Operational non-compliance involving a Boeing 737-376, VH-TAF, Sydney, New South Wales, on 7 June 1993

Summary

The Boeing 737 (VH-TAF) had been cleared to taxi to and hold short of runway 16. Approaching the hold point at runway 16, the pilot switched to Tower frequency and advised that he was ready. The controller replied with 'Good morning'. Mistaking this transmission for 'line up' the pilot proceeded onto the runway. As he taxied across the hold line, he noticed a light aircraft about 2-3 NM on final approach to runway 16 and heard the tower controller clear the aircraft to land. The pilot then asked the controller to confirm that he had been given clearance to lineup. The controller responded in the negative and cleared VH-TAF for an immediate take-off.

The landing clearance of VH-XLA was cancelled and the pilot advised to continue the approach. After VH-TAF became airborne, VH-XLA was cleared to land.

Occurrence summary

Investigation number 199301735
Occurrence date 07/06/1993
Location Sydney
State New South Wales
Report release date 19/06/1994
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Operational non-compliance
Occurrence class Incident

Aircraft details

Manufacturer The Boeing Company
Model 737-376
Registration VH-TAF
Sector Jet
Operation type Air Transport High Capacity
Departure point Sydney NSW
Destination Melbourne NSW
Damage Nil

Wheels up landing involving a Piper PA-31-350, VH-KIJ, King Island, Tasmania, on 10 June 1993

Summary

During the landing roll the right landing gear collapsed. The pilot reported that the indication was that the gear was locked down prior to the landing gear collapse.

Prior to this flight the aircraft had undergone maintenance which included some work on the right main landing gear. While damage to the components of the collapsed gear precluded assessment of the downlock switch settings, it is likely that incorrect adjustment of the switch allowed the hydraulic power pack to be switched off before the right main gear was properly down and locked.

As a consequence, it is probable that the aircraft was landed with the right main gear not locked down, although the cockpit indication was that the gear was locked down.

Occurrence summary

Investigation number 199301729
Occurrence date 10/06/1993
Location King Island
State Tasmania
Report release date 28/03/1994
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Wheels up landing
Occurrence class Incident

Aircraft details

Manufacturer Piper Aircraft Corp
Model PA-31-350
Registration VH-KIJ
Sector Piston
Operation type Charter
Departure point Moorabbin VIC
Destination King Island TAS
Damage Minor

Depart/app/land wrong runway involving a Fairchild SA226-TC, VH-WGX and Piper PA-44-180, VH-FRI, Wagga Wagga, New South Wales, on 9 June 1993

Summary

Circumstances

VH-FRI was carrying out airwork at Wagga and was preparing for a practice VOR/DME approach to runway 05. Wagga air traffic control (ATC) were using runway 23 as the runway in use and this was also the runway to which most training aircraft were making their approaches.

At 1235 hours the pilot of VH-FRI requested a runway 05 VOR/DME approach and ATC replied that he could expect a runway 23 VOR/DME approach and wrote this detail on the flight progress strip. The two crew members in VH-FRI did not realise that the controller had issued an expectancy for a different runway to that requested and continued to position their aircraft for an approach to runway 05.

At 1244 hours ATC approved VH-FRI to make a sector entry for a runway 23 VOR/DME approach. Again the crew did not notice that the runway given was not the one requested. The controller passed overshoot instructions to VH-FRI that would keep that aircraft clear of VH-WGX which was approaching Wagga on a flight from Albury and had been instructed to track for a landing on runway 23.

The cloud was five octas at 2,000ft and therefore a visual sighting by ATC was not guaranteed. However the controller had sighted VH-WGX at approximately 5 - 8 NM from the field and he continued to look for VH-FRI in the same direction but nearer to the runway as VH-FRI was sequenced to be first.

At 1259 hours the controller had still not sighted VH-FRI and decided to look in the direction of the runway 05 final approach and saw VH-FRI commencing an overshoot on that runway. He immediately issued new instructions to both aircraft that maintained visual separation standards and a breakdown in separation was averted.

Significant Factors

1. The crew of VH-FRI, having requested runway 05, continued to hear runway 05 even though the controller was saying runway 23.

2. The air traffic controller, having expected a request for runway 23, misheard the pilot request an approach for runway 05 and continued to issue instructions for a runway 23 approach procedure.

Occurrence summary

Investigation number 199301723
Occurrence date 09/06/1993
Location Wagga Wagga
State New South Wales
Report release date 27/09/1993
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Depart/app/land wrong runway
Occurrence class Incident

Aircraft details

Manufacturer Fairchild Industries Inc
Model SA226-TC
Registration VH-WGX
Sector Turboprop
Operation type Air Transport Low Capacity
Departure point Albury NSW
Destination Wagga Wagga NSW
Damage Nil

Aircraft details

Manufacturer Piper Aircraft Corp
Model PA-44-180
Registration VH-FRI
Sector Piston
Destination Cootamundra NSW
Damage Nil

Airframe event involving a Cessna 172RG, VH-NAY, Bacchus Marsh, Victoria, on 9 June 1993

Summary

The student pilot was conducting solo consolidation flying. While taxiing after a landing on runway 27 the nosewheel assembly collapsed.

