Navigation - Other involving a Boeing 747-200, VR-HKG, Mount Isa, Queensland, on 14 May 1993

Summary

The flight plan for the aircraft, Sydney to Hong Kong, was received at Brisbane Air Traffic Control at approximately 1130 hours EST with a planned departure time from Sydney of 1300 hours. A departure message was received at 1325 hours. No other flight plan details were received on the aircraft by either Brisbane or Darwin Air Traffic Control.

At 1540 hours, the aircraft reported at Mt Isa, estimating position BROCK at 1600 hours. According to the flight plan, the next position reporting point should have been GOVE. There was no conflicting traffic and the aircraft was cleared via BROCK.

Twenty minutes prior to the aircraft's departure from Sydney, the aircraft commander was advised of an increase in zero fuel weight for the aircraft and amended the flight plan as a result. The handling agent for the operator failed to submit the updated plan. The reason for this omission was not determined.

Occurrence summary

Investigation number 199301356
Occurrence date 14/05/1993
Location Mount Isa
State Queensland
Report release date 22/10/1993
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Navigation - Other
Occurrence class Incident

Aircraft details

Manufacturer The Boeing Company
Model 747-200
Registration VR-HKG
Sector Jet
Operation type Air Transport High Capacity
Departure point Sydney NSW
Destination Hong Kong
Damage Nil

Airframe event involving a Grob Twin Astir, VH-KYK, 2 km east of Narrogin, Western Australia, on 15 April 1993

Summary

The aim of the flight was to provide air experience (gliding) for a military pilot. During a loop, the instructor heard small noises but saw nothing amiss. On completion of the loop, the instructor observed a ripple on the top surface of the starboard wing and advised the other pilot to return to land. Subsequent inspection revealed a compression fracture on the top surface of the starboard wing.

Occurrence summary

Investigation number 199301343
Occurrence date 15/04/1993
Location 2 km east of Narrogin
State Western Australia
Report release date 30/10/1993
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Fuselage/wings/empennage
Occurrence class Accident

Aircraft details

Manufacturer Grob - Burkhart Flugzeugbau
Model Twin Astir
Registration VH-KYK
Sector Other
Operation type Flying Training
Departure point Narrogin WA
Destination Narrogin WA
Damage Substantial

Abnormal engine indications involving a Boeing 737-377, VH-CZK, Melbourne, Victoria, on 16 January 1993

Summary

During take-off a pronounced thrust lever split was noticed. The N1 was split by 5% and, after manually adjusting the power levers, the pilot reported that the number 2 engine N1 and EGT rose rapidly above maximum limits. Thrust levers were retarded at 120 knots (V1 was 138 knots) and the take-off was rejected. On the taxiway some smoke was seen coming from the tyres. An inspection showed that excessive lubrication of the landing gear brake units had caused the smoke when the brakes were overheated. No damage was evident. The number 2 engine was found to have sticky and out of adjustment variable stator vanes (VSV). These were lubricated and adjusted, and subsequent operations were normal.

Significant factors

1. The pilot rejected the take-off below V1 due to a power anomaly.

2. The number 2 engine variable stator vanes required adjustment and lubrication.

3. Excess lubrication on the landing gear brake units generated smoke after the rejected take-off.

Occurrence summary

Investigation number 199301329
Occurrence date 16/01/1993
Location Melbourne
State Victoria
Report release date 11/06/1993
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Abnormal engine indications
Occurrence class Incident

Aircraft details

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

Ground strike involving a Bell 47J-2A, VH-KHZ, Head of Bight, South Australia, on 12 May 1993

Summary

The helicopter was being repositioned near a cliff edge. As it was lifted to a one metre hover a gust of wind tilted the tail down and the pilot felt a 'thump'. He initially raised the collective control, but the helicopter began to rotate rapidly to the right. The throttle was closed and the collective control lowered to prevent the helicopter from falling over the cliff edge. The helicopter landed heavily, after rotating through 270 degrees, bending and breaking the skid cross tubes.

Inspection revealed that the tail rotor guard had failed when it contacted the ground. It was then struck by the tail rotor causing the tail rotor drive shaft to fail at the main transmission.

