VH-FCU was enroute Gladstone-Brisbane and was being radar vectored for a left base for runway 01. VH-CZM had departed Brisbane on a standard instrument departure off runway 01. This involves the aircraft intercepting and tracking the 360 degree radial from Brisbane and, at 10 DME Brisbane, turning left and tracking for Kilcoy. Both aircraft were under the control of Brisbane Approach. At the time of the occurrence, the Approach position was occupied by a trainee controller under the supervision of a training officer.

The training officer alerted the trainee to the potential confliction between the two aircraft as VH-CZM turned left for Kilcoy. However, as the trainee was about to instruct VH-FCU to turn, a number of radio transmissions prevented him transmitting the instruction until a loss of separation was unavoidable. The aircraft came within four miles of one another while vertical separation did not exist. The trainee was an experienced approach controller from another centre and had only recently begun training in Brisbane. The training officer was aware of the trainee's experience level and delayed his intervention on this basis.

The following factors were considered relevant to this occurrence:

1. The Approach position was occupied by a trainee controller under the supervision of a training officer.

2. The training officer delayed his intervention in the process because of the trainee's previous experience.

3. Other radio traffic delayed the trainee issuing instructions to the aircraft which would have ensured separation.

The pilot was mustering sheep on his property and had handed off two mobs to ground handlers. He was on his fourth pass and was in a 45-degree left turn, descending from 100 to 50 ft at about 70 kts when he realised that he was too close to the sheep and applied left rudder to slip the aircraft away from the sheep. He then attempted to bring the wings level with aileron and arrest the descent without releasing the left rudder pressure. As the aircraft approached 50 ft, the pilot realised he could not recover and closed the throttle. The aircraft struck the ground with the left wing. The propeller then contacted the ground and the aircraft cartwheeled, coming to rest in a distance of about 40 m facing 180 degrees from the direction of flight.

9V-STT was en-route from Perth to Singapore and tracking via air routes B469 then R586 after Carnarvon, cruising at flight level (FL) 350. VH-EAL was also Perth for Singapore but tracking via air route G337 at FL350. The routes flown by the two aircraft are initially laterally separated but, because the cross-track tolerance changed as the aircraft proceeded north, it was necessary to apply separation to ensure that the standards were not infringed. This action was not completed by the air traffic controller responsible for the aircraft by the required point along the routes, and the standards were infringed.

About 30 minutes prior to the incident there was a change of controller on the sector responsible for the aircraft. The controller commencing duty thought that he had confirmed that correct separation existed. The handing over controller believed the other controller had referred to two different aircraft when they discussed the adequacy of the separation during the handover. The controller assuming responsibility for the aircraft had recently returned from a period in the Perth Control Tower and may have forgotten, because of a lack of recent experience, that the cross-track tolerances of the two routes vary.

The handing over controller was recently rated in the position and assumed that the more experienced controller was aware of the lack of separation between the routes. Safety Action: The Civil Aviation Authority is redesigning the route structure, and this should remove the potential for separation reductions in this area of airspace.

FACTUAL INFORMATION

On final approach to Launceston, maximum nose-up stabiliser trim was insufficient to trim out the nose-heavy force. After landing it was found that 60 golf bags weighing approximately 1,300 kg had not been included on the aircraft load trim sheet. The golf bags belonged to a tour group of 60 people who were to travel some days after this occurrence. They were bulk delivered to the baggage handling area at Melbourne Airport to be forwarded to Launceston on a space available basis to meet a requirement that they be available when the group arrived.

The load controller and the baggage loaders were aware that the golf bags were to be moved on a space available basis. The operator's Ramp Manual requires that a load plan must be prepared for each flight. It states that a load plan is an instructional document which specifies where cargo, special load items, livestock, mail, and baggage are to be loaded on an aircraft. The document is produced by the load control section and distributed to members of the loading team so they can perform their duties in the correct loading of the aircraft.

It is necessary to follow the load plan to ensure that the load is correctly segregated and all weight and balance requirements are met. When the loading of an aircraft differs from the load plan, the load controller is to be consulted. On this occasion the loading supervisor informed the load controller that the aircraft was full but did not tell him that the 60 golf bags were on board. The load controller was aware that low density cargo was on board. He had not considered it possible to load the golf bags as well and they were not included in the load plan.

At the time of the occurrence, the load plan declaration stated:

This aircraft has been loaded in accordance with these instructions except for the deviations recorded. The load has been secured in accordance with company regulations. The loading supervisor did not sign the declaration, nor did the load controller seek such certification prior to completing the load and trim sheet. Two load conditions are shown in the following list.

The first column is the load displayed on the load plan accepted by the crew. The second column is the estimated load with the extra 60 golf bags.

