Loss of separation involving a Boeing 747, and McDonnell Douglas F/A-18A, 70 km east of Sydney, New South Wales, on 15 March 1993

Summary

Singapore Airlines Flight 288 [SIA288] was maintaining Flight Level [FL] 310 on a flight from Auckland to Singapore. It had been cleared to transit Restricted Area R588 at FL 310 by Sydney Sector 5 who had correctly co-ordinated the clearance with Williamtown Approach control.

Four RAAF FA18A aircraft, operating as Shogun Section, had completed an exercise to the south of R588 and requested a clearance from Williamtown Approach control to return to Williamtown for a landing. The controller cleared Shogun Section to transit R588 at FL 310 from south to north on a course that was in conflict with SIA288.

As the aircraft approached each other, Williamtown Approach noticed the confliction and passed traffic information to Shogun Section, who then initiated evasive action by climbing above the level of SIA288.

The crew of SIA288 was not given traffic information by Sydney control but saw two FA18A aircraft and assessed that their own aircraft would pass behind. They therefore elected not to take any other action.

The aircraft passed within 2.7 NM of each other with 900 ft vertical difference. The required separation standard is 5 NM or 2,000 ft and, as such, a breakdown in separation occurred.

Significant Factors

1. The RAAF controller issued clearances for SIA288 and Shogun Section without correct application of the appropriate separation standards.

Occurrence summary

Investigation number 199300532
Occurrence date 15/03/1993
Location 70 km east of Sydney
State New South Wales
Report release date 26/07/1993
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 McDonnell Douglas Corp.
Model F/A-18A
Registration Unknown
Sector Jet
Operation type Military
Departure point Williamtown NSW
Destination Williamtown NSW
Damage Nil

Aircraft details

Manufacturer The Boeing Company
Model 747
Registration Unknown
Sector Jet
Operation type Air Transport High Capacity
Departure point Auckland NZ
Destination Singapore
Damage Nil

Ground handling involving a Fokker B.V. F28 MK 1000, VH-FKF, Geraldton, Western Australia, on 15 March 1993

Summary

A passenger reported that incorrect techniques were used when refuelling the aircraft, with respect to the earthing of the aircraft. The report was correct, however, investigations revealed that the petroleum company and the CAA were in the final stages of negotiation to change the relevant Civil Aviation Orders (CAO's). Although not in accordance with the CAO's, the procedure used was not dangerous, according to the petroleum company representative and was acceptable to the CAA.

Occurrence summary

Investigation number 199300530
Occurrence date 15/03/1993
Location Geraldton
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 Ground handling
Occurrence class Incident

Aircraft details

Manufacturer Fokker B.V.
Model F28 MK 1000
Registration VH-FKF
Sector Jet
Operation type Air Transport High Capacity
Departure point Exmouth WA
Destination Geraldton WA

Hydraulic involving a Cessna 404, VH-BPO, Ararat, Victoria, on 29 January 1993

Summary

In the circuit area at Ararat the landing gear failed to extend. After two attempts to recycle, both hydraulic flow lights illuminated indicating loss of hydraulic fluid. The aircraft returned to Essendon where the landing gear was extended by the emergency system and the aircraft landed safely.

Hydraulic oil was leaking from the right wing root area. Investigation showed that an aluminium high-pressure pipe had fractured due to fatigue. The pipe was replaced with a flexible hose in accordance with a locally approved modification.

Occurrence summary

Investigation number 199300529
Occurrence date 29/01/1993
Location Ararat
State Victoria
Report release date 26/05/1993
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Hydraulic
Occurrence class Incident

Aircraft details

Manufacturer Cessna Aircraft Company
Model 404
Registration VH-BPO
Sector Piston
Operation type Medical Transport
Departure point Warrnambool VIC
Destination Ararat VIC
Damage Nil

Wheels up landing involving a Beech Aircraft Corp 58, VH-SMW, Adelaide Airport, South Australia, on 16 March 1993

Summary

The flight proceeded normally until on approach to Adelaide Airport, when the pilot found he could not extend the landing gear. The emergency system was also tried but still no gear down indication could be obtained.

A wheels up landing was then made on runway 30.

Later inspection of the gear system revealed that on the last gear up selection a gear motor over-run had occurred. This caused the gear to be jammed in the up position and for the emergency gear extension mechanism to be damaged. The reason for the gear motor over-run was a defect in the dynamic brake relay which prevented the motor operation from ceasing in the normal up position.

Significant Factors

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

1. A dynamic brake relay was defective.

2. The emergency gear extension system became damaged as a result of the defective dynamic brake relay.

Occurrence summary

Investigation number 199300526
Occurrence date 16/03/1993
Location Adelaide Airport
State South Australia
Report release date 27/10/1994
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 Beech Aircraft Corp
Model 58
Registration VH-SMW
Sector Piston
Operation type Charter
Departure point Port Lincoln SA
Destination Adelaide SA
Damage Substantial

Runway excursion involving a Thorp Engineering T-18, VH-CMC, Kalgoorlie, Western Australia, on 24 February 1993

Summary

After an uneventful landing, the aircraft veered to the left and ran off the side of the runway, despite the correcting control inputs from the pilot. The left wheel entered soft dirt and swung the aircraft further to the left, causing it to head towards an earthen bank. The pilot prevented the aircraft from hitting the bank by ground looping the aircraft, which damaged the aircraft by placing excessive side loads on the undercarriage. The pilot was familiar with the aircraft, and the wind was light and variable.

