Jump to Content

Sequence of events

The Short Bros SD 3-60-300 (Shorts) was being radar vectored by air traffic control for an instrument landing system (ILS) approach to runway 15 at Cairns.

The weather conditions were fluctuating about the landing minima with low cloud and rain passing through the local area in general "stream" conditions. The automatic terminal information service was quoting a cloud base of 1,000 ft with lower patches and visibility reduced to 5,000 m in passing showers. The conditions were observed to deteriorate during periods of heavy rain showers and the air traffic control tower staff updated each crew as appropriate.

As the Shorts intercepted the final approach path at 14 NM from touchdown, the aerodrome controller informed the approach controller that the weather had deteriorated at the aerodrome and that there was a likelihood that the Shorts would carry out a missed approach. The approach controller informed the crew and transferred them to the tower frequency so that the aerodrome controller could provide timely updates of the changing weather situation.

At 0744:05 Eastern Standard Time, the pilot of a Cessna 208 (Cessna) reported ready to depart on the aerodrome control frequency and was instructed to line-up. At that time, the Shorts was approximately 9 NM from touchdown with a ground speed of 120 kts.

The aerodrome controller received a departure instruction of "Left 360 unrestricted" from the approach controller (who was also providing the departure service). The pilot of the Cessna was then given a take-off clearance in accordance with that instruction but with an additional instruction to remain on the aerodrome controller's frequency when airborne. The aircraft commenced take off roll at approximately 0745:00; when the Shorts was approximately 7.5 NM from the runway 15 threshold.

At 0745:05, the crew of the Shorts was informed that the rain was increasing at the field and that the runway lights were on stage 6; the maximum intensity.

At 0746:04, the pilot of the Cessna was asked to expedite his climb through 2,000 ft and, at 0746:30, the crew of the Shorts was cleared to land.

At 0748:29, the pilot of the C208 apologised for the slow rate of climb and commented that he was "... just doing his best". At about the same time, the crew of the Shorts commenced a missed approach and, at 0748:39, they were instructed to maintain 1,500 ft and informed that there was "... traffic abeam you now at the 9 o'clock position". That transmission by the aerodrome controller was followed, at 0748:56, by a broadcast to the pilot of the Cessna saying "... caution traffic in the missed approach".

At 0749:07, the aerodrome controller updated the traffic information to the crew of the Shorts with "... caution, the traffic is in your 12 o'clock position at half a mile". The reply was garbled and included the statement "... we are maintaining one thousand at the moment..." which was followed by words that were not completely discernible but included "... one thousand five hundred..."

At 0749:27, the pilot of the Cessna was instructed to report leaving 1,500 ft and replied that he had left that altitude. A subsequent radar analysis indicated that the aircraft was climbing through 1,550 ft at that time.

At 0749:40, the approach controller checked with the aerodrome controller to ascertain his plan for separation. The reply was that there was "... not much to do". However, at 0749:51, the aerodrome controller broadcast to the crew of the Shorts that radar indicated traffic in the same position at the same level. The reply was that the crew had sighted the Cessna and were passing that aircraft.

Radar analysis indicated that the aircraft had passed at approximately 0749:50 with a minimum horizontal distance of about 70m and a vertical displacement of between 100 - 200 ft. The required separation standard was either 3 NM horizontally or 1,000ft vertically. There had been an infringement of separation standards.

Missed approach and departure procedures

Due to the constraints of terrain surrounding the Cairns aerodrome, both the missed approach and departure procedures required tracking in a 40 degree sector to the north east. The missed approach required an initial climb straight ahead to the Middle Marker, then a climbing left turn onto a heading of 030 degrees to intercept the 045 radial of the Cairns VOR (Very High Frequency navigation aid), with a climb to 4,000 ft or a level assigned by air traffic control.

