Loss of separation involving a Fokker B.V. F28 MK 4000, VH-EWB and McDonnell Douglas DC-10, 9M-MAS, 100 km east-south-east of Taroom, Queensland, on 17 December 1992

Summary

The aircraft was given a requirement to reach FL310 by a specified time (43) in order to gain separation from opposite direction traffic at FL290. After the specified time (at 44) the pilot reported that he was unable to reach FL310 and was unable to maintain FL300. The aircraft was given immediate descent to FL270. Shortly afterwards the pilot advised that he was able to climb to FL310. A procedural breakdown in separation with the opposite direction traffic occurred.

The crew reported that they had maintained the climb rate using the vertical speed of the aircraft autopilot. This had caused the airspeed to decay because the climb performance of the aircraft was unable to sustain the climb rate demanded. It then became necessary for the aircraft to descend in order to regain its speed and performance.

Occurrence summary

Investigation number 199203065
Occurrence date 17/12/1992
Location 100 km east-south-east of Taroom
State Queensland
Report release date 17/10/1996
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 Fokker B.V.
Model F28 MK 4000
Registration VH-EWB
Sector Jet
Operation type Air Transport High Capacity
Departure point Mt Isa QLD
Destination Brisbane QLD
Damage Nil

Aircraft details

Manufacturer McDonnell Douglas Corp.
Model DC-10
Registration 9M-MAS
Sector Jet
Operation type Air Transport High Capacity
Departure point Brisbane QLD
Destination Kuala Lumpur Malaysia
Damage Nil

Airborne collision involving a Schempp-Hirth Flugzeugbau GmbH Ventus B, VH-GFN and Grob G 103 Twin II, VH-IUR, 16 km west of Jondaryan, Queensland, on 26 December 1992

Summary

After an aero tow to 2000 feet above ground level, the two seat Grob glider descended before the pilot located a thermal. The flight was to give a visiting Japanese glider pilot an experience of gliding in Australia. Two other gliders were launched, and they commenced thermalling in an adjacent thermal.

The Grob pilot later joined the other gliders in their thermal and remained there while climbing from 2500 feet to 3000 feet above ground level. With the other gliders still in the thermal and at least 200 feet higher, the pilot elected to leave and tracked north at 50 knots. A short time later the glider experienced a collision, and the pilot observed another glider immediately above and overtaking.

Suspecting tail damage, the pilot elected to conduct a descent at low speed without the use of dive brakes. The descent in sinking air took about 20 minutes. Both aircraft landed uneventfully.

The pilots later concluded that the single seat glider had departed from the thermal shortly after the two-seater, without the pilot of the single seat aircraft being aware that the other had left. They both departed in the same direction. Because the inter-thermal speed for the single seat glider was 70 knots the pilot accelerated to that speed, using the 200 feet of vertical separation that had existed with the two-seat glider. The result was that neither pilot was able to see the other aircraft prior to the collision.

Occurrence summary

Investigation number 199203079
Occurrence date 26/12/1992
Location 16 km west of Jondaryan
State Queensland
Report release date 08/08/1996
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Airborne collision
Occurrence class Incident

Aircraft details

Manufacturer Grob - Burkhart Flugzeugbau
Model G 103 Twin II
Registration VH-IUR
Sector Other
Operation type Gliding
Departure point McCaffrey's Field QLD
Destination McCaffrey's Field QLD
Damage Minor

Aircraft details

Manufacturer Schempp-Hirth Flugzeugbau GmbH
Model Ventus B
Registration VH-GFN
Sector Other
Operation type Gliding
Departure point McCaffrey's Field QLD
Destination McCaffrey's Field QLD
Damage Minor

Aerodrome related event involving a Boeing 737-377, VH-CZF and Short Bros SD330, VH-KNQ, 6 km north-west of Brisbane, Queensland, on 11 December 1992

Summary

Due to smoke haze conditions, the senior tower controller had advised other controlling agencies some hours previously that the tower could not exercise visual separation in the circuit area. Aircraft were being provided with radar separation for landing.