Occurrence summary

Investigation number 199301327
Occurrence date 12/05/1993
Location Head of Bight
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 Ground strike
Occurrence class Accident

Aircraft details

Manufacturer Bell Helicopter Co
Model 47J-2A
Registration VH-KHZ
Sector Helicopter
Operation type Aerial Work
Departure point Head of Bight SA
Destination Head of Bight SA
Damage Substantial

Collision with terrain involving a Zenith CH200, VH-DNE, near Mareeba Airport, Queensland, on 13 May 1993

Summary

The pilot was taking his passenger for a flight to demonstrate the aircraft. Following preflight and pre-take-off checks the take-off was commenced from runway 28. The aircraft accelerated normally until 60 knots when the aircraft was established in a 400 feet per minute climb. As the aircraft crossed the upwind threshold it began to sink. The pilot checked the performance and found that the airspeed was 60 knots, and the engine was developing full power. He lowered the nose of the aircraft to the straight and level attitude and the aircraft maintained level flight. However, as the nose was raised again to outclimb trees ahead, the aircraft again began to sink. The pilot turned the aircraft to the right towards a clear area but was unable to avoid the trees.

The aircraft came to rest upright in an area covered by 15 foot high regrowth. The pilot was able to extricate himself from the wreckage but because of his injuries could not free the passenger.

The pilot had not operated from Mareeba prior to this flight and was unaware that local pilots do not normally use runway 28 for take-off because of downdraughts near the upwind threshold.

At the time of the accident the weather was fine and clear with a temperature of 22 degrees Celsius and no wind.

Occurrence summary

Investigation number 199301326
Occurrence date 13/05/1993
Location near Mareeba Airport
State Queensland
Report release date 08/06/1993
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Collision with terrain
Occurrence class Accident
Highest injury level Serious

Aircraft details

Manufacturer Zenith Aircraft Company
Model CH200
Registration VH-DNE
Serial number 229
Sector Piston
Operation type Private
Departure point Mareeba QLD
Destination Mareeba QLD
Damage Destroyed

Collision on ground involving a Cessna 210L, VH-MHC, Home Valley Station, Western Australia, on 8 May 1993

Summary

The pilot had landed the aircraft and was decelerating on the runway when an object was seen in the grass directly ahead. Avoiding action was not possible and the left mainwheel hit the object, which was later identified as an old runway marker. The marker was thrown up and hit the tailplane, causing damage of the left horizontal stabiliser. The marker was partly rusty and was obscured from observation because of the long grass and the camouflaging effect of the surrounding colours.

The pilot elected to test fly the aircraft and then return to home base without first consulting an engineer.

Occurrence summary

Investigation number 199301306
Occurrence date 08/05/1993
Location Home Valley 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 Ground strike
Occurrence class Accident

Aircraft details

Manufacturer Cessna Aircraft Company
Model 210L
Registration VH-MHC
Sector Piston
Operation type Charter
Departure point Kalumburu WA
Destination Home Valley Station WA
Damage Substantial

Operational non-compliance involving a Cessna 210N, VH-TFE, Darwin, Northern Territory, on 12 May 1993

Summary

The pilot was engaged on his second charter flight for the day from Darwin. A clearance for an immediate take-off was given but the pilot delayed on the taxiway until prompted by the tower controller.

The departure clearance was via Lee Point to the north, but the aircraft was observed tracking to the west. As there were three other aircraft in the circuit, the pilot was again instructed to track via Lee Point which he acknowledged. The aircraft continued to track west and was instructed to turn onto a heading of 360 degrees to avoid circuit traffic. A short time later the aircraft made a 180 degree turn and advised the tower he was returning to Darwin. A traffic alert was given by the tower controller and the other aircraft in the circuit altered course to prevent a breakdown in separation.

Being unfamiliar with the area, the pilot stated that he had confused East Point (west of Darwin) with Lee Point.

The previous evening, the pilot had worked at a part-time position until 0100. He then worked from 0600 until 1100 on the day of this flight before commencing his rostered flying duties.

Occurrence summary

Investigation number 199301311
Occurrence date 12/05/1993
Location Darwin
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 Operational non-compliance
Occurrence class Incident

Aircraft details

Manufacturer Cessna Aircraft Company
Model 210N
Registration VH-TFE
Sector Piston
Operation type Charter
Departure point Darwin NT
Destination Garden Point NT
Damage Nil

Rejected take-off involving an Embraer EMB-110P1, VH-LNB and Piper PA-28-180, VH-WIL, Port Lincoln, South Australia, on 5 April 1993

Summary

VH-WIL was operating in the circuit area at Port Lincoln for the purpose of testing the installation of a Mogas conversion. The LAME who had carried out the work was the pilot-in-command. He was accompanied by the owner who was seated at the right hand control position. After entering downwind for a touch-and-go landing on runway 23, the pilot, while testing the new fuel pump switch, inadvertently selected the master switch off. When the master switch was reselected, the VHF radio, which had been set to the MTAF frequency, defaulted to 121.5 Mhz. The pilot then selected an incorrect frequency. At the same time, VH-LNB taxied and lined up on runway 19 for departure to Adelaide after making all the necessary radio calls. VH-WIL made an approach and landed just past the threshold of RWY 23. As the pilot applied power again for take-off, the passenger sighted VH-LNB rolling on RWY 19. The pilot of VH-WIL aborted his take-off well short of the intersection of the two runways, selected the correct frequency and called VH-LNB.

