The pilot had been spraying the paddock all morning and, for nearly four hours, had been crossing a set of wires running across the field almost at right angles to the aircraft's flight path. On the third run of the fifth load for the day the aircraft's main wheels contacted the top wire of a two wire set, and the forward motion was arrested causing the aircraft to impact the ground.

During the ground impact sequence the pilot was thrown from the aircraft when a seat belt anchor point failed due to corrosion. The pilot had no recollection of any events during the day of the accident. Determination of the actual position of the wire was possibly made more difficult by the wire and one of the support poles tending to blend into the background. A possible contributory factor was that the pilot's concentration may have been reduced due the death of a relative the day before the accident.

The pilot initiated a take-off after last light utilising the headlights of a parked motor vehicle to light part of the strip. Added to the poor lighting available, the windscreen of the aircraft became partially fogged, reducing the pilot's view in the proposed take-off direction. During the take-off run the aircraft began to veer to the left and, although the pilot attempted to abandon the take-off, it ran off the strip and struck a fence.

During approach to the Armidale circuit a vibration was felt followed by fluctuating power indications on the left engine. The vibration increased, so the left engine was shut down and the propeller feathered. After landing, oil was observed leaking from a hole in the top of the left engine crankcase.

Investigation revealed a fatigue failure of the crankshaft which then caused the failure of two connecting rods, one of which punctured the crankcase causing the oil loss.

Metalurgical examination of the crankshaft failure revealed that the fatigue crack had initiated from grinding stress cracks in the aft radius of the No. 5 connecting rod journal. Grinding rework had been performed in this area during the previous engine overhaul, 15 hours before the failure.

The pilot was above his desired descent profile so he selected the landing gear down before entering the circuit area. On arrival in the circuit area, the radio became inoperative due to an electrical failure and the pilot was given a green light by the tower controller as a clearance to land. Shortly after the nosewheel contacted the runway, it collapsed, followed almost immediately by the right main landing gear collapsing.

The aircraft slewed right and came to rest off the sealed surface approximately 250 metres from the departure end of the runway. The pilot indicated that, although it was his habit to check the green landing gear light and the mechanical indicator after selecting the landing gear down and prior to landing, he could not recall whether he had done so on this occasion.

The aircraft's crew requested a climb to a higher cruising altitude. The Flight Service Officer passed on the request to the responsible Air Traffic Control (ATC) Officer. The correct phraseology and verification procedures were not used between the two, and the aircraft was issued with a climb clearance before the ATC officer had determined that such a clearance was appropriate. The ATC officer subsequently issued a correct clearance and no conflictions resulted.

The pilot reported that smoke was entering the cockpit and that it was accompanied by a burning smell. Subsequently most of the electrical system failed. The aircraft was diverted to Bundaberg and landed without further incident. Examination of the aircraft by maintenance engineers found that the electrical system had been subjected to a high voltage situation and significant damage had been caused to the avionics.

The DME (Distance Measuring Equipment) was found to have been the source of the smoke and probably the burning smell. The aircraft is equipped with a high voltage warning light and the engineers found that it illuminated as soon as power was applied to the electrical system. The pilot reported that the light did not illuminate in flight.

Pirate section [2 X FA18] departed Williamtown for Townsville on climb to Flight Level [FL] 310 at 1112 hours. The section was on a track direct to the reporting point GWYDIR which is the boundary position between Sydney and Brisbane air traffic control [ATC] areas of responsibility. This departure time was relayed to Brisbane sector control by Sydney sector via the intercom line and the Brisbane flight progress strips were activated. The GWYDIR strip at both AACCs indicated the same estimate of 1144 hours.

VH-OGD [Boeing 767] was proceeding at FL 370 on a regular public transport flight from Cairns to Sydney and was tracking via GWYDIR on the reciprocal track to Pirate section.

Sydney sector provided Brisbane sector with a radar identification of Pirate section when those aircraft were approximately 50 NM from the boundary. The leader of Pirate section then requested climb to FL 350 and, after all the appropriate coordination was carried out, this was approved by ATC.

Pirate section realised that they were making time against their flight plan and attempted to pass an amended estimate for GWYDIR to ATC. VHF communications between the aircraft and ATC were poor and, despite two or three attempts, this message was not received by ATC.

During this period the Brisbane sector controllers [procedural and radar] realised that the type of formation being used by Pirate section may involve an infringement of the 2,000 ft vertical separation standard required for the passing of the section with VH-OGD. Because of the poor communications with Pirate section, it required several transmissions to ascertain the type of formation being used and, as no definite answer was received from the crew, it was assumed that the aircraft were in Standard Formation. This meant that one aircraft could be up to 500 ft above the other and would therefore infringe the separation standard in use. Brisbane ATC decided to initiate a cruise level change to guarantee vertical separation and instructed Pirate section to descend to FL 340 with a requirement to reach that level by time 1140 hours. This instruction was acknowledged by Pirate section and complied with.

Brisbane sector had calculated the time of 1140 hours based on a time of passing which was calculated on the respective estimates at GWYDIR for both Pirate section and VH-OGD. Although GWYDIR was within radar coverage, the track that the aircraft were using left radar coverage approximately 30 NM north west of GWYDIR and therefore a procedural standard was required.

The Brisbane sector radar controller was monitoring the progress of Pirate section following the radar hand off from Sydney but did not inform the procedural controller that the section was significantly early in relation to their estimate for GWYDIR.