The standard instrument departure required a left turn at the earlier of 400 ft or the departure end of the runway, onto an assigned heading between 350 - 030 degrees. The lowest altitude for radar vectoring in this sector was between 1,000ft and 3,300ft depending on the precise position of the aircraft at the time.

This combination of tracking requirements resulted in a guaranteed tracking conflict whenever a missed approach was commenced when a departing aircraft was within 3NM of the aerodrome. Furthermore, an infringement of separation standards would occur whenever a missed approach was carried out in instrument meteorological conditions without vertical separation being established.

Separation standards

Air traffic controllers were limited to a minimum altitude of 1,500 ft for terrain clearance in the case of a missed approach. To establish the vertical separation standard of 1,000 ft (or 500 ft in an emergency), a departing aircraft would have to be at or above 2,500 ft (or 2,000 ft in an emergency). When the Shorts was established in the missed approach turn, it was climbing through 700 ft while the Cessna had left 1,300 ft.

The radar standard was not achieved as the tracks crossed each other approximately 2NM north east of the runway. As the aircraft had to track in the same narrow sector of airspace, it would have been some minutes before a radar standard could be established.

Visual separation was not an option due to the prevailing weather conditions. The aerodrome controller could not see either aircraft as they came into conflict.

Lateral separation - the Manual of Air Traffic Services section 6-4-3 stated "lateral separation is considered to exist between an arriving aircraft that subsequently commenced final approach, and a departing aircraft that has been cleared on a segregated flight path". That is, a situation where the departing aircraft will not be manoeuvring within 45 degrees of the reciprocal of the final approach path while an aircraft is on the final approach path. The assigned heading of 360 degrees for the Cessna did not comply with that standard.

Longitudinal separation standards did not apply because they required distances greater than those required for radar standards.

Aircraft performance

The Shorts, a 36 passenger aircraft, had seven persons on board and very little freight. Consequently, when the missed approach was commenced, the crew attained a rate of climb of 700 - 800 ft/min. They stated that 300 - 600 ft/min was their expected rate of climb.

The Cessna was at maximum take-off weight and, because of the heavy rain, the pilot had selected the Inertial Separation Handle to bypass mode. That operation helped to divert heavy rain droplets around the engine so that the risk of flame-out was reduced.

When airborne, the pilot of the Cessna experienced severe turbulence and downdrafts, along with buffeting from the gusty wind and heavy rain. The combination of the prevailing weather conditions and the selection of bypass mode resulted in a degraded climb performance from that normally expected. Radar analysis indicated that the Cessna had an average rate of climb of 400 ft/min from take-off to the point of closest proximity and, at times, a rate of climb near zero. The pilot stated that he expected a rate of climb between 800 - 1,200 ft/min.

Air traffic control procedures

The Manual of Air Traffic Services (MATS) section 6-4-3 specified the procedures to be applied in the case of an arriving aircraft and an aircraft taking-off. It stated that "a departing aircraft may be permitted to take off during the period before an arriving aircraft will commence its final approach" but goes on to say that such take-off clearance "... is conditional upon the application of separation after take-off is commenced".

Final approach was defined as 8NM from the runway 15 threshold. The aerodrome controller may have complied with the distance requirement as the Cessna was cleared for take-off when the Shorts was approximately 8NM from the threshold.

Cairns Local Instructions (TWR - 29) reinforced the provisions of MATS in the specific instance of the conflicting missed approach and departure headings from runway 15. They stated that "... consideration must be given to increase the cut-off distance used between the landing aircraft and the aircraft commencing take-off when weather conditions are such that visual or radar separation of the overshooting aircraft and departing aircraft cannot occur". Local Instructions did not specify clearly who had the responsibility for separating the missed approach from the departing aircraft. Approach control was responsible for the airspace but the aerodrome controller had to advise the approach controller of the most appropriate heading consistent with the ability to provide separation with other airborne traffic.

