The aircraft's crew requested a climb to a higher cruising altitude. The Flight Service Officer passed on the request to the responsible Air Traffic Control (ATC) Officer. The correct phraseology and verification procedures were not used between the two, and the aircraft was issued with a climb clearance before the ATC officer had determined that such a clearance was appropriate. The ATC officer subsequently issued a correct clearance and no conflictions resulted.

The pilot reported that smoke was entering the cockpit and that it was accompanied by a burning smell. Subsequently most of the electrical system failed. The aircraft was diverted to Bundaberg and landed without further incident. Examination of the aircraft by maintenance engineers found that the electrical system had been subjected to a high voltage situation and significant damage had been caused to the avionics.

The DME (Distance Measuring Equipment) was found to have been the source of the smoke and probably the burning smell. The aircraft is equipped with a high voltage warning light and the engineers found that it illuminated as soon as power was applied to the electrical system. The pilot reported that the light did not illuminate in flight.

Pirate section [2 X FA18] departed Williamtown for Townsville on climb to Flight Level [FL] 310 at 1112 hours. The section was on a track direct to the reporting point GWYDIR which is the boundary position between Sydney and Brisbane air traffic control [ATC] areas of responsibility. This departure time was relayed to Brisbane sector control by Sydney sector via the intercom line and the Brisbane flight progress strips were activated. The GWYDIR strip at both AACCs indicated the same estimate of 1144 hours.

VH-OGD [Boeing 767] was proceeding at FL 370 on a regular public transport flight from Cairns to Sydney and was tracking via GWYDIR on the reciprocal track to Pirate section.

Sydney sector provided Brisbane sector with a radar identification of Pirate section when those aircraft were approximately 50 NM from the boundary. The leader of Pirate section then requested climb to FL 350 and, after all the appropriate coordination was carried out, this was approved by ATC.

Pirate section realised that they were making time against their flight plan and attempted to pass an amended estimate for GWYDIR to ATC. VHF communications between the aircraft and ATC were poor and, despite two or three attempts, this message was not received by ATC.

During this period the Brisbane sector controllers [procedural and radar] realised that the type of formation being used by Pirate section may involve an infringement of the 2,000 ft vertical separation standard required for the passing of the section with VH-OGD. Because of the poor communications with Pirate section, it required several transmissions to ascertain the type of formation being used and, as no definite answer was received from the crew, it was assumed that the aircraft were in Standard Formation. This meant that one aircraft could be up to 500 ft above the other and would therefore infringe the separation standard in use. Brisbane ATC decided to initiate a cruise level change to guarantee vertical separation and instructed Pirate section to descend to FL 340 with a requirement to reach that level by time 1140 hours. This instruction was acknowledged by Pirate section and complied with.

Brisbane sector had calculated the time of 1140 hours based on a time of passing which was calculated on the respective estimates at GWYDIR for both Pirate section and VH-OGD. Although GWYDIR was within radar coverage, the track that the aircraft were using left radar coverage approximately 30 NM north west of GWYDIR and therefore a procedural standard was required.

The Brisbane sector radar controller was monitoring the progress of Pirate section following the radar hand off from Sydney but did not inform the procedural controller that the section was significantly early in relation to their estimate for GWYDIR.

When Pirate section reported at GWYDIR at 1139 hours the Brisbane sector procedural controller realised that they were five minutes early and recalculated the time of passing on which the level change requirement was based. This resulted in the correct time for the Pirate section to reach FL 340 being 1137 hours and as they had not reported at that level until 1139 hours [their actual position at GWYDIR] a breakdown in separation may have occurred.

Pirate section were on radar at the time and VH-OGD appeared on the radar screen at about the same time approximately 30 NM north west of the position of Pirate section. This distance did constitute a radar standard, but this could not be guaranteed until VH-OGD was identified by the radar controller [a situation that occurred after Pirate section had passed GWYDIR].

The crew of Pirate section stated that they had actually been maintaining FL 340 prior to GWYDIR and, although they cannot remember exactly how long before, it is probable that a breakdown in separation did not occur.

Significant Factors

1. The poor VHF communications between ATC and Pirate section inhibited the passing of significant operational information.

2. The communication between the Brisbane sector radar and procedural controllers was ineffective.

Circumstances

The crew of VH-EWD had flight planned for a regular public transport flight from Canberra to Coolangatta using the route designator C4CBCGXX where XX is the modifier for that particular route. The Melbourne computer aided flight strip printing system interpreted the XX modifier as a track via Bindook and Sydney. The systems used by the airline and Canberra Air Traffic Services (ATS) interpreted XX as a track via Yass and Mudgee.