When the two subject aircraft were approaching for a landing on runway 14, the slower aircraft was in front. That aircraft was asked to maintain its best possible speed and the following aircraft was slowed as much as possible. Separation reduced to below the radar limit when the aircraft were on final approach, with the second aircraft still unable to see the aircraft in front, about three miles ahead. Both aircraft landed safely.

The approach controller had not taken sufficient action to ensure that the aircraft were adequately separated during the approach to land.

FACTORS

1. Smoke haze reduced visibility.

2. The approach controller did not provide adequate separation to the landing aircraft.

Occurrence summary

Investigation number 199203060
Occurrence date 11/12/1992
Location 6 km north-west of Brisbane
State Queensland
Report release date 27/09/1993
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Incident

Aircraft details

Manufacturer Short Bros Pty Ltd
Model SD330
Registration VH-KNQ
Sector Turboprop
Operation type Air Transport Low Capacity
Departure point Maroochydore QLD
Destination Brisbane QLD
Damage Nil

Aircraft details

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

Aerodrome related event involving a Boeing 737-376, VH-TAF, 50 km south-east of Townsville, Queensland, on 31 March 1992

Summary

Sequence of events

The workload on the Arrivals sector at the time had been low with a number of aircraft on frequency but little radio work or co-ordination to conduct.

Two Boeing 737s, VH-TAI and VH-CZF, inbound from Brisbane via route T53 were cleared to descend by the Arrivals controller, TAI to Flight Level 220 (FL220) and CZF to FL330. TAI was also cleared to track direct for a 16 NM final for runway 01.

Another B737, TAF, was overflying Townsville en route from Brisbane to Cairns, initially maintaining FL350. Prior to reaching the area controlled by Townsville Approach the crew was instructed to operate the aircraft's transponder on a discrete code to indicate to the Approach controller that it was overflying. Normally, when aircraft are about 35 NM north of Townsville and this system is in use, pilots are instructed to select their normal transponder code.  They are then handed off to Cairns radar and later instructed to contact Cairns Control.

The radar system in use at the time was not capable of presenting information to facilitate aircraft identification on the radar screen so the controller had to maintain a plastic indicator (known as a "shrimp boat") to indicate each particular aircraft.

The over-flying aircraft was instructed to change to normal transponder code and was cleared to descend to FL210 in accordance with normal procedures. However, the hand-off to Cairns was not conducted and the investigation could not determine how accurately the "shrimp boat" position was maintained. The Cairns controller subsequently queried the position of TAF, and the aircraft was then handed off between controllers.

About this time, a C130 aircraft departed Townsville for Amberley along an outbound track of 155 degrees and climbing to FL210. The Arrivals controller did not generate a "shrimp boat" for the C130 at that time although this was his normal practice. When the C130 had reached about 30 NM south of Townsville, the other aircraft inbound from Brisbane, TAI and CZF, were entering the lower portion of the radar screen at about 85 NM from Townsville and coming under the control of the Arrivals controller.  Both aircraft were close together and conducting a stepped descent that had been arranged with a previous controller. That controller had advised the Arrivals controller that he had limited the descent of TAI to FL220 due to the C130 climbing to FL210. This level had been recorded on the flight strip being used by the Arrivals controller for TAI.

In order to identify both aircraft the controller instructed the crew of TAI to select their transponder to standby. This aircraft was slowly diverging from CZF and tracking direct to a 16 NM final position to the south of

Townsville. The "shrimp boat" for the over-flying aircraft, TAF, was incorrectly moved to the screen indication (radar paint) for TAI, while another "shrimp boat" for CZF was created.  After a report by TAI, CZF was cleared to a new level.  No entry was made on the flight strip.