Cairns controllers operated in such a way that the aerodrome controller separated an aircraft on the missed approach path with other traffic, using visual separation until an alternative standard could be achieved. As the weather conditions precluded such an option, a specific alternative was required. Tower controllers were not rated to provide radar separation and could only use the radar display "for information". However, Local Instructions specified that it was the aerodrome controller's responsibility to ensure that radar separation existed between an aircraft on short final and not yet in sight and an aircraft becoming airborne.

MATS 6-5-1 allowed a tower controller to provide an uncoordinated radar vector to initiate separation in cases such as a missed approach. However, MATS required Local Instructions to specify the details. Cairns Local Instructions did not specify any such details.

Aerodrome controller

The controller had considered extending the cut-off distance but believed that, as the Shorts had not commenced final approach, he could safely clear the Cessna for take-off. He had witnessed numerous departures by Cessna 208 type aircraft and had an expectancy that the aircraft would climb at a rate which would enable vertical separation to be easily achieved if the Shorts commenced a missed approach. He also expected the Cessna to proceed at a speed that would position that aircraft well ahead of the Shorts at the crossing point of the departure track and the missed approach path.

Although the approach controller had nominal responsibility for the airspace, the aerodrome controller had assumed separation responsibility when he retained the pilot of the Cessna on his radio frequency for departure. As the Cessna departed, the controller observed that it did not turn in accordance with the standard instrument departure instructions but continued for approximately half a mile before commencing the turn. He then noticed that the rate of climb was not as good as he had expected and, at 0746:11, asked the pilot to expedite through 2,000 ft and report leaving 2,000 ft. That instruction was to maintain his traffic management plan of achieving vertical separation with any missed approach procedure and would have provided a 500 ft emergency standard if he maintained the Shorts at 1,500 ft in the missed approach.

As the aircraft closed to within 1.5 NM, the controller gave traffic information to both crews. However that information did not include the aircraft type, or height, or relative height. The information was only position and distance to the crew of the Shorts and included the words "... traffic abeam you now at the 9 o'clock position". That information was incorrect as the Shorts was in a left turn and the traffic was actually in the 12 o'clock position moving towards the 2 o'clock position. The pilot of the Cessna was advised "Caution, traffic on the missed approach". The controller asked the other controllers in the tower at the time for advice but they were unable, in the time available, to offer an alternative course of action.

When the crew of the Shorts made a broadcast that they were "... maintaining 1,000 (feet) at the moment..." in the middle of a transmission that was broken and partly unintelligible, the controller neither questioned the crew as to their mention of the words "... one thousand five hundred..." during that broadcast nor did he issue an altitude instruction. However, he did obtain an altitude report from the pilot of the Cessna which indicated that the aircraft had left 1,500 ft on climb. The controller's subsequent conversation with the approach controller indicated that he was satisfied with the separation standard saying "...(the Shorts) supposed to be maintaining 1,000 (ft) the other has left 1,500 (ft) ...".

The controller was of the opinion that the altitude read outs from the Shorts were varying so much that he did not know that the aircraft had not maintained 1,000 ft. Radar analysis of the readouts indicated a relatively steady increase in height over the 90 seconds from 0748:30 - 0750:00 but with two "spikes" at approximately 1,100 ft (at approximately time 0749:07) and 1,500 ft (at approximately time 0749:45).

Approach controller

The approach controller had issued the departure instruction for the Cessna believing that, as the Shorts was about 8NM from touchdown, the aerodrome controller would not depart that aircraft until after the arrival, or that the Shorts was in sight and reasonably assured of a landing. However, the terminology used by the aerodrome controller "next CYC" indicated that the Cessna would commence take off within 1 minute of the receipt of a departure instruction.