The Civil Aviation Authority (CAA), while retaining the XX modifier, had recently changed the applicable route from Bindook/Sydney to Yass/Mudgee. The airline and Canberra ATS had effected the appropriate software changes for the route modifier whereas Melbourne ATS had not.

EWD departed Canberra at 0850 EST and tracked via the Yass/Mudgee route as expected by Canberra Air Traffic

Control (ATC). As the vertical limit of Canberra ATC is 10,000 ft, co-ordination procedures between Canberra and Melbourne Sector require the notification of an impending departure to be given to Melbourne prior to the aircraft becoming airborne.  On this occasion co-ordination was not carried out until after EWD had departed. 

Additionally, when Canberra Approach informed Melbourne Sector of EWD's departure, the controller incorrectly referred to the aircraft as EWG.

On receiving the departure advice, the Melbourne controller actioned his EWD flight strip and changed the callsign to EWG. The track details on his strip indicated a track via Bindook and Sydney. As there was no other traffic in that portion of airspace, he elected to wait until he had confirmed the callsign with Canberra and observed the aircraft on radar before taking any additional amendment action. At 0853 Melbourne Sector contacted Canberra Approach to confirm the callsign of the aircraft on the Yass track as their radar was indicating EWD.

Further co-ordination took place between Melbourne and Canberra, which confirmed that the Coolangatta bound aircraft was tracking via Yass and Mudgee. The Melbourne controller subsequently amended all details held in the Area Approach Control Centre for the flight and EWD proceeded without incident.  There was no breakdown in separation and the transfer of responsibility from Canberra to Melbourne was performed in accordance with the prescribed procedures.

CONCLUSION

Significant Factors

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

1. Melbourne ATS had not made the necessary software changes for the route, thus the route modifier being used by Melbourne ATS was incorrect.
2. Canberra Approach Control did not co-ordinate the impending movement of VH-EWD with Melbourne Sector prior to its departure.
3. Canberra Approach Control subsequently used an incorrect callsign when co-ordinating VH-EWD's departure.

SAFETY ACTION

In response to safety deficiencies identified during this investigation the CAA amended their procedures for the allocation of route designator modifiers.  The CAA airspace and air-route structure reviews are changing the parameters of design in respect to these problems and intend that all the new air routes will require new route modifiers for flight planning purposes.

On the second flight for the day the pilot took off with an identical load as on the first flight, but the aircraft would not climb after liftoff. The aircraft was operating with a tailwind, and it was suggested that a gust may have reduced aircraft performance. The pilot recognised the lack of performance immediately and commenced dumping the load, but the performance did not increase sufficiently to avoid contact with two fences and some scrub. Although the aircraft was damaged, the pilot was able to fly a circuit and land on the strip.

The pilot was issued with an amended clearance "Radar Two West Maitland 3000" and was instructed to turn left heading 290 degrees and report leaving 2000 ft. After take-off the aircraft maintained runway heading and penetrated Sydney Control Zone to a point 6 NM west of Sydney. VH-CJA, a Cessna 402, was in potential confliction with VH-TJH, a Boeing 737, on final approach for runway 07 at Sydney.

Civil Aviation Authority Aeronautical Information Circular (AIC) Sydney (Kingsford Smith Airport) 17/93 dated 2 April 1993 stated that "Bankstown Air Traffic Control will instruct pilots in VMC by day, to remain clear of the Sydney CTR when departure instructions have been issued by Sydney ATC which require left turns to headings that will enable the aircraft to remain clear of the Sydney CTR".

The pilot of CJA was not issued with instructions in accordance with AIC 17/93 and had not remained clear of the Sydney Control Zone as required by the Aeronautical Information Publication.

Safety Action

The safety deficiency identified during this investigation resulted in the following Safety Advisory Notice being issued on 30 September 1993.

"The Bureau of Air Safety Investigation suggests that Air Traffic Services and Safety Regulation Divisions of the Civil Aviation Authority review procedures in respect to the Bankstown Runway 11 Radar Two Departure."

An unidentified Beechcraft Bonanza passed within 50 feet overhead Piper PA28, VH-JIO. At the time the PA28 was flying in a north westerly direction at 3500 feet, and the Bonanza was flying in a north easterly direction. Visual meteorological conditions prevailed. The two pilots in the PA28 did not see the other aircraft until it was too late for evasive action. It is possible that the Bonanza pilot did not see the PA28 because there was no obvious attempt to evade.

