The student was landing at the completion of a solo training flight. After an apparently normal touchdown, the aircraft suddenly swung to the right and tipped forward on to its nose, collapsing the nose gear leg in the process. The pilot reported that, after landing, she applied right rudder to correct the aircraft back to the centreline but inadvertently applied right brake. This resulted in her losing directional control of the aircraft.

Findings

1. The pilot inadvertently applied right brake while attempting to control direction by the application of right rudder.

2. The pilot lost directional control of the aircraft. 3. The pilot's flying experience level was low.

Boeing 767, CF-BEG, had departed Sydney at 1352 hours on a regular public transport flight to Auckland and was climbing to Flight Level (FL) 370. The aircraft was being controlled by Sydney Arrivals North who maintained it at FL 270 due to the presence of an opposite direction aircraft. When the controller was able to radar separate these aircraft he climbed CF-BEG to FL 290 as other arriving traffic precluded the use of a higher level at that time. Arrivals North then handed over the control of CF-BEG to Sector 5 who immediately asked how separation was being achieved with N68065, a Douglas DC10 aircraft maintaining FL280, which was inbound to Sydney from Auckland and on the reciprocal track to CF-BEG.

The Arrivals controller claimed to have no knowledge of N68065, and immediate checks were made of the aircraft altitudes. This check revealed that CF-BEG was maintaining FL 290 and therefore a 1,000 ft separation standard had been achieved. The arrivals north flight progress strip had been placed on the console, but the controller had not placed it in the flight progress board to indicate the confliction. The arrivals controller was performing the combined duties of Arrivals North and Arrivals South at the time due to a comfort break requirement of the other controller.

Sector 5 was being performed by a controller under training supervised by a suitably rated check controller. The trainee had recognised the conflict between N68065 and CF-BEG and had twice attempted to pass a separation requirement to Arrivals North. Each time the arrivals controller was busy, and the co-ordination was unsuccessful. As the sector traffic situation increased in workload due to poor weather and several aircraft diversions, the trainee forgot to make a third attempt to pass this information, and the check controller was unable to arrange for it to be done.

The approach procedural controller had received the co-ordination on N68065 from sector 5 and had updated the information on the flight progress strip and passed it to the arrivals north controller who did not immediately place the strip in the flight progress board. The strip was still in front of the arrivals controller at the time of the occurrence. Workload was considered to be moderate.

Findings

1. Arrivals north controller was on combine and his workload was considered moderate.

2. The arrivals north controller had not placed the flight progress strip for N68065 onto the flight progress board and was thus unaware of its operation.

3. Due to the moderate workload at the arrivals north position, the controller was unable to accept incoming verbal communications which would have alerted him to the possibility of a conflict between N68065 and CF-BEG.

The aircraft and instructors from an aero club were based at Eulan Downs to train a group of five students to the general flying progress test (GFPT) standard. The instructor and student had planned to carry out an upper air sequence prior to returning to Fairfield to commence circuit training. After the completion of the upper air flying the instructor decided to demonstrate a practice forced landing. The forced landing was commenced at 2500 feet above mean sea level (the elevation of the airstrip is 600 feet amsl).

During the descent the instructor found it necessary to adjust his circuit, to ensure a landing on the airstrip, such that a base turn was commenced approximately abeam the threshold and the aircraft aligned on final at about 20 feet above the ground. The instructor reported that the indicated airspeed was 60 knots and the flaps were still selected up when the aircraft was aligned on final. The aircraft stalled at this point and landed heavily on the airstrip. All three legs of the landing gear were torn off and the aircraft slid for about 20 metres before coming to rest.

As the landing gear was retracted after take-off, the baggage door warning light illuminated and a noise consistent with a propeller strike was heard. The aircraft returned for a landing on runway 34, and on inspection the nose locker door was found open. A piece of baggage was missing. A bag was found on the runway and there was evidence of propeller slash marks on it. The pilot stated that he had checked the nose locker door prior to starting engines and it was locked. The door may have become unlocked due to baggage pressure on it. The lock has been replaced as a precautionary measure.

During the pre-flight check at Los Angeles, when the Standby Power switch was selected to Battery, the captain's electronic navigation displays went blank, the upper Engine Indication and Crew Alerting System (EICAS) display transferred to the lower screen, and an additional message 'Standby Bus Main' was displayed. It was later determined that the standby inverter was missing from the aircraft. Investigation determined that the inverter had been removed in Sydney on the previous day, to service another aircraft.

Maintenance engineers involved with the removal did not raise the appropriate documentation as they were unaware of the requirements of the company Policy and Procedures Manual. No formal shift handover was conducted, consequently subsequent shift personnel were unaware of the missing component and released the aircraft for service. The aircraft was then flown to Los Angeles.

During the departure preflight cockpit check at Sydney, the correct responses were displayed when the standby power test was performed but the crew were not alerted to the additional 'Standby Bus Main' message as the checklist does not mention it. EICAS display transfer to the lower screen was not noticed as the cockpit was sunlit and the captain's navigation instrument displays were selected to low intensity at the time.

Significant factors

1. The maintenance crew was unaware of the required documentation procedures.

2. The maintenance crew did not conduct a formal shift handover.

3. The cockpit checklist was deficient with regard to testing the standby power system.

Safety action

As a result of this investigation the operator advised that they had initiated the following safety actions in respect to the deficiencies relating to the training of certifying engineers on the requirements of the company Policy and Procedures manual:

1. The course notes for the LAME Introduction Course were distributed to all LAMEs including those at line stations. A where to find it booklet was also given to AMEs. These actions were completed by the end of August.

