Aviation safety investigations & reports

Beech Aircraft Corp 1900D, VH-IMH

Investigation number:
199901959
Status: Completed
Investigation completed

Summary

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The crews of all four aircraft had planned to use the same air route between Port Macquarie and Taree. VH-IMA and VH-TQO were arriving at Port Macquarie while VH-IMH and VH-SVV were departing. Due to minor deviations in track-keeping, all four aircraft were to the west of the nominal track.

Weather conditions were such that a layer of cloud existed upwards from approximately 7,000 ft.

Although the flight service officer provided a timely and up-to-date directed traffic information service to all crews, radio communications between the crews of IMA and IMH, and between IMH and SVV were insufficient to ensure self-separation between their aircraft. The high number of radio transmissions on the various frequencies, when combined with the frequency management requirements of each crew, limited the opportunities for adequate radio contact.

The crews of IMA and IMH maintained altitudes in Class "G" airspace without broadcasting their intentions on the flight service frequency. In addition, while both crews were maintaining a listening watch on the flight service frequency for 8 minutes prior to their aircraft passing, neither crew made radio contact with the other.

Analysis of the recorded radar data indicated that the aircraft passed within 1,000 m horizontally and 200 ft vertically while IMA was maintaining 8,000 ft.

None of the aircraft were fitted with an Airborne Collision Avoidance System (ACAS). An ACAS would, most probably, have improved the situational awareness of the crews to the extent that a more effective traffic management plan may have been undertaken.

The lack of adequate situational awareness of the crews of IMA and IMH resulted in two regular public transport aircraft coming into relatively close proximity without either crew carrying out a positive separation plan.

The investigation identified safety deficiencies in respect to timely conflict alerting and self-separation procedures and contains seven recommendations to the Civil Aviation Safety Authority addressing those deficiencies.

Download Final Report
[Download  PDF: 214KB]
 
 
 
General details
Date: 28 April 1999   Investigation status: Completed  
Time: 2006 hours EST    
Location   (show map): 37 km S Port Macquarie, Aero.    
State: New South Wales   Occurrence type: Separation issue  
Release date: 02 May 2001   Occurrence class: Airspace  
Report status: Final   Occurrence category: Incident  
  Highest injury level: None  

Aircraft 1 details

Aircraft 1 details
Aircraft manufacturer Beech Aircraft Corp  
Aircraft model 1900  
Aircraft registration VH-IMH  
Serial number UE-230  
Type of operation Air Transport Low Capacity  
Damage to aircraft Nil  
Departure point Port Macquarie, NSW  
Departure time 2002 hours EST  
Destination Williamtown, NSW  

Aircraft 2 details

Aircraft 2 details
Aircraft manufacturer Beech Aircraft Corp  
Aircraft model 1900  
Aircraft registration VH-IMA  
Serial number UE-7  
Type of operation Air Transport Low Capacity  
Damage to aircraft Nil  
Departure point Sydney, NSW  
Departure time 1930 hours EST  
Destination Port Macquarie, NSW  

Aircraft 3 details

Aircraft 3 details
Aircraft manufacturer Piper Aircraft Corp  
Aircraft model PA-31  
Aircraft registration VH-SVV  
Serial number 31-7405175  
Type of operation Charter  
Damage to aircraft Nil  
Departure point Port Macquarie, NSW  
Departure time 1959 hours EST  
Destination Sydney, NSW  
Last update 13 May 2014