As the situation developed, the controller monitored the radio frequency of the aerodrome controller to observe the plan for separation. He had heard the requirement to remain with the tower given to the pilot of the Cessna and considered that the aerodrome controller had accepted the responsibility for separation with this action. As the radar display indicated that the aircraft were on conflicting tracks and at similar altitudes, other controllers asked what separation was being applied. The approach controller replied that the aerodrome controller was providing the separation but elected to prompt the tower with the question "you right?". This coordination occurred at 0749:40, approximately 10 seconds before the point of closest proximity, and was the first contact between the controllers since the departure instruction for the Cessna was issued.

Emergency training

The Cairns air traffic controllers had not received regular training in emergency or unusual situations. Tower controllers had last undertaken formal refresher training in October 1997. However, the aerodrome controller had been absent on recreational leave and did not attend the training. He had received formal tuition in dealing with similar circumstances during his aerodrome control training in December 1997 and January 1998.

The aerodrome controller stated that he had experienced only one missed approach due to poor weather in his 3 years at Cairns. As the incident developed, he asked for advice from his fellow tower controllers but as they were occupied with their own tasks, they were unable to give a properly considered response.

Pilot of the Cessna

The pilot was conducting a single pilot operation and had intended to comply with the requirements of the standard instrument departure by turning left at 400 ft or the departure end of the runway. However, when airborne, the initial climb did not proceed as well as expected, with severe turbulence and heavy rain buffeting the aircraft. The airspeed was not increasing as quickly as he would have liked and at the upwind end of the runway the aircraft had only reached an altitude of 200 - 250 ft. Consequently the pilot elected to continue on runway heading until a more stable climb was achieved. The left turn was commenced at an altitude of 300 ft and an indicated airspeed of approximately 70 kts. There was no broadcast to air traffic control indicating the variation to the standard procedure.

Once the aircraft had turned onto the assigned heading of 360 degrees, the pilot made every effort to maximise the rate of climb but was limited by the aircraft performance in turbulent weather conditions. At 0748:29, he broadcast to the aerodrome controller that he was experiencing a slower than normal rate of climb.

When, at 0748:56, he was given conflicting traffic information, he attempted to sight the other aircraft but found visibility limited in cloud and heavy rain. Shortly after, the aircraft broke into a small clear patch and the pilot saw the Shorts just below and marginally to his left. He estimated that the aircraft would pass just behind his own and elected not to take any evasive action.

Crew of the Shorts

The co-pilot was the flying pilot and, as the aircraft approached the minima, the crew found themselves in cloud, heavy rain and subjected to severe turbulence culminating in their decision to commence a missed approach.

The crew's main preoccupation was to ensure the safe climb-out of their aircraft in the left turn required by the procedure and, as they were experiencing instrument meteorological conditions, their first priority was to fly the aircraft. Consequently, they did not immediately inform air traffic control of their commencing a missed approach. Before they could broadcast any details, the aerodrome controller issued an instruction for them to maintain 1,500 ft and passed traffic information. As they were still in cloud and rain, their lookout was both occasional and of limited effect.

A short time later, the controller issued an updated traffic alert indicating that the other aircraft was half a mile ahead. The response from the pilot in command was that they were maintaining 1,000 ft temporarily but still climbing to 1,500 ft as cleared by air traffic control. The pilot in command had intended to maintain 1,000 ft after the traffic information had been passed but the co-pilot did not hear the instruction as it was said during the radio broadcast to air traffic control and during a period of intense flying activity. As the pilot in command was about to reiterate the maintain 1,000 ft instruction to the co-pilot, the aircraft broke into the same clear patch as the Cessna and they saw that aircraft ahead and slightly above. The co-pilot levelled the aircraft momentarily to ensure that they would pass beneath the Cessna and then continued the climb to 1,500 ft when established clear of it.

 

Weather

The general conditions of low cloud and heavy rain made any visual reference unlikely for both pilots and controllers. As both crews were operating in instrument flying conditions, the chances of their making visual contact with the other aircraft were low. Therefore, the presence of a break in the cloud of sufficient size to allow such sighting was of a fortuitous nature and could not be relied on for tactical planning purposes.