When Pirate section reported at GWYDIR at 1139 hours the Brisbane sector procedural controller realised that they were five minutes early and recalculated the time of passing on which the level change requirement was based. This resulted in the correct time for the Pirate section to reach FL 340 being 1137 hours and as they had not reported at that level until 1139 hours [their actual position at GWYDIR] a breakdown in separation may have occurred.

Pirate section were on radar at the time and VH-OGD appeared on the radar screen at about the same time approximately 30 NM north west of the position of Pirate section. This distance did constitute a radar standard, but this could not be guaranteed until VH-OGD was identified by the radar controller [a situation that occurred after Pirate section had passed GWYDIR].

The crew of Pirate section stated that they had actually been maintaining FL 340 prior to GWYDIR and, although they cannot remember exactly how long before, it is probable that a breakdown in separation did not occur.

Significant Factors

1. The poor VHF communications between ATC and Pirate section inhibited the passing of significant operational information.

2. The communication between the Brisbane sector radar and procedural controllers was ineffective.

Circumstances

The crew of VH-EWD had flight planned for a regular public transport flight from Canberra to Coolangatta using the route designator C4CBCGXX where XX is the modifier for that particular route. The Melbourne computer aided flight strip printing system interpreted the XX modifier as a track via Bindook and Sydney. The systems used by the airline and Canberra Air Traffic Services (ATS) interpreted XX as a track via Yass and Mudgee.

The Civil Aviation Authority (CAA), while retaining the XX modifier, had recently changed the applicable route from Bindook/Sydney to Yass/Mudgee. The airline and Canberra ATS had effected the appropriate software changes for the route modifier whereas Melbourne ATS had not.

EWD departed Canberra at 0850 EST and tracked via the Yass/Mudgee route as expected by Canberra Air Traffic

Control (ATC). As the vertical limit of Canberra ATC is 10,000 ft, co-ordination procedures between Canberra and Melbourne Sector require the notification of an impending departure to be given to Melbourne prior to the aircraft becoming airborne.  On this occasion co-ordination was not carried out until after EWD had departed. 

Additionally, when Canberra Approach informed Melbourne Sector of EWD's departure, the controller incorrectly referred to the aircraft as EWG.

On receiving the departure advice, the Melbourne controller actioned his EWD flight strip and changed the callsign to EWG. The track details on his strip indicated a track via Bindook and Sydney. As there was no other traffic in that portion of airspace, he elected to wait until he had confirmed the callsign with Canberra and observed the aircraft on radar before taking any additional amendment action. At 0853 Melbourne Sector contacted Canberra Approach to confirm the callsign of the aircraft on the Yass track as their radar was indicating EWD.

Further co-ordination took place between Melbourne and Canberra, which confirmed that the Coolangatta bound aircraft was tracking via Yass and Mudgee. The Melbourne controller subsequently amended all details held in the Area Approach Control Centre for the flight and EWD proceeded without incident.  There was no breakdown in separation and the transfer of responsibility from Canberra to Melbourne was performed in accordance with the prescribed procedures.

CONCLUSION

Significant Factors

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

1. Melbourne ATS had not made the necessary software changes for the route, thus the route modifier being used by Melbourne ATS was incorrect.
2. Canberra Approach Control did not co-ordinate the impending movement of VH-EWD with Melbourne Sector prior to its departure.
3. Canberra Approach Control subsequently used an incorrect callsign when co-ordinating VH-EWD's departure.

SAFETY ACTION

In response to safety deficiencies identified during this investigation the CAA amended their procedures for the allocation of route designator modifiers.  The CAA airspace and air-route structure reviews are changing the parameters of design in respect to these problems and intend that all the new air routes will require new route modifiers for flight planning purposes.

On the second flight for the day the pilot took off with an identical load as on the first flight, but the aircraft would not climb after liftoff. The aircraft was operating with a tailwind, and it was suggested that a gust may have reduced aircraft performance. The pilot recognised the lack of performance immediately and commenced dumping the load, but the performance did not increase sufficiently to avoid contact with two fences and some scrub. Although the aircraft was damaged, the pilot was able to fly a circuit and land on the strip.

The pilot was issued with an amended clearance "Radar Two West Maitland 3000" and was instructed to turn left heading 290 degrees and report leaving 2000 ft. After take-off the aircraft maintained runway heading and penetrated Sydney Control Zone to a point 6 NM west of Sydney. VH-CJA, a Cessna 402, was in potential confliction with VH-TJH, a Boeing 737, on final approach for runway 07 at Sydney.

Civil Aviation Authority Aeronautical Information Circular (AIC) Sydney (Kingsford Smith Airport) 17/93 dated 2 April 1993 stated that "Bankstown Air Traffic Control will instruct pilots in VMC by day, to remain clear of the Sydney CTR when departure instructions have been issued by Sydney ATC which require left turns to headings that will enable the aircraft to remain clear of the Sydney CTR".

The pilot of CJA was not issued with instructions in accordance with AIC 17/93 and had not remained clear of the Sydney Control Zone as required by the Aeronautical Information Publication.

Safety Action

The safety deficiency identified during this investigation resulted in the following Safety Advisory Notice being issued on 30 September 1993.

"The Bureau of Air Safety Investigation suggests that Air Traffic Services and Safety Regulation Divisions of the Civil Aviation Authority review procedures in respect to the Bankstown Runway 11 Radar Two Departure."