An engineering inspection of the nosewheel assembly discovered that a fatigue failure had occurred. A forging which attaches the nosewheel hydraulic actuator to the fuselage broke.

A Civil Aviation Authority Airworthiness Surveyor has inspected the aircraft and intends to have the failed component further inspected in a laboratory.

Significant Factor

The following factor was considered relevant to the development of the accident:

1. A forging failed because of fatigue.

Occurrence summary

Investigation number 199301725
Occurrence date 09/06/1993
Location Bacchus Marsh
State Victoria
Report release date 26/10/1994
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Accident

Aircraft details

Manufacturer Cessna Aircraft Company
Model 172RG
Registration VH-NAY
Sector Piston
Operation type Flying Training
Departure point Bacchus Marsh VIC
Destination Bacchus Marsh VIC
Damage Substantial

Rejected take-off involving a Boeing 737-377, VH-CZJ, Melbourne Airport, Victoria, on 10 June 1993

Summary

A clearance to line up on the runway had previously been given. The crew reported that after they were cleared for take-off and were applying take off power a vehicle was seen approaching the runway on taxiway alpha. They observed the vehicle continue and cross the runway in front of them. The take-off was rejected from a relatively low speed.

A different version of events was presented by control tower staff. A clearance was given for the vehicle to cross the runway. They said that as the aircraft was on the taxiway approaching the runway it was judged that the vehicle would be clear of the runway. The Manual of Air Traffic Services allows a take-off clearance to be given if, in the opinion of the controller, no collision risk exists and there is reasonable assurance that separation will exist when the aircraft commences take-off roll. A take-off clearance was given under this provision when the air traffic controller assessed it was safe to do so. Although the situation may have been tighter than expected the vehicle was seen moving away from the runway when the take-off was rejected.

It has not been possible to resolve the discrepancies between these two versions of the events.

Significant Factors

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

1 It was not possible to assign factors to this incident.

Occurrence summary

Investigation number 199301718
Occurrence date 10/06/1993
Location Melbourne Airport
State Victoria
Report release date 27/10/1994
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Rejected take-off
Occurrence class Incident

Aircraft details

Manufacturer The Boeing Company
Model 737-377
Registration VH-CZJ
Sector Jet
Operation type Air Transport High Capacity
Departure point Melbourne VIC
Destination Adelaide SA
Damage Nil

Near collision involving a Saab SF-340A, VH-EKD and Cessna Aircraft, Devonport Airport, Tasmania, on 5 June 1993

Summary

VH-EKD was approaching the circuit and about to join downwind at 1000 feet when a Cessna aircraft was sighted ahead at the same altitude. A left turn was made and the other aircraft was passed some 300 metres away.

The pilot of VH-EKD had made all the required calls on the MTAF frequency but no response was received. He also made calls after he incident but was unable to establish contact. The registration of the other aircraft could not be established.

Significant Factors

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

1. The pilot of unidentified aircraft did not make the required radio calls.

Occurrence summary

Investigation number 199301662
Occurrence date 05/06/1993
Location Devonport Airport
State Tasmania
Report release date 18/10/1993
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Near collision
Occurrence class Incident

Aircraft details

Manufacturer Cessna Aircraft Company
Model Unknown
Registration Unknown
Sector Piston
Damage Nil

Aircraft details

Manufacturer Saab Aircraft Co.
Model SF-340A
Registration VH-EKD
Sector Turboprop
Operation type Air Transport Low Capacity
Departure point Melbourne VIC
Destination Devonport TAS
Damage Nil

Collision with terrain involving a Piper PA-34-200, VH-CRT, 1 km south of Minlaton, South Australia, on 9 June 1993

Summary

On arrival overhead Minlaton, at the lowest safe altitude of 1600 feet above mean sea level, the pilot identified the town and airport. A visual descent to 500 feet above ground level was continued as the aircraft joined the circuit for runway 33. The pilot flew a tight circuit and after aligning the aircraft on final looked into the cockpit for a final check of the power settings. When he looked out, he had lost sight of the runway lights and before he could take corrective action the aircraft struck the ground about 800 metres before the runway threshold.

The left outer wing struck the ground and then a fence and was broken off, the landing gear was torn off and the aircraft came to rest after a ground slide of about 75 metres. The pilot was uninjured and vacated the aircraft unaided.

A second aircraft which arrived overhead Minlaton a short time after VH-CRT, advised Adelaide of the accident. The pilot of this aircraft then held in the area for about 20 minutes because of poor visibility and light before a landing could be accomplished.