Missed approach and departure procedures

These procedures were so constrained by terrain considerations that, whenever an aircraft commenced a missed approach, a conflict would occur unless the aerodrome controller could visually monitor the aircraft with any departure until a specific separation standard was achieved.

Even using the 030 degrees heading option for the departure, the missed approach procedure would have, at best, resulted in the aircraft tracking parallel to each other approximately 1 -1.5 NM apart; a situation that would still result in an infringement of separation standards if no vertical separation existed. As the terrain prevented a departure heading east of 030 degrees, the situation would have required the missed approach track to be north west of 030 degrees to guarantee a divergence.

Air traffic control procedures

MATS 6-4-3 allowed an unrestricted departure prior to an arriving aircraft commencing final approach provided a specific lateral separation standard of a minimum of 45 degrees between the departure track and the reciprocal of the final approach track existed. If the departure heading had been between 015 and 030 degrees, this standard would have been achieved. However, because of the limitations of the missed approach track and the weather situation, the maintenance of the separation standard could not be expected and an alternative standard would need to be established.

MATS also allowed for a departure when an aircraft had commenced final approach provided a reasonable assurance existed that a landing could be accomplished or that separation standards could be applied between the aircraft in a missed approach and the aircraft desiring take-off clearance. In this case the weather precluded any guarantee of the Shorts landing and no separation assurance was in place.

It may have been possible to use the lateral separation standard of 45 degrees between tracks if the departure heading had been between 015 - 030 degrees. However, even if this option had been taken, MATS required an allowance to be made when, among other things, missed approaches were likely, and/or, a faster aircraft was approaching in respect of a slower aircraft taking off. Both circumstances applied to this occurrence.

Cairns Local Instructions (TWR - 29) gave further guidance in the specific case of runway 15 when "... consideration must be given to increase the cut-off distance used between the landing aircraft; and the aircraft commencing takeoff." Because the Shorts was between 9 - 7.5 NM during the time that the Cessna was processed for departure, some doubt existed as to which circumstance applied. In either case the departure was conditional on a separation standard being applied and, as the heading issued was not 45 degrees from the approach track, neither of the lateral separation standards were useable.

As the aircraft were on conflicting tracks without any vertical separation established, a radar vector may have been appropriate. The approach controller was rated to perform the task but did not have either crew on frequency. The aerodrome controller had the radio contact but was not rated to perform the task. However, as the aircraft came into close proximity, an emergency radar vector by the aerodrome controller may have increased the minimum distance between the aircraft. MATS 4-1-1 para 3.f authorises any controller to take any necessary action to ensure aircraft safety.

Separation standards

Procedural lateral separation with the final approach path was possible under the provisions of MATS but not under the terms of the departure instructions issued by the approach controller. As the tracks of both aircraft were not laterally separated (a situation that became a direct conflict when the Shorts commenced a missed approach) an alternative form of separation was required.

The aerodrome controller may use visual separation based on judgement and experience to provide initial separation until a more specific standard is achieved. However, in the prevailing weather conditions adequate visual contact with both aircraft was not possible. Therefore, this standard was not appropriate.

Radar separation of 3 NM was not appropriate as the conflict occurred within 2 NM of the aerodrome. In addition, as both aircraft were heading in the same sector of airspace, the likelihood was that the standard would not be achieved for some time. Longitudinal standards were also unlikely to be attained in the short term for similar reasons.

Vertical separation was applicable but relied on the Cessna becoming established 1,000 ft above the Shorts. As the Cessna was starting from a position below that of the Shorts, the standard was not available during the initial climb phase. A standard of 500 ft was useable initially as a form of emergency separation. However, the limitations were the same as for the 1,000 ft standard.

There was an option to amend the departure heading for the Cessna to provide initial lateral separation; the limitations of this option have been discussed above. Consequently, no separation standard existed at the time the Cessna departed and separation assurance was neither achieved nor positively sought until the conflict was unavoidable.