Load displayed on the load plan accepted by the crew	Estimated load with the extra 60 golf bags
Bay 1 (most fwd) 26 kg	350 kg
Bay 2 26 kg	472 kg
Bay 3 260 kg	468 kg
Bay 4 212 kg	212 kg
Bay 5 325 kg	500 kg
Bay 6 (most aft) 325 kg	500 kg

Bays 1 to 4 are in the forward fuselage and received most of the extra load, thereby adding to the forward centre of gravity.

The horizontal stabilizer trim setting listed on the load trim sheet was 1.3 units nose up. The crew did not notice any extra nose-down moment during takeoff. It only became evident during the approach and landing. The investigation team recalculated the trim, taking into account the most probable baggage loading condition. It was concluded that the aircraft was still just within the forward limit of the centre of gravity envelope at take-off. The required take-off horizontal stabilizer trim setting would have been 2 units nose up on a 3-unit scale. VH-FKO was the most nose-heavy F28 in this operator's fleet.

The load controller stated that to compensate for this he had blanked out the front row of four seats. However, the computer-generated load trim sheet showed that the aircraft was "trimmed by seat row" and, using the code "BLKD 0", showed that no seats were blocked. The requirement for the front row of four seats to remain unoccupied because of balance considerations was not brought to the attention of the cockpit and cabin crews. The aircraft had a fuel load of 4,400 kg in the wing tanks. No fuel was carried in the centre tanks.

The centre of gravity moved rearwards with fuel burn. There were 65 passengers including 4 infants who occupied 61 out of 74 seats. The investigation did not determine if passengers were redistributed in the cabin after takeoff, resulting in some or all of the four front seats being occupied. When combined with the nose-down force generated by the weight of the 60 golf bags, any forward movement of passengers would have moved the centre of gravity up to or just outside the forward limit, depending on how many of the front row seats were occupied.

The operator uses a system of standard passenger and baggage weights rather than actual weights when compiling a load trim sheet. Accordingly, the actual weights on this flight could not be determined.

ANALYSIS

Most passenger jet aircraft have a large centre of gravity range and variations from a load plan may be permissible provided the aircraft is loaded within the centre of gravity limits. The F28 aircraft type has only a small tolerance to variations from a load plan which conforms to the manufacturer's specifications. The loading supervisor did not certify that the aircraft had been loaded in accordance with the operator's instructions. Certification is part of the operator's quality assurance safety net.

On this occasion the safety net failed. The reason the documentation was not signed could not be clearly established. The operator stated that the reason the loading supervisor did not sign the load plan was an industrial issue rather than a safety issue. The reason maximum nose-up stabiliser trim was insufficient to trim out the nose-heavy force during the approach and landing was not determined.

Findings

1. The cargo and baggage were not loaded in accordance with the load plan.

2. The 60 golf bags were not included in the weight and balance calculation on the load trim sheet.

3. Some passengers may not have been seated in accordance with the load plan during the approach and landing.

4. Maximum nose-up stabiliser trim was insufficient to trim out the nose-heavy force during the approach and landing.

Significant factors

1. The loading supervisor did not certify for the accuracy of the loading and did not ensure that the load controller was aware of the difference between the load plan and the actual loading.

2. The load controller did not advise the cockpit and cabin crews that the front row of four seats was not to be occupied due to balance considerations.

SAFETY ACTION

The Bureau of Air Safety Investigation issues safety advisory notice SAN 960031 to the Civil Aviation Safety Authority. The Bureau of Air Safety Investigation informs the Civil Aviation Safety Authority that it is possible, unless adequate notification is given to cockpit and cabin crew, that the movement and reseating of passengers can inadvertently cause an out of balance situation of certain aircraft under certain loading conditions. Furthermore, as a result of this occurrence, the operator advised that it had initiated the following

Safety actions

1. Established an aircraft load management group. This group compromises company personnel dedicated to establishing operating procedures to ensure aircraft are loaded in accordance with regulatory and company requirements. The group is also required to conduct audits of all operator ports to ensure all requirements are being met in the field and to develop a training syllabus for all staff involved with the loading of aircraft.

2. Initiated an aircraft load management training course. This course is designed for state managers, operations managers, ramp supervisors, load controllers, senior clerks, senior freight clerks and leading hand loaders. The course syllabus covers all aspects of aircraft loading, weight and balance and the legal requirements of the Civil Aviation Regulations and Civil Aviation Orders.

3. Developed an aircraft abnormal loading alert form to provide staff with a method of reporting any incidents or events which may compromise company procedures or matters of safety with regard to the loading of aircraft.

4. Introduced a requirement for the leading hand who loaded the aircraft, to sign a declaration on the load sheet. The declaration states: "I certify that: - loading staff have been instructed to load this aircraft in accordance with the load plan - all deviations from the load plan have been reported - all ULDS [container] and bulk cargo have been loaded and secured in accordance with company procedures".