2. Maintenance Memo Number M1884 was issued to alert all LAMEs to their responsibility to follow approved procedures. It provided information as to which volume would be relevant to the particular work area.

3. In conjunction with item 2, Department Heads checked and, in some cases, improved the availability of the appropriate P.&P. Manuals in their areas. This was completed prior to the end of August.

4. In order to provide a concise and accurate analysis of incidents for those persons who need to know we have introduced a Quality Alert Bulletin. The objective of which is to ensure all benefit from the lessons learned. The information is depersonalised for obvious reasons.

5. While there was nothing wrong with the existing procedure for serviceable transfer (Vol. 5 chapter 3-40-05) we took the opportunity to emphasise its existence when it was revised.

Maintenance Memo M1880 refers.' The Bureau of Air Safety Investigation made the following interim recommendations on 9 February 1994:

IR940015

The Bureau of Air Safety Investigation recommends that the Civil Aviation Authority liaise with the Boeing Commercial Airplane Company, in conjunction with the Australian operator, to amend the B747-438 Flight Deck Preparation Checklist to include reference to additional EICAS messages that will be displayed when an unacceptable condition exists with the standby power system.

The CAA response stated, in part: 'The Authority believes that the abnormal indication of the Captain’s display blanking and EICAS transfer to the secondary screen should have been sufficient indication that there was a problem with the aircraft systems. We do not believe it is reasonable to expect aircraft systems to compensate for abnormal maintenance actions and the range of inappropriate actions that are possible would make such an approach difficult to address. Nevertheless, the Authority will raise the matter of amendment to the B747-400 Flight Deck Preparation Checklist to highlight that further investigation of any unusual indications during flight deck preparation checks is necessary.'

The operator response stated: 'I have enclosed a copy of a revised page for the 747-400 Operations Manual. This revision has been written as a result of the referenced A.S.I.R. The revision is highlighted by a margin line bar and will be processed as part of a general revision to go to printing at the end of the week. Rather than make the comment specific to the Standby Power check, I have included it as part of the preamble to the whole flight deck preparation. I feel that this is more appropriate as there are potentially other areas where a similar problem could occur should these circumstances ever arise again.

IR940016

The Bureau of Air Safety Investigation recommends that (the operator) conduct a review of policy relating to shift handover procedures to include directions for individuals as well as supervisors.

The operator response stated, in part: 'The reason the static inverter was not fitted to VH-OJB was that the engineer who removed the inverter failed to carry out the requirements of the Policy and Procedures manual in regards to not entering in the aircraft log book or work package that the inverter had been removed from the aircraft to service the other aircraft. By making an entry as required the person removing the item is also fulfilling the requirements of an individual handover as this entry has to be acquitted prior to the Maintenance Release being certified.

After the investigation of this incident the engineer involved was counselled and disciplinary action was effected against him. As well the Policy and Procedures manual reference to the actions required when cannibalising aircraft components has been amended to clarify the requirements when carrying out this function. These procedures have since been widely distributed to all Sydney Line Maintenance staff.'

A surf competition was being held. Teams with their equipment were on the beach. The pilot made a landing approach from over the sea, with an estimated 15 knot tailwind, towards the designated helicopter landing site where two other media helicopters had already landed. The pilot was being guided into the landing site by another helicopter pilot on the ground.

On short final he realised that his rotor downwash had diverted to the right front of the helicopter and was dislodging equipment on the beach. He immediately aborted the approach and landed elsewhere. The diverted downwash lifted a surf boat which struck and injured a female competitor.

The pilot had been spraying the paddock all morning and, for nearly four hours, had been crossing a set of wires running across the field almost at right angles to the aircraft's flight path. On the third run of the fifth load for the day the aircraft's main wheels contacted the top wire of a two wire set, and the forward motion was arrested causing the aircraft to impact the ground.

During the ground impact sequence the pilot was thrown from the aircraft when a seat belt anchor point failed due to corrosion. The pilot had no recollection of any events during the day of the accident. Determination of the actual position of the wire was possibly made more difficult by the wire and one of the support poles tending to blend into the background. A possible contributory factor was that the pilot's concentration may have been reduced due the death of a relative the day before the accident.

The pilot initiated a take-off after last light utilising the headlights of a parked motor vehicle to light part of the strip. Added to the poor lighting available, the windscreen of the aircraft became partially fogged, reducing the pilot's view in the proposed take-off direction. During the take-off run the aircraft began to veer to the left and, although the pilot attempted to abandon the take-off, it ran off the strip and struck a fence.

During approach to the Armidale circuit a vibration was felt followed by fluctuating power indications on the left engine. The vibration increased, so the left engine was shut down and the propeller feathered. After landing, oil was observed leaking from a hole in the top of the left engine crankcase.

Investigation revealed a fatigue failure of the crankshaft which then caused the failure of two connecting rods, one of which punctured the crankcase causing the oil loss.

Metalurgical examination of the crankshaft failure revealed that the fatigue crack had initiated from grinding stress cracks in the aft radius of the No. 5 connecting rod journal. Grinding rework had been performed in this area during the previous engine overhaul, 15 hours before the failure.

The pilot was above his desired descent profile so he selected the landing gear down before entering the circuit area. On arrival in the circuit area, the radio became inoperative due to an electrical failure and the pilot was given a green light by the tower controller as a clearance to land. Shortly after the nosewheel contacted the runway, it collapsed, followed almost immediately by the right main landing gear collapsing.

The aircraft slewed right and came to rest off the sealed surface approximately 250 metres from the departure end of the runway. The pilot indicated that, although it was his habit to check the green landing gear light and the mechanical indicator after selecting the landing gear down and prior to landing, he could not recall whether he had done so on this occasion.