During agricultural operations, one propeller blade moved to coarse pitch while the aircraft was flying at a height of 50 feet. Power was reduced, the load dumped and the pilot carried out a forced landing in a nearby paddock.

Investigation revealed that one counterweight roller bearing shaft had failed in fatigue across the split-pin hole. The split-pin hole is drilled close to where the bearing shaft exits the hub flange. The hub has now been modified to locate the split-pin in the threaded section at the opposite end of the shaft.

Approaching Cairns the crew received the automatic terminal information service which gave the following information: "runway 15, wet, wind 170 degrees 12 knots, QNH 1014, temperature 22, 3 okta (cloud) at 2,500ft, lower patches, showers in area." Following a Distance Measuring Equipment (DME) arrival, the crew reported visual with the field at four nautical miles. They flew a visual circuit, tracking via a left downwind for runway 15.

During the base turn, the crew lost visual contact with the runway lights because a rain shower was positioned across the final approach path. The flying pilot (first officer) initiated an overshoot and commenced a right turn towards high terrain. The turn continued through some 250 degrees to 090 degrees magnetic, heading out to sea. The crew then conducted an instrument approach to runway 15 followed by a normal landing.

The right turn conducted by the crew allowed the aircraft to track outside the circling area limit of 4.2nm (7.8km). During the turn the lowest altitude of the aircraft was approximately 1,400ft in an area where the radar lowest safe altitude is 3,300ft.

The investigation revealed that the crew were under two misapprehensions. Both pilots believed that they would stay in visual meteorological conditions during the missed approach by conducting a right turn, although they had no way of assuring this on a dark night. The crew also thought that they were further off the coast (hence clear of high terrain) than they were. Prior to commencing the circuit the crew did not foresee the possibility of a missed approach and did not brief for that eventuality.

The procedures laid down in the Aeronautical Information Publication indicate that the crew should have remained inside the manoeuvring area for the DME arrival procedure following the loss of visual reference with the runway approach lights at night. This could best have been accomplished by continuing the left turn to intercept the 040 degree radial, whilst at the same time commencing a climb to the lowest safe altitude of 5,000ft (the procedure laid down for a missed approach off a DME Arrival).

FACTORS

1. The crew did not brief for the possibility of a missed approach in the circuit considering that rain showers were in the area.

2. They made a spontaneous, inappropriate decision to turn right thus tracking near high terrain.

Circumstances

Canberra approach/departures control was being operated on combine due to training requirements. The training officer had confidence in the trainee's ability to handle the situation as the traffic level was light and the trainee was in his final two weeks of training prior to a rating proficiency check.

VH-WNK [Cessna 210] was maintaining 9,000ft on a flight from King Island to Bankstown and was established on the 210 radial of the Canberra VOR.

VH-EWF [Fokker F28] departed Canberra for Melbourne at 0906 hours and was instructed to maintain 8,000ft due to an expected confliction with VH-WNK.

When the trainee controller identified VH-EWF he expected that the aircraft would climb sufficiently quickly to be able to reach a level above VH-WNK before the radar separation standard of 5nm was infringed. On this basis he climbed VH-EWF to Flight Level 190 with a requirement to report leaving 10,000ft.

As the distance between the two aircraft reduced, the training officer asked the trainee what action he intended to take. The trainee was considering his reply when the training officer instructed him to turn VH-EWF so that radar separation would be maintained. At that precise moment the trainee commenced a transmission to another aircraft on an unrelated matter and a few seconds delay occurred before a radar vector was issued to VH-EWF. The training officer elected not to use the override system as he judged that the time taken to activate the system would be similar to that taken by the trainee to complete the transmission. As the crew of VH-EWF were complying with the instruction the separation reduced to 3nm before the flight paths diverged. As vertical separation had not been established, a breakdown in separation occurred.

Significant Factors

1. The trainee approach/departures controller misjudged the climb performance of VH-EWF.

2. The rated approach/departures controller allowed the situation to develop to the stage where there was insufficient time to guarantee that separation standards would be maintained.

