The aircraft was cleared via Kinglake and Epping for a landing on runway 27 at Melbourne. The aircraft proceeded south of the cleared track and did not comply with heading change instructions from Melbourne Tower to get the aircraft back on track. The aircraft was transferred back to approach control where it was vectored and descended for a landing on runway 34. There was no breakdown in separation.

Investigation determined that on the approach to Melbourne there was confusion in the cockpit between the two crew members. En route the captain had asked the first officer to request runway 34. This had not been done. From some distance out the captain was planning to land on runway 34 but the first officer was basing his actions on a landing on runway 27.

It was established that the ILS selectors were tuned to 109.3 which is the runway 27 ILS frequency, but it was not established exactly how communication between the captain and the first officer broke down to the extent that they both thought they were going to land on different runways.

Significant Factors

The following factors were considered relevant to the development of the incident:

• There was confusion between the captain and the first officer as to which runway they were going to land on.

The pilot, on his eighth solo flight, was conducting touch and go landings. On the third landing, the aircraft was observed to bounce several times before the nose gear collapsed and the propeller contacted the runway.

The pilot advised that the paddock was sprayed in north south runs starting on the eastern side and progressing to the west. After completing the north south spray runs the pilot did not orbit the paddock and re-familiarise himself with the hazards before commencing the clean-up run.

Before reaching the end of the clean-up run, he remembered a power line that he was approaching. He pulled up but the main landing gear struck the power line. The aircraft rapidly slowed and the power line broke. The aircraft then crashed through trees and hit the ground.

Significant Factors

The following factors contributed to the development of the accident:

1. The pilot did not re-familiarise himself with the hazards in the paddock, prior to commencing the clean-up run.

2. The pilot forgot about the existence of a power line until it was too late to avoid it.

The pilot was conducting solo circuit training. During a touch-and-go landing the aircraft landed heavily and bounced. The pilot attempted unsuccessfully to go-around, but the aircraft ran off the runway before coming to rest. The pilot was inexperienced on tailwheel aircraft.

The aircraft was cruising 1000 feet above ground level, to remain clear of cloud, when the windscreen was suddenly covered with oil. The pilot transmitted a MAYDAY call and attempted to make a forced landing on the Great Eastern Highway.

During an attempt to expedite the landing, because of approaching traffic, the pilot forgot to lower the landing gear and the aircraft touched down with the landing gear retracted before skidding off the road and into the bush. The oil had been released through an unsecured oil filler cap.

The aircraft was cleared to climb to Flight Level (FL) 390. After departure, and when on Brisbane Approach (South) frequency, the pilot requested FL 370. This was approved and co-ordinated by the Approach (South) controller with the Brisbane Sector 1 Radar controller. Prior to this, the Sector 1 Procedural controller had co-ordinated the original level clearance for the aircraft with the Brisbane Sector 2 Procedural controller as FL 390.

The Sector 1 Radar controller annotated FL 370 on the flight strip. Normally, the Sector 1 Procedural controller would then have co-ordinated this change with the Sector 2 Procedural controller. However, this was not done and was not detected by the Sector 1 Radar controller. He later handed off the aircraft to the Sector 2 Radar controller without reference to the level. (This is the correct procedure when the current level assigned has been co-ordinated procedurally.) The aircraft was transferred to Sector 2 and reported on climb to FL 370 to the Sector 2 Radar controller.

However, the discrepancy with the co-ordinated level was not detected and when control of the aircraft was transferred to Sydney Sector 2 the level was co-ordinated as on climb to FL 390. Later, while the aircraft was still in the Brisbane FIR, the Sydney Sector 2 Radar controller noticed that the aircraft was maintaining FL 370. This was queried with Brisbane and the oversight was discovered. An examination of the voice tape recording showed that when the aircraft called Sector 2 reporting on climb to FL 370, the Sydney Sector 2 Radar controller was coordinating a handoff to the Brisbane Sector 2 Radar controller and the two transmissions over-ran. This made the transmission from the aircraft difficult to hear clearly.

However, the Brisbane Sector 2 Radar controller did not confirm the level from the aircraft but assumed it to be FL 390 as that was the level shown on the flight strip. The Sector 1 Radar controller, after writing FL 370 on the flight strip, did not follow this up with any coordination checks as was standard procedure. The controller indicated that an aspect relating to the control of a military aircraft was on his mind around the time of the omission. This may have been a level of distraction sufficient to cause the omission.