Occurrence summary

Investigation number 199301297
Occurrence date 05/04/1993
Location Port Lincoln
State South Australia
Report release date 31/12/1993
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 Embraer-Empresa Brasileira De Aeronautica
Model EMB-110P1
Registration VH-LNB
Sector Turboprop
Operation type Air Transport Low Capacity
Departure point Port Lincoln SA
Destination Adelaide SA
Damage Nil

Aircraft details

Manufacturer Piper Aircraft Corp
Model PA-28-180
Registration VH-WIL
Sector Piston
Operation type General Aviation
Departure point Port Lincoln SA
Destination Port Lincoln SA
Damage Nil

Airspace incursion involving a Embraer-Empresa Brasileira De Aeronautica EMB-110P1, VH-XFK, 33km NW Cairns, QLD on 5 May 1993

Summary

When the aircraft left the control area on its previous flight, it was noted by ATC staff that the transponder was not operational. The operator was informed that the equipment was unserviceable but that the aircraft would be allowed into the control area on its return flight. However, when the aircraft reported outside the control area (OCTA) for a clearance it was denied on the basis that the transponder was unserviceable. This left the aircraft crew with the option of proceeding OCTA or landing somewhere else. The crew continued OCTA but inadvertently infringed the 3,000 step north of Cairns due to unfamiliarity with VFR procedures in the area and difficulty with the radio navigation chart presentation. As a result of this investigation, ATS has modified their approach to this type of situation. Aircraft crews will no longer be forced OCTA under similar circumstances. One of the problems inherent in the present radar system in Cairns is that only transponder returns can be seen beyond 50nm to the north-west due to terrain shielding of the primary radar. ATC's first option should have been to reroute the aircraft to track in from the north to give primary radar coverage earlier. A second option was to bring the aircraft in on a procedural clearance.

Occurrence summary

Investigation number 199301250
Occurrence date 05/05/1993
State Queensland
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Incident

Aircraft details

Manufacturer Embraer-Empresa Brasileira De Aeronautica
Model EMB-110P1
Registration VH-XFK
Sector Turboprop
Departure point Aurukun QLD
Destination Cairns QLD
Damage Nil

Fuel starvation involving a Robinson R22 Beta, VH-HLK, 35 km north of Halls Creek, Western Australia, on 7 May 1993

Summary

The pilot was positioning the aircraft so that a left-handed shooter could take aim and shoot from the left seat. The aircraft was at about 40 feet above ground level and with minimal forward speed when the engine suddenly began running roughly and, after several back-fires, stopped. The pilot was unable to enter auto-rotation, and the aircraft landed heavily. The main rotor struck and severed the tail boom, and the aircraft skids were flattened during the impact.

Inspection of the wreckage revealed that the fuel selector was partially closed and that insufficient fuel, for normal operation, was able to reach the engine. An assessment of the sequence of events indicates that it is probable that, as the shooter was positioning the rifle for the shot, its butt made contact with the unprotected fuel selector lever and moved it to the partially closed position. The height at which the engine failure occurred prevented the pilot from cushioning the landing.

Safety Action

During the initial stages of the investigation, the Bureau issued Interim Recommendation IR930075 to the Civil Aviation Authority. It recommended:

That the Civil Aviation Authority advise R22 operators of the possibility for unintentional movement of the rear bulkhead mounted fuel selector and consider implementing a requirement for fuel selector protection to minimise inadvertent operation.

They subsequently advised that the Authority was in agreement with the recommendation and had issued an appropriate letter to all R22 operators on the matter. The Robinson Helicopter Company had also been advised of the accident and would be forwarded a copy of the letter.

Occurrence summary

Investigation number 199301252
Occurrence date 07/05/1993
Location 35 km north of Halls Creek
State Western Australia
Report release date 11/03/1994
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Engine failure or malfunction, Fuel starvation
Occurrence class Accident
Highest injury level Minor

Aircraft details

Manufacturer Robinson Helicopter Co
Model R22 Beta
Registration VH-HLK
Sector Helicopter
Operation type Aerial Work
Departure point Palm Well WA
Destination Palm Well WA
Damage Substantial