Loss of separation involving a Boeing 757, VR-UBC and Boeing 747-400, VR-HOZ, Elbis Route B583/ Butpa Route A461, on 11 December 1993

Summary

Co-ordination was received by Darwin Control from Unjung Pandang for VR-HOZ tracking via air route A461, advising its estimated time at BUTPA and that it was maintaining FL330. The level was read back by the Darwin controller, who then co-ordinated this information to Perth International Flight Service Unit without advising the flight level as this was not required by standard procedures.

The Darwin controller then requested information from Unjung Pandang on V8-RBC, inbound to Darwin on air route B583, which is a converging route with A461. V8-RBC had an estimated time of arrival at the ELBIS position within 10 minutes of the estimated time of arrival for VR-HOZ at the BUTPA position. This required that both aircraft be vertically separated by 2,000 feet when they arrived at these reporting positions. In sequence V8-RBC and VR-HOZ positions for ELBIS and BUTPA were co-ordinated by Perth International Flight Service Unit to Darwin Control, advising that both aircraft were maintaining FL370.

Darwin Control queried the level of VR-HOZ and asked that confirmation be obtained from the aircraft. As a precaution V8-RBC was instructed to descend to FL350. Darwin Control contacted Ujung Pandang who confirmed that VR-HOZ was maintaining FL330, but when contact was made with the aircraft the pilot advised that they had been cleared to FL370 by Manila while in Philippine airspace.

Although the incorrect co-ordination received by Darwin Control resulted in the required vertical separation not being maintained, the aircraft had not come into close proximity of each other when vertical separation was re-established.

Safety Action

The Civil Aviation Authority have issued a local operating instruction at Darwin which requires flight levels to be included in co-ordination between Darwin Control and Perth International Flight Service Unit.

Occurrence summary

Investigation number 199304116
Occurrence date 11/12/1993
Location Elbis Route B583/ Butpa Route A461
State International
Report release date 19/06/1994
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Loss of separation
Occurrence class Incident

Aircraft details

Manufacturer The Boeing Company
Model 747-400
Registration VR-HOZ
Sector Jet
Operation type Air Transport High Capacity
Departure point Hong Kong
Destination Melbourne VIC
Damage Nil

Aircraft details

Manufacturer The Boeing Company
Model 757
Registration VR-UBC
Sector Jet
Operation type Air Transport High Capacity
Departure point Brunei International
Destination Darwin NT
Damage Nil

Wheels up landing involving a Government Aircraft Factories N24A, VH-DHF, Douglas Daly Experimental Station, Northern Territory, on 14 December 1993

Summary

The aircraft was landed with the landing gear retracted. The pilot advised that he may have been distracted during the approach by his aerial inspection of the strip.

Occurrence summary

Investigation number 199304128
Occurrence date 14/12/1993
Location Douglas Daly Experimental Station
State Northern Territory
Report release date 14/06/1994
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Wheels up landing
Occurrence class Accident

Aircraft details

Manufacturer Government Aircraft Factories
Model N24A
Registration VH-DHF
Sector Turboprop
Departure point Daly River Mission NT
Destination Douglas Daly Exper. Station NT
Damage Substantial

Forced/precautionary landing involving a Szybowcowy Zakland Doswiadczalny SZD-32A Foka-5, VH-GZD, Grafton, New South Wales, on 28 November 1993

Summary

The pilot reported that the initial launch was slow, and that he held the nose down until the speed increased to about 50 knots, at which time he began a normal climb. At about 100 feet the speed decreased, the pilot lowered the nose, and the launch cable parachute deployed over the canopy. The parachute and wire wrapped around the right wing and pulled the glider towards a line of trees. The pilot banked left to avoid the trees and was able to level the wings before ground impact. The aircraft struck the ground whilst still sideslipping left, tearing off the landing skid and fracturing the left wing.

Relevant Factors

1. The pilot failed to avoid the tow cable after its release.

2. Control was lost due to the cable being wrapped around the right wing.

Occurrence summary

Investigation number 199304074
Occurrence date 28/11/1993
Location Grafton
State New South Wales
Report release date 05/09/1996
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Forced/precautionary landing
Occurrence class Accident

Aircraft details

Model SZD-32A Foka-5
Registration VH-GZD
Sector Other
Departure point Grafton NSW
Destination Grafton NSW
Damage Substantial

Airframe event involving a Beech Aircraft Corp 58, VH-SQG, Jandakot Airport, Western Australia, on 7 December 1993

Summary

The flight was scheduled as a dual instrument training flight. As the student brought the aircraft to a stop prior to the engine run-up the gear-up warning horn momentarily sounded, and the gear-up warning light flashed once or twice. The instructor took control and checked the landing gear warning systems.