SIGNIFICANT FACTORS

1. The Sector 1 Radar controller failed to pass a change of level to the next sector, possibly because he was distracted.

2. The Sector 2 Radar controller failed to confirm the aircraft's level.

SAFETY ACTION

On 19 August 1993, an instruction was issued by the Manager Brisbane AACC amending the procedural requirements so that controllers are now required to provide an adjacent unit or position with advice of an amended level whilst affecting handover.

In response to this, and other recent incidents in this area, the Bureau of Air Safety Investigation, in co-operation with the Civil Aviation Authority, have conducted further investigations, resulting in the publication of BASI Investigation Report BS/930154 titled, "An Investigation of Systemic Factors Underlying Air Safety Occurrences in the Brisbane Area Approach Control Centre."

The aircraft departed Maroochydore on climb to a cleared level of flight level (FL) 260. After being transferred to Brisbane Approach (North), the aircraft requested an amended level of FL 240. The Approach (North) controller cleared the aircraft to maintain FL 240. Later, on transfer to Brisbane Sector 1, the aircraft reported on climb to FL 240. However, the Sector 1 controller had not been notified of the level change and was expecting the aircraft at FL 260.

Before the aircraft departed Maroochydore, there was a request for the aircraft to track direct to Singleton instead of the usual route via Farrel (a reporting point south-east of Maroochydore). The direct track took the aircraft close to overhead Brisbane during its climb. The Approach (North) controller agreed with the request. Potential conflictions with the aircraft included two aircraft inbound to, and two outbound from, Brisbane.

The request for the amended level was made while these aircraft were being processed and the controller annotated FL 240 on the flight strip but neglected to co-ordinate this information with Sector 1. It appears possible that the increased workload resulting from the aircraft being cleared direct to Singleton might have been sufficient to cause the controller to omit to conduct the co-ordination with Sector 1. There was no requirement for the controller to approve the level change requested by the aircraft.

At the time of the request, the aircraft was some distance from top of climb and the controller could have controlled his workload better by deferring the request.

SIGNIFICANT FACTORS

1. The controller agreed to a request for direct tracking which had a significant impact on his workload.

2. The controller unnecessarily approved a request from the aircraft for a level change at a time of high workload.

3. Probably as a result of 1. and 2. above, the controller failed to co-ordinate the change of level with the next sector.

SAFETY ACTION

On 19 August 1993, an instruction was issued by the Manager Brisbane AACC amending the procedural requirements so that controllers are now required to provide an adjacent unit or position with advice of an amended level whilst effecting handover.

In response to this, and other recent incidents in this area, the Bureau of Air Safety Investigation, in co-operation with the Civil Aviation Authority, have conducted further investigations, resulting in the publication of Investigation Report BS/930154 titled, "An Investigation of Systemic Factors Underlying Air Safety Occurrences in the Brisbane Area Approach Control Centre."

The Boeing 747 was cleared to descend to flight level 200 with a requirement to reach flight level 200 by Bindook. This requirement was to achieve separation with a Boeing 737 which had a requirement to reach flight level 210 before Bindook. When the B747 passed Bindook the aircraft was observed by radar to be at flight level 220, and this was confirmed by the pilot. The aircraft was immediately put on a heading to achieve separation with the 737 and no separation breakdown occurred.

The Sydney Sector One controller observed VH-OXD pass Singleton without deviating to avoid the restricted airspace R546B which was notammed active up to flight level 135. Headings were passed through Flight Service to the aircraft to avoid the restricted area. The pilot stated that he was aware of the activated restricted airspace and was intending to track clear of it. He accepted the heading provided by Flight Service which took him east of the boundary.

VH-OJJ had departed Cairns and was climbing through Flight Level (FL) 120 when it received a TCAS (Traffic Alert and Collision Avoidance System) warning. The subject of the alert was P2-AND, which was on descent inbound to Cairns from the north-east. Both aircraft took avoiding action, with VH-OJJ following the Resolution Advisory directions of the TCAS and adopting a descent.

The crew of P2-AND saw VH-OJJ and arrested their descent. The closest point of approach between the two aircraft was 1.14 NM laterally and 900 ft vertically. Both aircraft were under radar control by Cairns Approach at the time. The minimum separation standard under these circumstances is 3 NM laterally or 1,000 ft vertically.

The Approach Control console was manned by a controller who was being refamiliarised by another rated air traffic controller, following a period of absence. VH-OJJ had departed Cairns via a SID (Standard Instrument Departure) that left the aircraft on a climb-out track of 020 degrees. During the SID, the clearance was amended to allow the aircraft to track direct to the first enroute reporting point at AKTEL.