After identifying CZF, the controller wanted TAI to display its normal transponder code in order to identify that aircraft.  He incorrectly addressed his transmission to TAF, whose pilot acknowledged and added the information that he was approaching FL210.  The aircraft was cleared to descend to 9,000 ft and the Townsville QNH was given.  A frequency change instruction was issued to another aircraft and the Cairns controller advised that he had not yet heard from TAF. By that time TAF was no longer painting on the Townsville radar screen. The Arrivals controller instructed TAF to call Cairns Control and passed the correct frequency. Shortly after this instruction, because the aircraft he was observing as TAF had not displayed the correct transponder code, the controller again instructed TAF to select its normal transponder code and to use the "ident" facility.

The Cairns controller again contacted the Townsville Arrivals controller to ask why TAF had been given descent to 9,000 ft in Cairns' airspace.  It was at this time that the Arrivals controller realised that he had confused callsign's of the two aircraft. He then advised TAI to select its discrete transponder code and "ident".

Prior to this time, the Approach controller had wanted to hand the C130 off to the Arrivals controller. On looking across the room he realised that the Arrivals controller was busy attempting to identify two aircraft. The second Arrivals controller was also returning to the console and was aware that the controller was involved with talking to aircraft and conducting co-ordination simultaneously. He began to configure the console for two- controller operation. The Approach controller elected to retain control of the C130 until he was satisfied that the other controller could accept the aircraft. He was aware that the inbound track of TAI would pass close to the outbound track of the C130.

As soon as the Arrivals controller had obtained a transponder return, and without advising the crew of TAI that their aircraft was identified, he cleared the aircraft to descend to 9,000 ft.  As there was adequate radar separation between TAI and CZF, he also cleared CZF to descend to 9,000 ft. The Approach controller overheard this clearance given to CZF and went to the radar screen and pointed at the C130 return.  He was waved away by the Arrivals controller. The Approach controller and the new Arrivals controller co-ordinated rapidly and directed the C130 to maintain FL170 and TAI to maintain FL180. Shortly afterwards the pilot of TAI reported that he had just passed a C130. The strips for TAI and CZF did not reflect the levels to which both aircraft had been cleared.

CONCLUSION

Findings

  1. While attempting to resolve the traffic situation, the Arrivals controller confused the callsigns of TAF and TAI.
  2. After identifying TAI and CZF on radar, the Arrivals controller cleared both aircraft to descend to 9,000 ft causing a loss of separation standards between the climbing C130 and TAI.

Significant factors

  1. The controller did not follow local procedures to ensure that aircraft were correctly identified on the radar screen.
  2. The controller became confused and lost perception of the air traffic situation.

Occurrence summary

Investigation number 199202704
Occurrence date 31/03/1992
Location 50 km south-east of Townsville
State Queensland
Report release date 06/08/1996
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Incident

Aircraft details

Manufacturer The Boeing Company
Model 737-376
Registration VH-TAF
Sector Jet
Operation type Air Transport High Capacity
Departure point Brisbane QLD
Destination Cairns QLD
Damage Nil

Callsign confusion involving a Beech Aircraft Corp 58, VH-KEW and Beech Aircraft Corp 58, VH-WLC, Brisbane, Queensland, on 19 November 1992

Summary

The pilot of VH-WLC used the wrong callsign when commencing to taxi (i.e. VH-KEW). He changed to the correct callsign when ready to take off and advised ATC. The controllers had strips for both callsigns and changed the callsign on the strips initially used instead of changing strips. As a result, ATC had the aircraft route and altitude incorrect. Calls made by the pilot after take-off were mis-heard by the controllers.

