The pilot departed Moorabbin and conducted a practise instrument flight rules flight, including an instrument landing system approach at Essendon and a practise non-direction beacon approach at Cowes, before returning to Moorabbin. For most of the flight the pilot experienced communications problems with his very high frequency radio. He called inbound to Moorabbin Tower at Carrum and advised of his radio problem. Moorabbin Tower noted that the aircraft's transmissions were readable but there was a loud background squeal. Moorabbin Tower cleared the aircraft for a straight-in approach for runway 35 left and instructed the pilot to report at three miles. At the three miles inbound call the radio appeared to be working fine. At about two miles the pilot was given a clearance to land on runway 35 left.

The pilot thought that he checked that the landing gear had been selected down during the final approach, but he cannot remember whether or not the three green "gear down and locked" lights were illuminated. He first became aware of a problem when he heard a grinding noise during the touch down.

Engineers have subsequently found nothing wrong with the landing gear systems. The aircraft was equipped with a landing gear extender which could have automatically extended the gear under low airspeed/low power conditions, but the pilot had disengaged this system.

Significant Factors

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

1. For most of the flight the pilot had been distracted by radio problems.

2. The pilot forgot to select the undercarriage down prior to landing.

3. The pilot had disengaged the backup, automatic landing gear extension system.

The helicopter had been used for mustering throughout the day and had been refuelled from drums.

When the mustering was completed the last 15 litres from a partly used drum was pumped into the auxiliary fuel tank of the helicopter. Fuel samples were taken from the main tank and filter and the helicopter flown to nearby stockyards.

After a short time on the ground, the helicopter departed for the station homestead, about 37 km away. Approximately 10-15 minutes after refuelling, while cruising at 200-250 feet above ground level, the engine began to run roughly, and the rotor RPM began to decay. The pilot lowered the collective control and the engine stopped.

The helicopter was flying downwind in a 20-30 knot wind and the pilot was committed to a downwind autorotational landing. Touchdown was at 20-30 knots on rough ground made heavy by recent rains. The skids dug in and the helicopter nosed over and was substantially damaged. The pilot was uninjured and walked to the homestead for assistance.

Subsequent inspection by recovery personnel revealed water and dirt in the fuel filters.

VH-TJE was enroute Adelaide to Perth. After passing Esperance the pilot requested a change of level to flight level 290. Because the aircraft was less than 15 minutes from the Air Traffic Services (ATS) boundary with Perth, the request for level change was co-ordinated with Perth (ATS). It was during this co-ordination that it was realised that the Esperance position report had not been passed to Perth ATS by Melbourne ATS as required.

The Melbourne air traffic controller on duty when it was realised that the position report had not been passed to Perth ATS had taken over from two other controllers, a training officer and a trainee, who had just been involved in a separate incident and were relieved to explain to the ATS Centre Co-ordinator what had happened.

It has not been determined whether the relieving air traffic controller inherited the problem or whether he failed to pass on the position report. There was no breakdown in separation. Perth ATS was expecting the aircraft. Had the request for change of level not been co-ordinated with Perth, Perth ATS would soon have asked for the position report anyhow.

Significant Factors

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

1. The air traffic controller had just taken over the position.

2. A previous controller may have failed to pass on the position report.

3. An air traffic controller did not comply with laid down procedures.

The pilot had landed at the island strip on several previous occasions. A normal approach and landing was made on strip 27. Near the end of the landing roll the nose wheel struck a small rock, collapsing the nose gear leg.

Significant Factors

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

1. Obstacle on strip surface.

2. The pilot did not take adequate steps to ensure the strip was free of obstacles.

Circumstances

Singapore Airlines Flight 222 [SIA 222] had departed Sydney for Singapore at 1548 hours EST and passed over Darwin at Flight Level [FL] 370. As this level was non-standard and the aircraft was going to enter Indonesian airspace, the crew were asked if they could accept climb to FL390 [a standard level] prior to the boundary position [KIKEM]. When the crew replied in the affirmative, Darwin ATC issued a clearance for the aircraft to climb to FL390 with a requirement to reach that level by KIKEM. This instruction was issued at 1918 hours CST and was clearly and correctly read back by the crew.

Darwin ATC coordinated this information with Bali ATC as per the coordination agreement between Australia and Indonesia.