Significant Factors

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

1. The pilots in the PA28 did not see the other aircraft until it was too late for evasive action.

2. It is possible that the pilot in the Bonanza did not see the PA28.

3. It is probable that pilot lookout was inadequate.

The aircraft was 4 miles southwest of Sydney turning right onto heading 160 for left downwind runway 34, and was assigned descent to 4000 feet. Radar information indicated that the aircraft had descended to 3000 feet and this was confirmed by the pilot. The aircraft was recleared to climb immediately to 4000 feet for separation with departing traffic on runway 25.

The crew reported that the cockpit workload at the time was high and the pilot not flying missed the "500 feet to go" call. The pilot flying continued the descent to 3000 feet, forgetting that he had been assigned 4000 feet.

The aircraft was engaged on a passenger charter flight to Hayman and Hamilton Islands. The first flight from Shute Harbour to Hayman Island was without incident and the aircraft carried out a water landing. The landing gear was then extended and the aircraft taxied via the boat ramp to the terminal area. After boarding a passenger, the pilot taxied the aircraft back onto the water and retracted the landing gear. At this stage, he noted that the aircraft electrical system voltage indication was low and that there was no charge rate indicated. He decided to take off and fly to Hamilton Island and land on the runway. Hamilton Island is the maintenance facility for the operator.

Approaching Hamilton Island, the pilot attempted to make radio contact with the company but received no reply. The Hamilton Island Control Tower was not manned as it was outside its hours of operation. The pilot was unable to ascertain the position of the landing gear as the normal position indicators were not illuminated. He decided to overfly the runway at low level to gain the attention of company ground staff so that they could check the position of the landing gear. There were rain showers and high humidity in the area and the pilot experienced difficulty in observing the gear position via the wingtip-mounted mirrors.

The ground staff blocked the runway with a vehicle, signalled with a red light from the control tower and waved their arms in a fashion which the pilot took to be an indication that he should not land on the runway but alight on the water. However, the signals were meant to convey the message that the landing gear was not fully extended.

After briefing the passengers to put on their life jackets and adjust their seat belts, the pilot made an approach to the water to the north of the runway. The approach was normal but immediately after touchdown the aircraft nosed over and floated inverted in a nose-down attitude. The pilot escaped from the aircraft, which was filling with water, and then assisted the passengers to escape. They were all rescued uninjured by watercraft.

When the aircraft was recovered, it was found that all the wheels were locked in the up position except the left mainwheel which was partially up. Subsequent testing of the landing gear system could not find any fault in the hydraulic-powered extension/retraction system. The electrical failure was traced to a faulty transistor in the voltage regulator

The manual hydraulic landing gear extension system is activated by selecting the gear down with the normal lever and then operating a handle to pump down the four legs of the gear. The action of the lever is light and, when the gear is down, the lever is difficult to move. The position is then checked in the mirrors and by observing the left nosewheel position from the cockpit through the side window. It is considered probable that on this occasion, the pilot, having initially failed to fully extend the gear, selected the gear position lever to the up position and continued pumping, while never achieving a fully up position on all gear legs.

The pilot was experienced on the aircraft type and had completed the required company flight checks. However, his last check on this aircraft type was six months previously, and that check did not include the operation of the emergency gear extension system.

SIGNIFICANT FACTORS

1. The voltage regulator suffered an internal failure which resulted in the battery failing and no electrical power being available to the aircraft.

2. The weather conditions resulted in the cabin windows fogging, making observation of the landing gear position mirrors difficult.

3. The pilot was not adequately familiar with the operation of the emergency landing gear extension system.

4. The signals given to the pilot were misinterpreted as an instruction to alight on the water.

Once airborne from the departure runway, the landing gear was selected up. However, the gear did not complete the up cycle and the in-transit light remained on. All subsequent attempts to cycle or extend the gear were unsuccessful. During the subsequent landing roll, the gear collapsed.

Examination of the landing gear found that gear teeth had broken off the left main actuator crown wheel. Parts of the teeth were imbedded in the pinion gear. A similar type aircraft type in the operator's fleet was also found to have cracking around teeth in one of the landing gear crown wheels.

The CAA Airworthiness section advise that the manufacturer is aware of similar problems elsewhere and is currently undertaking remedial action.