Aircraft performance

Although the aerodrome controller expected the Cessna to out-climb the Shorts, operational factors were such that the opposite was the case. MATS 4-1-1 paragraph 13 informed controllers of such a possibility. In addition, in the case of the Cessna, several factors in the first 4 minutes of flight indicated that operations were not as expected.

Aerodrome controller

The controller had a traffic management plan that relied on an expected aircraft performance of the Cessna and Shorts types. This expectation was based on his observations since arriving at Cairns. The plan was twofold; either the Cessna would out-climb the Shorts and vertical separation would be established, or the Cessna would reach the point at which the missed approach track would conflict with the departure track first and pass clear of that point before the Shorts entered the area of conflict. There was no consultation with the approach controller and no discussion of any alternative plan even though the weather conditions precluded visual separation as an initial standard.

As the flight of the Cessna progressed, the controller realised that the climb was not as good as expected but elected to continue with his original plan hoping that one of the alternatives would still work. Separation assurance had not been implemented.

When the crew of the Shorts reported maintaining 1,000 ft the controller established that the Cessna had left 1,500 ft, thus indicating a 500 ft emergency separation standard. However, no instruction was issued to the crew of the Shorts other than a climb to 1,500 ft. Additionally, the poor quality of the radio transmission and the mention of 1,500 (ft) by the crew should have raised sufficient doubt in the controller's mind to warrant clarification.

Although the aerodrome controller considered that the radar altitude read-out from the SD36 was erratic, other controllers expressed concern over the fact that they saw the altitudes of the aircraft indicate similar levels as they approached the point of closest proximity. When the approach controller questioned the separation status, albeit with an oblique comment, the reply was that there was "not much to do mate, ..." indicating that he had done all that was required, even though no separation standard had been achieved. However, a few seconds later he issued updated traffic information to the crew of the Shorts indicating that the other aircraft was in the same position at the same level.

The passing of traffic information when an aircraft is in cloud and heavy rain and the crew are flying the aircraft with reference to instruments, was unlikely to result in a sighting; even though it did in this case. However, passing traffic information when a near collision is imminent is sound practice.

Approach controller

The controller had been surprised when he realised that the aerodrome controller had cleared the Cessna for take off ahead of the arriving Shorts. He realised that if a missed approach resulted, then a conflict was imminent. He assumed that the aerodrome controller had accepted separation responsibility and chose to allow him to continue with that role but made no attempt to establish what standard was being used. Even though the last known information was that the Shorts was likely to conduct a missed approach and visual separation was unlikely, no coordination was instigated to adequately determine the status of separation in his airspace.

Other controllers reported that as the situation developed, they had asked what was happening and made comments such as "do something". The reply was that the aerodrome controller was providing the separation. Eventually he could see that the radar indicated a near collision situation and questioned the aerodrome controller, but this was with very ambiguous words and when the aircraft were only 10 seconds from the point of closest proximity.

Training

The circumstances surrounding the occurrence were not often experienced at Cairns. Consequently, the combination of events were such that many controllers had never seen this scenario before and were not fully familiar with how to resolve the confliction. The procedures were such that this type of incident could have happened at any time in recent years.

Although initial training covered the procedures contained in Local Instructions, some controllers could not remember any recent "Team" discussions on unusual or emergency situations and formal abnormal situation refresher training had not been regularly undertaken.

Pilot of the Cessna

Operational decisions were taken with the safety of the flight in mind and as a result of the prevailing weather conditions; the full effect of which were not known until actually encountered.

The pilot had intended to comply with the departure instructions as he commenced take-off roll but found himself unable to continue with that plan as a result of constant turbulence and downdrafts.