Occurrence summary

Investigation number 199301651
Occurrence date 09/06/1993
Location 1 km south of Minlaton
State South Australia
Report release date 28/03/1994
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Collision with terrain
Occurrence class Accident

Aircraft details

Manufacturer Piper Aircraft Corp
Model PA-34-200
Registration VH-CRT
Sector Piston
Operation type Charter
Departure point Adelaide SA
Destination Minlaton SA
Damage Substantial

Forced/precautionary landing involving a Hughes Helicopters 269B, VH-XBN, 90 km west of Landor Station, Western Australia, on 5 June 1993

Summary

The aircraft was engaged in a shooting operation at the time of the accident. Whilst in a shallow descent about 180 feet above scrubby trees, the pilot applied power to fly away. The engine failed to respond and the main rotor RPM reduced. The pilot was forced to land the helicopter amongst the trees. It was reported that the power reduction may have been caused by a faulty fuel control unit.

Occurrence summary

Investigation number 199301652
Occurrence date 05/06/1993
Location 90 km west of Landor Station
State Western Australia
Report release date 30/08/1993
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

Manufacturer Hughes Helicopters
Model 269B
Registration VH-XBN
Sector Helicopter
Operation type Aerial Work
Departure point 95 km W Landor Station WA
Destination 95 km W Landor Station WA
Damage Substantial

Hard landing involving a Piper PA-28-161, VH-CBF, Moorabbin, Victoria, on 6 June 1993

Summary

The student pilot was conducting his second period of solo flying involving three circuits and Airwork in the training area. On approach after returning from the training area the aircraft was high and fast, but the pilot persisted with the approach. He then forced the aircraft onto the runway causing it to bounce. The aircraft was substantially damaged in the ensuing very hard touchdown. The training organisation has revised its procedures to give more adequate instruction covering this type of occurrence.

Significant factors

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

1. The pilot had very low experience.

2. The pilot persisted with an approach that was high and fast.

3. During the landing attempt the pilot made inappropriate control inputs.

4. The training organisation had not given the pilot adequate instruction on how to handle this type of event.

Occurrence summary

Investigation number 199301637
Occurrence date 06/06/1993
Location Moorabbin
State Victoria
Report release date 03/08/1995
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Hard landing
Occurrence class Accident

Aircraft details

Manufacturer Piper Aircraft Corp
Model PA-28-161
Registration VH-CBF
Sector Piston
Operation type Flying Training
Departure point Moorabbin
Destination Moorabbin
Damage Substantial

Runway incursion involving a Beech Aircraft Corp B200C, VH-AMB, Sydney, New South Wales, on 5 June 1993

Summary

Circumstances

At 0341 hours the driver of Qantas tug Red Charlie requested permission to tow a Qantas B767 aircraft from the Qantas Maintenance Area to the International Terminal Bay 30. The driver was cleared by ATC to tow the aircraft via taxiway foxtrot and hold short of runway 16. This instruction was acknowledged by the driver.

VH-AMB was arriving at Sydney on a flight from Armidale and was on final approach to runway 16.

As the tug approached the holding point for runway 16 the Aerodrome Controller [ADC] issued the hold short instruction a second time which was again acknowledged by the driver. The ADC had decided that VH-AMB would land before the tug would be given permission to cross runway 16 and issued a landing clearance to that aircraft at 0345 hours.

It had been common practice during the night shift, for tug drivers to receive a clearance to cross runway 16 at the point at which the ADC issued the second hold short instruction. With this expectancy in mind, the tug driver thought he had received a clearance to cross runway 16 when he acknowledged the second hold short instruction.

The holding point for runway 16 on taxiway foxtrot is not easily recognised from the tower at night and controllers therefore had to rely on pilots/drivers complying with any instruction received. As Red Charlie was approaching this holding point, it was not possible for the ADC to accurately determine the position of the tug and aircraft.

At 0346.10 hours the pilot of VH-AMB informed the tower that he had an aircraft in front of him on the runway. The ADC immediately cancelled the landing clearance and established that Red Charlie was clear of runway 16, having crossed that runway. As VH-AMB was still in a position to land, a second landing clearance was issued at 0346.55 hours.

VH-AMB continued the approach and landed safely.

Significant Factors

1. The driver of Red Charlie had an expectation that he would be given a clearance to cross runway 16 at the time the second hold short instruction was issued.

2. The position of the taxiway foxtrot holding point is difficult to visually judge at night from the control tower. 3. The driver of Red Charlie did not read back the instruction to hold short of runway 16. 4. There is no ATC requirement for the read back referred to in 3 above.

Safety Actions

The Bureau of Air Safety Investigation issued a Safety Advisory Notice [SAN930310] to Qantas Airways, the Civil Aviation Authority and the Federal Airports Corporation. It stated that:

The Bureau of Air Safety Investigation advises that formal radio procedures instruction should be included in all airside driver training and suggests that ATC could have an input into such training.

Occurrence summary

Investigation number 199301641
Occurrence date 05/06/1993
Location Sydney
State New South Wales
Report release date 07/01/1994
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Runway incursion
Occurrence class Incident

Aircraft details

Manufacturer Beech Aircraft Corp
Model B200C
Registration VH-AMB
Sector Turboprop
Operation type Medical Transport
Departure point Armidale NSW
Destination Sydney NSW
Damage Nil