3. The training officer's override facilities were not conducive to immediate correction of a trainee's error.

After the pilot selected the landing gear down, no gear locked down indication was received. The pilot elected to remain in the circuit area and attempted to rectify the problem. He observed that the right main gear was "dangling" and attempts to lower it by both the normal and emergency methods were unsuccessful.

After about 45 minutes when no solution could be found the pilot was advised that a landing with the landing gear retracted was the recommended course of action. The aircraft was subsequently landed on runway 12 with the gear retracted.

Inspection of the landing gear system found that a casting attached to the right gear actuator had failed. As a result, the right gear leg could not be driven to the down position.

The pilot of VH-WSA was carrying out training at the Casino navaid. The pilot of VH-CFQ reported inbound to Casino, also for training at the navaid. VH-CFQ had arranged a 500 feet vertical separation with the pilot of VH-WSA. However, the pilot of VH-CFQ reported that the radio transmissions from VH-WSA were difficult to read and that he was not aware that VH-WSA also intended training at Casino. When he lost sight of VH-WSA the pilot of VH-CFQ assumed that VH-WSA had departed the area and continued descending. Both pilots next sighted each other when their aircraft passed nose to nose with about 100 metres lateral separation and with VH-CFQ at a slightly lower altitude.

The Cessna 152, VH-IVT was on a dual training flight, and was carrying out right hand circuits on runway 11 right. The Beech 58, VH-EUA was carrying out training circuits, also on runway 11 right, and had nominated right hand circuits during taxi. On the second circuit, when the aircraft was established on the downwind leg, the pilot of VH-EUA reported "downwind touch-and-go". The Tower controller instructed the pilot to follow VH-IVT which was turning onto final approach. After this touch-and-go, the pilot of VH-EUA was offered a left hand circuit by the Tower controller. The pilot declined the offer as this was to be his last circuit. The option of a left circuit was suggested to assist in providing separation between the two aircraft which had vastly different performance.

Two other aircraft were in the circuit (a Robinson R22 VH-HER, and a Cessna 152 VH-HCG) but both had been issued landing instructions for completion of their flights. The occupants of the tower cab, the Tower controller and the Tower Coordinator, were monitoring the circuit traffic in the normal manner. They had noted that VH-IVT and VH-EUA were approximately half a circuit apart when an additional aircraft, a Beech 76, VH-JWX called inbound to the Bankstown circuit. The pilot of that aircraft was asked to report at Warwick Farm. The controllers could not see this aircraft at the time, and both moved to the rear of the tower in an attempt to sight VH-JWX which was approaching from a westerly direction.

While this was occurring, VH-EUA had completed the touch and go and was in a climbing right turn onto downwind. The pilot reported "downwind full stop" and the controllers, who had now obtained visual contact with VH-JWX, turned their attention back to the south-eastern circuit area. The pilot of VH-IVT called downwind touch and go at that time and as they looked up at the downwind position they saw VH-IVT in a steep turn and diverging from what appeared to be very close proximity with VH-EAU. When the Tower controller checked with the pilot of VH-EUA to confirm that they were following VH-IVT the pilot replied "we didn't even see him".

The pilot flying VH-EUA from the left hand control seat reported that he saw VH-IVT at his 10 o'clock position and increased his bank angle to avoid the other aircraft. The pilot in the right hand control seat of VH-EUA was operating the radio and had not seen VH-IVT.

The instructor in the right hand control seat of VH-IVT stated that after completing the turn onto downwind he sighted the other aircraft slightly below and about 50 feet away. He immediately took over and commenced a climbing turn to the right. The instructor said that the other aircraft would not have been visible from the left and seat, and a collision may have occurred if avoiding action had not been taken.