Crew of the Shorts

The crew had made a standard missed approach decision and the pilot in command had intended to maintain the aircraft at 1,000 ft initially. However, the instruction to the co-pilot was made at the same time as the pilot in command was broadcasting to air traffic control. The words were heard by the aerodrome controller but not by the co-pilot. This situation led to a misunderstanding, in that the controller thought the aircraft was going to maintain 1,000 ft but the crew continued to climb to their assigned level of 1,500 ft.

 
  1. The geographical restraints of high terrain surrounding the Cairns aerodrome required all aircraft movements in instrument meteorological conditions to proceed into a 40 degree sector of airspace.
  2. The Cairns runway 15 missed approach and departure procedures required all aircraft to turn into the same narrow sector of airspace.
  3. The weather conditions were such that missed approaches were likely and that the aerodrome controller would not be able to provide visual separation.
  4. The departure instructions for the Cessna placed that aircraft into a direct track conflict with the runway 15 missed approach path.
  5. The aerodrome controller's decision not to increase the cut-off distance beyond 8NM resulted in a reduction of the safety buffers in the separation plan.
  6. The aerodrome controller's separation plan relied on the performance of the Cessna being sufficient to climb above the Shorts.
  7. The performance of the Cessna was not as good as that expected by the aerodrome controller.
  8. The weather conditions encountered by the Cessna were such that the pilot needed to reduce the fair weather climb performance for operational safety reasons.
  9. The coordination between the aerodrome controller and the approach controller was inadequate.
  10. The Cairns Local Instructions did not authorise the use of radar by the aerodrome controller for separation purposes.
  11. Neither the aerodrome controller nor the approach controller applied positive separation assurance techniques.
  12. Cairns tower controllers had not received adequate ongoing refresher training in emergency and/or unusual situations.
 

Local safety action

As a result of the investigation, Airservices Australia has:

  1. Introduced a revised missed approach procedure on 17 June 1999. This procedure changed the outbound heading from 030 degrees to 015 degrees, and
  2. Introduced Cairns Local Instruction TLI99/105 which restricted the available headings for departures to 030 degrees only, when missed approaches are likely.

The combined effect of these actions was to provide a nominal 15 degree buffer between the departure and missed approach paths.

Airservices Australia management at Cairns has introduced a program of regular in-flight emergency response and abnormal situation refresher training for tower staff. The first course was completed between 19 - 23 July 1999.

Recommendation

As a result of the investigation the Australian Transport Safety Bureau (formerly Bureau of Air Safety Investigation) issued the following recommendation to Airservices Australia on 23 December 1999:

R19990227

That Airservices Australia review ongoing refresher training for all staff. In particular, to ensure that adequate discussion and simulation of unusual situations pertinent to specific locations is included in the syllabus.

Airservices Australia responded on 7 February 2000 accepting the recommendation.

The Australian Transport Safety Bureau classified the response as CLOSED - ACCEPTED

 
General details
Date: 12 March 1999 Investigation status: Completed 
Time: 0750 hours EST Investigation type: Occurrence Investigation 
Location   (show map):4 km N Cairns, Aero. Occurrence type:Loss of separation 
State: Queensland Occurrence class: Airspace 
Release date: 27 March 2000 Occurrence category: Incident 
Report status: Final Highest injury level: None 
 
Aircraft 1 details
Aircraft manufacturer: Short Bros Pty Ltd 
Aircraft model: SD3-60 
Aircraft registration: VH-SUR 
Serial number: VH-SUR 
Type of operation: Air Transport Low Capacity 
Damage to aircraft: Nil 
Departure point:Townsville, QLD
Departure time:0645 hours EST
Destination:Cairns, QLD
Aircraft 2 details
Aircraft manufacturer: Cessna Aircraft Company 
Aircraft model: 208 
Aircraft registration: VH-CYC 
Serial number: VH-CYC 
Type of operation: Charter 
Damage to aircraft: Nil 
Departure point:Cairns, QLD
Departure time:0746 hours EST
Destination:Croydon, QLD
 
 
 
Share this page Provide feedback on this investigation
Last update 13 May 2014