At 1935 hours SIA 222 reported at the position prior to the boundary [SATKO] at FL370. No mention of FL390 was made at this time by either the crew, or ATS. Perth FS instructed the crew to contact Bali control at KIKEM. Because ATS did not mention or query the crew with respect to FL390, the Captain of SIA 222 became unsure of the validity of the prior clearance and instruction. The flight crew did not question ATS about the clearance.

SIA 222 reported at KIKEM at 1956 hours but the aircraft was still at FL370 in contravention of the ATC clearance received.

Bali control then coordinated with Darwin ATC to confirm the level of SIA 222 and the aircraft was subsequently recleared to FL390.

There was no breakdown in separation.

Significant Factors

1. The crew of SIA 222 became unclear as to the validity of their air traffic control clearance after reporting at SATKO at FL370.

2. The crew of SIA 222 did not make any radio call to clarify the validity, or otherwise, of their air traffic control clearance.

3. The crew of SIA 222 did not reach FL390 by KIKEM which was in contravention of their air traffic control clearance.

Royal Australian Air Force VIP aircraft, call sign NVOY606, was enroute Sydney from Paraburdoo in Western Australia. The aircrew had flight planned to cruise at flight level (FL) 370. However, enroute NVOY606 progressively requested higher levels to FL430. A Melbourne air traffic controller failed to enter the change of level on one of five flight strips. The strip missed was the APOVO position strip which is used for co-ordination with Sydney air traffic controllers. When NYOY606 made a position report at APOVO the pilot reported his actual altitude which was different from the entry on the flight progress strip. This was a chance for the controllers to correct strip entry but at the time the controllers did not react. The altitude error was not discovered until the aircraft was transferred to Sydney control. There was no breakdown in separation with other aircraft.

At the time of the incident, an experienced air traffic controller was undergoing supervised training on Sector 1 (Adelaide to Perth). She failed to make the appropriate entry on the flight progress strip. Air traffic was busy at the time. The supervisor did not notice the oversight.

The Civil Aviation Authority has subsequently conducted an internal investigation. It was noted that the air traffic controller responsible for the oversight had been on duty for three and a half hours without a break. The size of the airspace controlled and the depiction of the route structure on the console was seen as demanding careful attention because, depending on the route, some flights require only two strips whereas others need five. The training officer noted that the short length of cord on his headset did not allow him the freedom of movement he would like when supervising/checking another controller. The controller under training noted that it was difficult to physically move quickly enough when trying to record information received from aircraft because of the size of the display area. The training officer also said that he would like a more elevated chair to enable a better view of the console when supervising.

The headset cord has since been lengthened and a couple of tall chairs have been provided for training officers.

Significant Factors

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

1. A change of level was not transcribed onto a position flight strip by the air traffic controller under training.

2. The training officer did not notice the failure of the controller under training to transcribe the flight level onto the flight progress strip.

3. Neither the training officer nor the trainee reacted to the different flight level reported by the pilot at the APOVO position report.

4. Air traffic was busy at the time of the incident.

VH-IBY and another aircraft VH-LCE were involved in Precision Aerial Delivery System (PADS) training. Two deployments were performed from VH-LCE. On the third drop which was the first drop from VH-IBY, the PADS unit was released from the aircraft, but during the deployment, the static line became detached from the aircraft seat rail attachment point. The crew member who had deployed the PADS became momentarily entangled in the static line and received a minor injury.

On the day of the occurrence the crew had difficulty locating a tiedown fitting which could be attached to the seat track of VH-IBY. The pilot produced a tiedown fitting which was subsequently attached to the left inboard seat rail track about two-thirds of the way forward. The PADS static line was then connected to the tiedown ring with a shackle.

Examination of the tiedown fitting revealed that it failed under applied load.

The tiedown fitting was identified as a Cessna Citation part and when attempts were made to install the same type of fitting onto the seat track of VH-IBY, the tiedown would not fit without spreading the tangs apart. Although the tiedown fitting used was an approved Cessna part, it was not approved for use on Aero Commander 500S type aircraft and therefore it did not fit the seat track profile of VH-IBY.

Safety Action

As a result of the investigation the following Interim Recommendation (IR930090) was made:

That the Civil Aviation Authority amends the wording of the PADS flight manual supplement to reflect specifically how and where the static line is to be secured to the aircraft. If tie down fittings are being used to secure the static line to the seat tracks, then those fittings should be approved and unambiguously identified for use in that aircraft type.