Significant Factor

• The Tower Controller and the Coordinator were distracted by an inbound aircraft and did not recognise the potential confliction between VH-EAU and VH-IVT.
• The pilot in command of VH-EAU did not adequately monitor the position of the aircraft ahead, VH-IVT, before he commenced a turn onto downwind.

Canberra Approach received coordination from Sydney Flight Information Service (2) (FIS) concerning VH-OFF estimating Shelleys at 0541 and cruising at 10,000 feet. Subsequently no call was received from the aircraft, but another aircraft which was conducting training at Canberra advised that VH-OFF was attempting to call Canberra. Instructions were passed to VH-OFF through this other aircraft that clearance through Canberra control area would not be available unless satisfactory two-way communications could be established. Shortly after this a code 7600 transponder squawk (Radio Failure) was observed on radar over Lake George inside controlled airspace. VH-OFF was instructed by FIS2 to call Canberra Approach but the aircraft did not establish contact and was instructed through FIS2 to leave controlled airspace.

The pilot of VH-OFF reported that he was able to communicate with other aircraft on Canberra Approach frequency, and Canberra Approach was the only station not reading VH-OFF. The pilot said that he had expected to establish communications with Canberra Approach and had decided initially to continue as per flight plan. He was then instructed to leave controlled airspace tracking 270 degrees and acknowledged this with two clicks of the microphone button. He advised FIS2 that he was able to descend clear of controlled airspace and remain visually clear of high terrain. No further communications problems were experienced for the remainder of the flight.

At 0758 EST, VH-OUD contacted Brisbane Approach 28km north of Brisbane at 3,000 feet requesting an airways clearance. Approach answered that a clearance was not available and that the aircraft was required to remain outside controlled airspace. Approach also told the aircraft to contact the Redcliffe common traffic advisory frequency (CTAF) and to call Approach again at 0805 EST.

Another aircraft, VH-HEI, was on descent inbound to Brisbane and had been assigned 3000 feet. As the progress of this aircraft was being monitored on radar, the Approach Controller realised that VH-OUD had penetrated the control area. Attempts to contact VH-OUD were unsuccessful so VH-HEI was vectored clear of VH-OUD. The separation standard of 5 miles was infringed during this sequence.

The pilot of VH-OUD contacted Approach again about 5 miles north of Brisbane Airport and was processed for landing. The pilot later said that he heard the instruction to remain outside controlled airspace. A short time later, however, he had been told to squawk ident on the aircraft transponder and was informed that VH-OUD had been radar identified. He interpreted this to mean that he could continue into controlled airspace at 3,000 feet.

The pilot was carrying out dual instruction for a student helicopter pilot. He reported that on the second practice "engine off landing", as the helicopter was sliding along the ground at about 20 kph, the aircraft encountered some rough ground. The front section of the left skid was torn off and the helicopter slewed to the left and tilted nose-down. The forward section of the right skid then separated and the main rotor blades contacted the ground before severing the tail boom.

After departing Essendon the aircraft climbed, as cleared by air traffic control, to cruise altitude 9,500 feet. A radar return and label were observed by the Sector 3 Radar Controller in the vicinity of Cowes, on the basis of which a Sartime for clearance to cross controlled airspace at Devonport was calculated. At or about the Sartime, Sector 3 contacted Flight Service 15 to ascertain if the aircraft was listening out on 120.7 (Area frequency). Contact was subsequently established with VH-PZP on 123.8 (Melbourne Control) and the pilot reported his position as 7 nautical miles (by Distance Measuring Equipment) south of Devonport. The aircraft had passed through the north western tip of Launceston controlled airspace without a clearance. No breakdown in separation occurred.

This flight was the pilot's second charter flight. He was unfamiliar with the area. Because this was his first Bass Strait crossing and because he did not hold an instrument rating he co-opted the assistance of another commercial pilot, who holds a current instrument rating, to act as the safety pilot. When he was flight planning, the pilot-in-command did not notice that the route would infringe controlled airspace. The safety pilot subsequently did not detect the penetration.