As he could find nothing wrong and he could not reproduce the momentary warning signals he deduced that it was safe to proceed with the flight. He did decide to test the integrity of the gear warning system before returning to the Jandakot circuit area. The flight proceeded normally with all landing gear indications and warnings operating correctly during the departure, an instrument approach and overshoot and a practice engine failure. During a second approach the landing gear did not extend when selected down.

Following a period of trouble shooting the landing gear was extended using the manual extension system. Three green lights were obtained, and the aircraft was landed at Jandakot. As the aircraft cleared the runway, the gear unsafe horn started to sound and the gear-up light started to flash. The pilot stopped the aircraft, confirmed that the three green position lights were indicating down and locked, the landing gear lever was in the down position, the gear motor circuit breaker was out and that the gear relay circuit breaker was in.

Whilst he was visually checking the circuit breakers, the gear motor momentarily made a sound. The pilot considered shutting down the aircraft but before he could take any action the aircraft gently rocked, and the right main landing gear collapsed. The three green gear down and locked lights were still illuminated. Subsequent investigation disclosed that the landing gear motor relay contacts were fused together creating a permanent landing gear up circuit.

Occurrence summary

Investigation number 199304077
Occurrence date 07/12/1993
Location Jandakot Airport
State Western Australia
Report release date 31/03/1994
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Landing gear/indication
Occurrence class Incident

Aircraft details

Manufacturer Beech Aircraft Corp
Model 58
Registration VH-SQG
Sector Piston
Operation type Flying Training
Departure point Jandakot WA
Destination Jandakot WA
Damage Minor

Loss of separation involving a Cessna 172P, VH-AUC and Piper PA-34-200T, VH-DIG, 6 km south of Perth, Western Australia, on 2 December 1993

Summary

The two aircraft were vectored by Perth Approach and given appropriate clearances to facilitate their relative arrivals at Jandakot from Perth. VH-AUC climbed to a higher altitude than cleared and caused a separation breakdown. The pilot in command of this aircraft was an instructor and had the other aircraft sighted but allowed her concentration to lapse and did not detect that her student had climbed in contravention of their airways clearance.

Occurrence summary

Investigation number 199304051
Occurrence date 02/12/1993
Location 6 km south of Perth
State Western Australia
Report release date 14/06/1994
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Loss of separation
Occurrence class Incident

Aircraft details

Manufacturer Cessna Aircraft Company
Model 172P
Registration VH-AUC
Sector Piston
Departure point Perth WA
Destination Jandakot WA
Damage Nil

Aircraft details

Manufacturer Piper Aircraft Corp
Model PA-34-200T
Registration VH-DIG
Sector Piston
Departure point Perth WA
Destination Jandakot WA
Damage Nil

Partial power loss involving a Cessna 441, VH-AZB, Big Bell, Western Australia, on 1 December 1993

Summary

Shortly after the aircraft took off, the left engine lost power and the pilot shut it down. A successful single engine landing was conducted at the departure airfield. It was discovered after landing that the left hand engine torque indicator circuit breaker had popped. The company engineers could not reproduce the fault. The fault has not reappeared.

Occurrence summary

Investigation number 199304052
Occurrence date 01/12/1993
Location Big Bell
State Western Australia
Report release date 14/06/1994
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Engine failure or malfunction
Occurrence class Incident

Aircraft details

Manufacturer Cessna Aircraft Company
Model 441
Registration VH-AZB
Sector Turboprop
Departure point Big Bell WA
Destination Perth WA
Damage Nil

Wheels up landing involving a Piper PA-30, VH-WJD, Renmark, South Australia, on 10 December 1993

Summary

The aircraft entered the circuit for a landing on runway 07. On final approach the pilot's vision was affected by sun glare so he diverted for an approach to runway 36. Because of this distraction in the circuit area the pilot forgot to extend the landing gear and landed 'wheels up'.

Occurrence summary

Investigation number 199304066
Occurrence date 10/12/1993
Location Renmark
State South Australia
Report release date 14/06/1994
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Wheels up landing
Occurrence class Accident

Aircraft details

Manufacturer Piper Aircraft Corp
Model PA-30
Registration VH-WJD
Sector Piston
Departure point Mildura VIC
Destination Renmark SA
Damage Substantial

Fuel exhaustion involving a Cessna 152, VH-JGK, Port Stephens, New South Wales, on 29 November 1993

Summary

The pilot made a mayday call reporting that the engine had failed at 400 feet over Port Stephens. As there was insufficient altitude to reach the shore, the pilot ditched in the water. Both occupants managed to evacuate the aircraft before it sank.