Occurrence summary

Investigation number 199300525
Occurrence date 24/02/1993
Location Kalgoorlie
State Western Australia
Report release date 29/06/1993
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Runway excursion
Occurrence class Accident

Aircraft details

Manufacturer Thorp Engineering Company
Model T-18
Registration VH-CMC
Sector Piston
Operation type Private
Departure point Unknown
Destination Kalgoorlie WA
Damage Substantial

Electrical systems involving a Fokker B.V. F28 MK 4000, VH-EWD, Melbourne, Victoria, on 16 January 1993

Summary

Shortly after take-off the warning annunciator for the 26V AC bus supply illuminated followed by a strong electrical burning smell. Power was removed from the bus and the smell diminished. After a successful landing the investigation disclosed that a power supply diode had overheated and failed.

Occurrence summary

Investigation number 199300524
Occurrence date 16/01/1993
Location Melbourne
State Victoria
Report release date 26/05/1993
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Electrical system, Fumes
Occurrence class Incident

Aircraft details

Manufacturer Fokker B.V.
Model F28 MK 4000
Registration VH-EWD
Sector Jet
Operation type Air Transport High Capacity
Departure point Melbourne VIC
Destination Launceston TAS
Damage Nil

Forced/precautionary landing involving a Cessna A188B/A1, VH-JWD, Chinchilla, Queensland, on 16 March 1993

Summary

The aircraft was undergoing a check flight after a 100 hourly inspection. It had not been used for at least 10 months, nor had it been stored correctly. After a number of simulated spray runs across the aerodrome the pilot climbed to conduct an approach to land. On late downwind at 350 ft agl the engine and propeller stopped. The pilot manoeuvred the aircraft towards a clear area but the aircraft landed heavily short of the area. The reason for the engine stopping was not determined.

Occurrence summary

Investigation number 199300511
Occurrence date 16/03/1993
Location Chinchilla
State Queensland
Report release date 14/07/1993
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Engine failure or malfunction, Forced/precautionary landing, Hard landing
Occurrence class Accident
Highest injury level Minor

Aircraft details

Manufacturer Cessna Aircraft Company
Model A188B/A1
Registration VH-JWD
Sector Piston
Operation type General Aviation
Departure point Chinchilla QLD
Destination Chinchilla QLD
Damage Destroyed

Ground strike involving a Grob G-115, VH-TGK, Parafield, South Australia, on 4 March 1993

Summary

The student pilot was conducting his third solo session of circuit training.

On the second circuit, which was to be a full stop, the aircraft encountered turbulence on short final which caused the aircraft to climb and drop a wing.

The pilot pushed the nose down then flared the aircraft. After touchdown, the aircraft bounced and began a series of purposing manoeuvres until the nose leg broke and the aircraft came to a stop with damage to the propeller, nose gear and tail skid.

Occurrence summary

Investigation number 199300513
Occurrence date 04/03/1993
Location Parafield
State South Australia
Report release date 09/03/1994
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 Grob - Burkhart Flugzeugbau
Model G-115
Registration VH-TGK
Sector Piston
Operation type Flying Training
Departure point Parafield SA
Destination Parafield SA
Damage Substantial

Partial power loss involving a Piper PA-31T, VH-DXI, Point Cook, Victoria, on 12 March 1993

Summary

When the pilot attempted to reduce propeller RPM from 2000 to 1900 the right propeller wound down to between 1100 and 1200 and the right torque exceeded maximum limits. The pilot shut down the engine and feathered the propeller when he was unable to regain control. A successful single engine landing was carried out.

The right engine beta light wiring was found to be routed close to the engine exhaust stack. Radiant heat from the exhaust stack had melted the insulation and had allowed the wires to contact and create an electrical short circuit. This had activated the propeller lock valve which effectively caused the propeller to operate at fixed pitch.

It could not be determined whether the burned wiring installation was installed in accordance with the manufacturers original design. A modification has now been incorporated to introduce fire sleeved wiring and a heat deflector baffle.

Occurrence summary

Investigation number 199300514
Occurrence date 12/03/1993
Location Point Cook
State Victoria
Report release date 19/06/1994
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 Piper Aircraft Corp
Model PA-31T
Registration VH-DXI
Sector Turboprop
Operation type Private
Departure point Point Cook VIC
Destination Essendon VIC
Damage Nil

Abnormal engine indications involving a Boeing 727-277, VH-ANF, 5.5 km south-west of Adelaide, South Australia, on 25 February 1993

Summary

The aircraft had just taken off when the fire warning for the centre (No. 2) engine activated. The crew carried out the engine fire drill, shut down the engine and commenced a right hand circuit for a landing back on runway 23.

A distress phase was declared by the tower and emergency services alerted. On downwind, the crew advised that a fire was no longer evident. The aircraft landed without further incident, and the passengers were evacuated through the front doors.

Subsequent investigation revealed that a weld in the bleed air "Y" duct for the de-icing system of the engine intake had suffered a fatigue failure. This allowed hot bleed air into the engine compartment which activated the fire warning system. This type of failure has occurred before and there are Service Bulletins addressing the problem.

Occurrence summary

Investigation number 199300485
Occurrence date 25/02/1993
Location 5.5 km south-west of Adelaide
State South Australia
Report release date 09/03/1994
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 727-277
Registration VH-ANF
Sector Jet
Operation type Air Transport High Capacity
Departure point Adelaide SA
Destination Melbourne VIC
Damage Nil