to be passed to pilots of IFR aircraft climbing or descending through the level of another conflicting IFR aircraft. The overriding intent of the traffic information service was to issue such information if there was any doubt regarding the possibility of a confliction.

The Beech pilot had requested radar service information from air traffic control while taxiing at Lismore. The controller issued the pilot with a secondary surveillance code for the flight and advised that a radar information service would be provided when the aircraft was identified on radar, and that there were no other aircraft observed in the area.

Both aircraft were fitted with dual very high frequency (VHF) radio transmitters and receivers. The pilots were monitoring the MBZ frequency on one receiver while also monitoring the air traffic control frequency on the second receiver, in preparation for requesting a clearance to enter Class E controlled airspace at 8,500 ft. The Beech pilot stated that he normally would not have monitored the air traffic control frequency until passing 4,000 ft, but decided to contact the controller early to request the radar information service. Prior to the commencement of the demonstration period, pilots would normally have simultaneously monitored the MBZ and flight service area frequencies to assist in maintaining their situational awareness during the departure phase.

Analysis

The pilots of both aircraft were reliant on mandatory radio broadcasts to gain an awareness of other traffic operating within the confines of the MBZ. It is possible that they had simultaneously broadcast their respective taxi reports, thus blocking each others transmissions. However, it is more likely that radio transmissions were inhibited by terrain shielding, resulting in neither crew being aware of the other aircraft while they taxied and departed. The demonstration procedures created a situation where pilots had one opportunity to become aware of other traffic. If they missed an MBZ broadcast, there was no other formal procedure to provide that information.

If a directed traffic information service had been in place at the time of this occurrence, a potential confliction would have been recognised by a third party. Traffic information would have been provided to the Beech pilot and the Saab crew, even if the MBZ reporting procedures had failed. In the past, the directed traffic information service provided a level of redundancy to the aviation system that was not available during the Class G airspace demonstration.

The radar information service was limited by the inability of the radar to detect aircraft at relatively low altitudes in that area. Despite attempts to obtain a radar advisory service as soon as possible after departing Lismore, the Beech pilot was unable to obtain traffic information from the radar controller. Supplementation of the radar information service with a directed traffic information service in such an area of limited radar coverage, would have enhanced the situational awareness of the respective flight crews. Alternatively, the provision of radar coverage from ground level to the lower limit of controlled airspace, together with a radar information service for taxiing aircraft, would have also minimised the potential for confliction.

A conflict was ultimately avoided because the pilots were using the air traffic control frequency. This was despite the fact that both aircraft were still operating within the MBZ and monitoring the MBZ frequency.

Significant Factors

  1. The Beech pilot and the Saab crew did not hear the taxi or departure transmissions from each other on the MBZ frequency.
  2. The air traffic control radar was unable to detect aircraft at an altitude that would have enabled the controller to provide pilots with timely traffic information.

Safety Action

As a result of this and other occurrences, together with a systemic investigation of the Class G Airspace demonstration, the Bureau of Air Safety Investigation issued interim recommendation IR980253 to the Civil Aviation Safety Authority on 8 December 1998:

"The Bureau of Air Safety Investigation believes that the Class G Airspace Demonstration has served its purpose. In the light of the safety concerns identified by this investigation, BASI recommends that the Civil Aviation Safety Authority should now terminate the demonstration. The results of the demonstration should be subject to a comprehensive evaluation that specifically addresses the safety concerns identified by BASI.

The evaluation process should take into account the time required to:

  1. review and analyse the demonstration;
  2. refine the model where required and conduct a proper safety analysis; and
  3. provide a comprehensive and effective education and training program for any subsequent changes to Class G Airspace.

If this is not achieved, the deficiencies identified in this investigation are likely to be repeated, thereby seriously compromising the successful introduction of future changes to airspace including reintroduction of Class G Airspace incorporating Radar Information Service and National Advisory Frequency".

The Bureau of Air Safety Investigation simultaneously issued the following related interim recommendations to the Civil Aviation Safety Authority:

"IR980260
The Bureau of Air Safety Investigation recommends that the Civil Aviation Safety Authority review program management policies and procedures for current and proposed changes to the aviation system, in the light of experience gained from the present Class G Airspace Demonstration.

IR980261
The Bureau of Air Safety Investigation recommends that the Civil Aviation Safety Authority, the Department of Transport and Regional Services and Airservices Australia review and clarify the roles and responsibilities of the respective organisations in relation to the regulation, design and management of airspace to ensure the safety integrity of the aviation system".

The Bureau of Air Safety Investigation simultaneously issued IR980261 to the Department of Transport and Regional Services and Airservices Australia as IR980256 and IR980257 respectively.

Subsequently, the Minister for Transport and Regional Services announced in Parliament on 9 December 1998 that the demonstration would cease on 13 December 1998.

General details
Date: 10 November 1998   Investigation status: Completed  
Time: 1140 hours ESuT    
Location   (show map): 9 km SW Lismore, (NDB)    
State: New South Wales   Occurrence type: Separation issue  
Release date: 22 July 1999   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Aircraft 1 details

Aircraft 1 details
Aircraft manufacturer Beech Aircraft Corp  
Aircraft model 200  
Aircraft registration VH-AMB  
Serial number BL-131  
Type of operation Aerial Work  
Damage to aircraft Nil  
Departure point Lismmore, NSW  
Destination Glen Innes, NSW  

Aircraft 2 details

Aircraft 2 details
Aircraft manufacturer S.A.A.B. Aircraft Co  
Aircraft model 340  
Aircraft registration VH-SBA  
Type of operation Air Transport Low Capacity  
Damage to aircraft Nil  
Departure point Casino, NSW  
Departure time 1131 hours ESuT  
Destination Williamtown, NSW  
Last update 13 May 2014