The aircraft turned and tracked about 330 degrees to comply with the amended clearance. The supervising controller advised the operating controller that the track adopted would, in his opinion, not provide enough separation with P2-AND. The operating controller then gave VH-OJJ a heading of 330 degrees to steer.

The supervising controller allowed the situation to continue as the aircraft were still separated by some 25 NM, expecting the operating controller to take adequate steps to resolve the potential confliction. Approach Control was busy, having approximately 10 aircraft on frequency with several awaiting clearance to enter the control zone. When the supervising controller saw that a confliction was imminent, if the two aircraft continued on their present headings, he told the operating controller to turn VH-OJJ to the right, expecting a significant turn onto 020/040 degrees.

However, because of radio transmissions from other aircraft, some 20 seconds elapsed before the controller was able to instruct VH-OJJ to turn to a heading of 360 degrees. As VH-OJJ straightened on the new heading, the TCAS Resolution Advisory warning was received by the crew. The control technique used by the operating controller, and allowed to continue by the supervising controller, was flawed because it left the two aircraft in conflict from the time the crew of VH-OJJ was instructed to steer 330 degrees.

The controller had the option of using a failsafe technique by turning VH-OJJ early and further so that it would pass behind P2-AND. The option of applying altitude restrictions on both aircraft to achieve vertical separation was not considered. During the sequence, the supervising controller was sitting behind and to one side of the operating controller.

He was provided with a facility to listen to communications but was unable to directly issue instructions to aircraft. The supervising controller was surprised at the small turn given to VH-OJJ when the confliction was imminent, but it was then too late to take action. Later he said that he should have taken action earlier but the controller at the console was more experienced in the position. As a result, he was reluctant to interfere with the other controller's method of operation. Prior to this shift, the operating controller had been absent from work for 25 days. This period included recreation leave followed by sick leave. Unbeknown to his shift supervisor, he was under considerable stress due to illness in his family and had not fully recovered from influenza. Refamiliarisation can be undertaken under the supervision of any rated controller, even if the latter has only himself or herself just been rated. Other training is carried out by a training officer who has at least six months experience in the position or has received training in instructional techniques. A refamiliarisation officer is not required to have received training in instructional techniques.

SIGNIFICANT FACTORS

1. The operating controller was unfit for duty due to his own illness and stress caused by family problems.

2. He did not inform his supervisor of the problems.

3. The supervising controller did not take timely action to resolve the confliction.

4. The operating console was inadequate for training/familiarisation in that there were no facilities for the supervising controller to communicate directly with aircraft.

SAFETY ACTION

During the course of the investigation the Bureau issued the following recommendation R930236:

It is recommended that the Civil Aviation Authority include complete and comprehensive documentation on the operation of TCAS in the Manual of Air Traffic Services and Australian Aeronautical Information Publication to provide:

(i) flight plan, progress strip and radar data tag indications when serviceable TCAS equipment is carried.

(ii) samples of unambiguous phraseology for aircrew to notify only TCAS TA and RA events to ATS.

(iii) samples of unambiguous phraseology for aircrew to use when diverting from and resuming flight profiles following an RA event.

A reply was received from the Civil Aviation Authority which stated, in part: 'The general comments on TCAS have been noted and are confirmed by our own information. I also advise that the recommendations listed have already been acted upon or are in the process of activation.

The Civil Air Operations Officers' Association of Australia have expressed the view that they are "convinced that the carriage of TCAS should be the subject of specific flight plan notification" and "that notification should be displayed for controller reference". (U.S. controllers receive flight plan notification and the information is also shown on radar data tag and/or flight progress strip.) District Offices have been asked for comment on the inclusion of the ICAO statement in MATS or otherwise given the Civil Air and BASI position.

Copies have been made of 2 videos; the first deals with the operation of TCAS from a pilot's perspective (30 minutes) and the second deals with the controllers side (10 minutes). Both were produced by the FAA. These videos have been distributed to the CAA District Offices for controller education. "Standard phrases" both for pilots and controllers are being devised for inclusion in AIP and MATS.

It is expected that these phraseologies, which are based on UK CAA and FAA phrases in use, will be included in the next AIP/MATS amendment. In conclusion it is agreed that it is important to raise both pilot and controller awareness of TAS. and the effect that it will have.' Other deficiencies identified during this investigation, including console modification and training considerations, are being analysed in order to formulate appropriate safety actions.