After recovery from the water, investigation revealed only the unusable fuel quantity remained in the tanks and the fuel strainer and carburettor bowl were empty. No mechanical defects were found with the aircraft apart from salt contamination.

Occurrence summary

Investigation number 199303960
Occurrence date 29/11/1993
Location Port Stephens
State New South Wales
Report release date 28/03/1994
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Fuel exhaustion
Occurrence class Accident

Aircraft details

Manufacturer Cessna Aircraft Company
Model 152
Registration VH-JGK
Sector Piston
Departure point Kempsey NSW
Destination Cooranbong NSW
Damage Substantial

ANSP info/procedural error involving a Boeing 737-377, VH-CZH, 55 km north-east of Ayers Rock (Yulara), Northern Territory, on 20 November 1993

Summary

On taxiing and after departure, the crew completed the required radio transmissions. They were advised to call Melbourne Control for an airways clearance prior to entering controlled airspace but were not advised of any conflicting traffic. When the crew requested clearance, Melbourne Control asked them if they were aware of an opposite direction aircraft that was leaving controlled airspace on descent to Ayers Rock. When the crew replied they were unaware of the traffic, Control gave details of the other aircraft.

The descending Boeing 737 was sighted ahead, and a left turn was commenced. The crew of the climbing aircraft estimated that the descending aircraft passed overhead with a vertical separation of about 1,000 ft. The climbing aircraft was then cleared to enter controlled airspace.

Safety Action

As a result of several occurrences involving opposite direction traffic conflictions, a NOTAM was issued that prescribed a new air route and specified a `racetrack' route pattern between Alice Springs and Ayers Rock. This route system will be made permanent during the review process being conducted by the Civil Aviation Authority.

Occurrence summary

Investigation number 199303957
Occurrence date 20/11/1993
Location 55 km north-east of Ayers Rock (Yulara)
State Northern Territory
Report release date 28/03/1994
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category ANSP info/procedural error
Occurrence class Incident

Aircraft details

Manufacturer The Boeing Company
Model 737-377
Registration VH-CZH
Sector Jet
Operation type Air Transport High Capacity
Departure point Ayers Rock NT
Destination Alice Springs NT
Damage Nil

Loss of separation involving a Boeing 747-400, F-GEXA and Beech Aircraft Corp B200C, VH-AMR, near Sydney Aerodrome, New South Wales, on 30 November 1993

Summary

The B747 was being radar vectored to a long left base to runway 34. The controller became anxious during the aircraft's approach as it was well above a normal descent profile. Despite prompting from the controller, the crew indicated that the descent profile was satisfactory. As the aircraft entered a long final approach, the captain asked for a left orbit to lose altitude as they were too high and not yet in the landing configuration. The B200C was also tracking in from the south-west for left base to runway 34, and about 10 NM behind the B747.

Because of this potential confliction, the controller refused the captain's request and directed the B747 onto a heading of 090 degrees and restricted its descent to 2,000 ft. The B747 crew did not hear or understand the heading restriction, did not read back the radar heading and continued in a right orbit. The controller ordered a reversal of the turn, with which the B747 crew complied. In the meantime, the lateral and vertical separation standards of 3 NM and/or 1,000 ft were compromised between the B200C and the B747.

Both crews were given traffic information on the other aircraft and visual separation was maintained until the radar separation standards were once again established. During the telephone interview, the B747 captain said that the first officer was flying and a little slow in configuring the aircraft. He (the captain) was handling the radio and until entering final approach was still convinced that an approach could be made with track lengthening.

He asked for an orbit to the left being unaware of the position of the following aircraft. He said that they did not hear the heading restriction and assumed that a right orbit was acceptable. The controller made an error of omission in not obtaining a readback of the heading. The controllers workload was light at the time of the incident.

FACTORS

1. The B747 crew of Air France 144 misjudged their descent profile and entered the final approach too high to complete a normal landing.

2. The B747 crew did not follow the instructions issued by ATC.

3. The controller did not obtain a readback of the heading information.

Occurrence summary

Investigation number 199303953
Occurrence date 30/11/1993
Location near Sydney Aerodrome
State New South Wales
Report release date 25/03/1994
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Loss of separation
Occurrence class Incident

Aircraft details

Manufacturer Beech Aircraft Corp
Model B200C
Registration VH-AMR
Sector Turboprop
Departure point Wagga Wagga NSW
Destination Sydney NSW
Damage Nil

Aircraft details

Manufacturer The Boeing Company
Model 747-400
Registration F-GEXA
Sector Jet
Operation type Air Transport High Capacity
Departure point Singapore
Destination Sydney NSW
Damage Nil