5. Appointed a national ramp manager to co-ordinate ramp and loading procedures across the network of ports used by the operator.

6. Introduced a system of examination and certification of the load controllers within handling companies on the international network. A similar scheme is being introduced for the domestic network.

7. Introduced an enhanced computerised weight and balance system. This system provides more automation to the loading process and will be introduced to enhance the documentation for the ramp staff.

8. Provided improved communications between the load controller and leading hand loaders with the introduction of two-way radios at the major stations.

On descent to Ayers Rock the pilot of VH-NJC contacted Adelaide Flight Service who advised that there was no other known conflicting instrument flight rules traffic. When approximately 37km from Ayers Rock, and approaching an altitude of 7,100 ft, the pilot made a broadcast on the Ayers Rock advisory frequency advising other aircraft in the area of his position. A reply was received from a visual flight rules aircraft reporting that it had departed Ayers Rock, was on a reciprocal heading, and also 37km from Ayers Rock, but at an altitude of 7,500 ft. The pilot stated that all mandatory radio calls had been made on departure. Both aircraft missed each other's calls as they were on different radio frequencies at the time the calls were made. Neither pilot saw the other aircraft.

Whilst returning from an aerial agriculture task, the Chief Pilot for the company elected to conduct some low flying over a lake. During this exercise, he misjudged his height, and the wheels contacted the water. The pilot lost control of the aircraft and it tipped over and came to rest inverted in the water. The pilot escaped without injury.

When VH-DLF was descending through 7,500 feet, 65 km from Adelaide, Adelaide Departures advised the pilot of an unidentified aircraft converging from his right. Departures continued to update the pilot of VH-DLF on the position of the other aircraft (which he was unable to sight, probably due to haze and the position of the setting sun) but were unable to advise the altitude of the other aircraft. A short time later the pilot of VH-DLF observed a Piper Pawnee aircraft, with a glider in tow, pass about 200 ft overhead.

At the time VH-DLF was descending through 6,300 ft. The pilot advised Departures of the near collision, and Departures confirmed that his aircraft was in controlled airspace. Attempts to contact the tug and glider by radio were unsuccessful. Subsequent investigation revealed that VH-IGR, a Piper Pawnee, had towed a glider (VH-IKO), cruising at about 6,500 ft, from Port Pirie to Murray Bridge at about that time. The lower limit of controlled airspace on their track was 4,000 feet and an airways clearance had not been requested by the tug/glider combination. Both pilots of the tug/glider combination advised that they had not seen VH-DLF and were unaware that they had violated controlled airspace.

The aircraft was to carry out insecticide spraying operations at a rice farm. The pilot made an approach to the airstrip from the south, with a tail wind of about 3 kts. The pilot said that, shortly after touchdown, he observed cattle straying near the edge of the strip and elected to go-around. As the aircraft became airborne the right main landing gear struck an adjacent levee bank. The impact detached the gear leg which then struck the right horizontal stabilizer, detaching the elevator. The pilot said that, by remaining in ground effect, he was able to complete a right circuit and land the aircraft back on the strip. On touchdown, directional control was lost and the aircraft ground looped, colliding with large water pipes and associated equipment.

Two B737 aircraft were tracking south on air route A464 at FL330, initially having a 10 minute separation standard, which reduced to 8 minutes before an RNAV distance standard could be achieved. Both aircraft then required diversion left of track to avoid weather, and as an RNAV distance separation standard could no longer be applied, a minimum separation of 10 minutes, or a change of cruising level for one aircraft was now required. Descent to Flight Level (FL)310 was not available due to crossing traffic, and neither aircraft could accept FL350.

A decision was made to descend the second aircraft to FL290, requiring the traffic on the crossing route to descend to FL280. Co-ordination of all possible separation methods with Brisbane Control required some time, especially as they were experiencing high workloads. The actual separation of the aircraft was continually monitored, and never less than 105km. As the lead aircraft had only been 8 minutes ahead of the other, a breakdown of separation occurred until vertical separation could be achieved.

The pilot had obtained the owner's permission for use of the private airstrip. Two trips were planned. The first flight was successfully completed with a landing at approximately 0630. The pilot then walked the length of the strip and found it to be in generally good condition, although with some shallow ruts. During the second landing on the island, when approximately 100 metres into the landing roll, the nosewheel struck a rut causing the landing gear strut to collapse. The aircraft slid for about 10 metres before coming to rest to the left of the strip.

The propeller and engine cowling had also sustained damage, and a fuel leak was evident. The pilot was not prepared to use the aircraft radio due to the risk posed by the fuel leak and as there was no other means of communication on the island, he was unable to inform air traffic services of the accident. When the pilot had not reported at the nominated time, communication checks were commenced, and an uncertainty phase was declared. Aircraft were then diverted to the island.