Interchangeability of approved fittings between aircraft of the same type may be compromised by nonstandard seat tracks being fitted into specific aircraft. i.e. Aerocommanders modified to Coastwatch specifications.

The Civil Aviation Authority responded as follows:

'I refer to BASI Interim Recommendation 930090 regarding the Flight Manual Supplement for the Precision Aerial Delivery System.

We do not entirely agree with the BASI Interim Recommendation.

In our view, the primary cause of the incident may have been either an excessively worn seat rail or use of an inappropriate tie down fitting - one neither supplied by the aircraft manufacturer nor locally approved for use in the Aero Commander. Use of improper tie downs in a restraint system will always introduce an unacceptable risk of failure of the system when carrying freight, baggage or any other application of these fittings. Increasing the amount of detail in the Flight Manual Supplement specific to PADS operation is not considered the most efficient means of addressing the problem and will not necessarily achieve the desired aim.

There is no concern that operators will deliberately disregard information relating to attachment of PADS static lines, so the details need only have advisory status. Flight Manuals and Flight Manual Supplements are a means by which the Authority exercises control over mandatory aspects of aircraft operation, but they represent a notoriously expensive and labour intensive activity. As a consequence of the Authority becoming a Government Business Enterprise there is substantial pressure to reduce the reliance on Flight Manual amendments, particularly where they only broadcast general or non-mandatory information.

The Authority is of the view that a more appropriate place for this information is the Operations Manual. These Manuals are readily amended, are familiar to company personnel and can be used to present information specific to individual aircraft and the company’s methods and operations. We will arrange for suitable details to be passed to relevant operators for insertion in their Operations Manuals.'

Status of response:  Closed - Accepted

The aircraft was engaged in aerial mustering operations. Whilst landing to disembark the passenger the pilot experienced intermittent cyclic control problems. He then took off again and during the next 5 to 10 minutes of cattle mustering he tested the cyclic control, but response was normal. A short time later, as the helicopter approached touchdown to re-embark the passenger, all cyclic control was lost. To avoid hitting the waiting passenger the pilot applied power to go around but was unable to control the helicopter's flight path and it impacted the ground nose first.

Inspection of the wreckage revealed that the cyclic control column had fractured at the location of the electrical wiring access hole near the base of the column. The fracture was caused by fatigue crack growth. The access hole had been elongated by mechanical filing and the fatigue origins were located at these abrasion damage sites.

Safety Action

The following interim recommendation was sent to the Civil Aviation Authority on 22 June 1993:

IR930094

That the Civil Aviation Authority advise all operators of this failure and mandate an inspection of the cyclic control column electrical loom access hole to ensure control column integrity.

The CAA in response issued AD/HU-269/102 on 2 August 1993.

Subsequently, results of finite element stress analysis of the failed cyclic pitch control column indicated that material yielding, at the lower electrical loom access hole, occurs below the design limit load. Evaluation of this cyclic control column design is being considered by the Civil Aviation Authority in consultation with the Federal Aviation Administration and the aircraft manufacturer.

When about to turn base for runway 31, the crew of VH-TJQ sighted two light aircraft heading in the opposite direction on the active side of the circuit. From prior communication, the crew of TJQ believed the two aircraft were joining the circuit on the dead side. The pilots of the two light aircraft spoke with American accents and were part of a group visiting Australia. Separation was maintained but it appeared to the crew of TJQ that the pilots of the light aircraft were not familiar with local procedures.

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

• Foreign aircrew apparently unfamiliar with local procedures.

VH-TJQ was cleared to leave controlled area on descent into Ayers Rock. Traffic information on a Boeing 737 taxiing at Ayers Rock for Alice Springs had been passed to TJQ along with advice to contact Adelaide Control passing F200 on descent. TJQ was later told to contact Adelaide Control early because of the departure of the Boeing 737 from Ayers Rock. On contact with Adelaide Control, TJQ was asked to report leaving F200. This was done but the response from Adelaide Control was cut out by another transmission. Direct contact was made with the opposite direction Boeing 737 which was now maintaining F180. TJQ then maintained F190 until the other 737 was sighted about eight miles ahead.