Occurrence summary

Investigation number 199203022
Occurrence date 19/11/1992
Location Brisbane
State Queensland
Report release date 17/10/1996
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Incident

Aircraft details

Manufacturer Beech Aircraft Corp
Model 58
Registration VH-KEW
Sector Piston
Operation type Charter
Departure point Brisbane QLD
Destination Wondai QLD
Damage Nil

Aircraft details

Manufacturer Beech Aircraft Corp
Model 58
Registration VH-WLC
Sector Piston
Operation type Charter
Departure point Brisbane QLD
Destination Goonoo QLD
Damage Nil

Collision with terrain involving a Hughes Helicopters 269C, VH-AJC, Corella Park Station, 30 km north-west of Cloncurry, Queensland, on 21 May 1992

Summary

The pilot and passenger were conducting inspections at various company facilities in the area. They had landed at a drilling site for an inspection which lasted over one hour. After a routine start-up and lift-off to a low hover, the helicopter commenced to move forward but the main rotor blades struck the ground.

The pilot considered that he had been unable to obtain correct cyclic control response during the take-off. No faults were found to indicate a control problem, although some parts at the top of the mast were substantially damaged during the accident.

Occurrence summary

Investigation number 199202576
Occurrence date 21/05/1992
Location Corella Park Station, 30 km north-west of Cloncurry
State Queensland
Report release date 20/02/1995
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 Hughes Helicopters
Model 269C
Registration VH-AJC
Sector Helicopter
Operation type Business
Departure point Corella Park Stn QLD
Destination Corella Park Stn QLD
Damage Substantial

Ground strike involving a Cessna U206G, VH-WKH, Lindeman Island, Queensland, on 24 January 1992

Summary

The aircraft was to take off from Lindeman Island. The strip was reported as being a bit rough. The pilot held the control column full back during the take-off run, however the nose gear struck the ground three or four times. As the aircraft speed approached take-off speed the nose gear collapsed, and the aircraft skidded to a halt in a nose-down attitude.

Occurrence summary

Investigation number 199202553
Occurrence date 24/01/1992
Location Lindeman Island
State Queensland
Report release date 12/06/1996
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 U206G
Registration VH-WKH
Sector Piston
Operation type Private
Departure point Lindeman Is QLD
Destination Hamilton Is QLD
Damage Substantial

Abnormal engine indications involving a de Havilland Canada DHC-8-102, VH-TQR, SYDNEY , NSW on 29 November 1992

Summary

During climb out of Sydney the left engine oil pressure warning illuminated, associated with a falling oil pressure indication. The left engine was shut down. ATC were advised of the problem and the aircraft returned to Sydney where an uneventful single engine approach and landing was carried out. Investigation revealed the rear bearing oil scavenge line was cracked and the rear turbine blades showed evidence of foreign object damage. Engine strip revealed a low pressure turbine blade had failed from fatigue. There is an improved blade assembly now available which the operator is using to upgrade the fleet.

Occurrence summary

Investigation number 199202532
Occurrence date 29/11/1992
State New South Wales
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 De Havilland Canada/De Havilland Aircraft of Canada
Model DHC-8-102
Registration VH-TQR
Sector Turboprop
Damage Nil

Abnormal engine indications involving a Saab SF-340B, VH-OLM, SYDNEY , NSW on 18 November 1992

Summary

Shortly after take-off, whilst climbing through 6000 feet, the left AC generator light illuminated and could not be reset. A loud vibration was heard and felt from the left engine. Visual inspection revealed black smoke coming from the generator vent, and remnants of red hot generator windings against the grill of the vent. There were no fire warnings but the engine was shut down to prevent further damage. The aircraft returned to Sydney where an uneventful single engine landing was carried out. Examination of the generator revealed that the drive end bearing had failed, allowing the rotor to contact the stator. The drive shaft however was reported to be in good condition, having failed to shear and disconnect the generator from the engine as intended. This matter has been referred to the Civil Aviation Authority for resolution with the manufacturer to ensure that the design of the generator drive shaft is suitable for the application.

Occurrence summary

Investigation number 199202527
Occurrence date 18/11/1992
State New South Wales
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 Saab Aircraft Co.
Model SF-340B
Registration VH-OLM
Sector Turboprop
Damage Nil

Partial power loss involving a Piper PA-31-350, VH-NDU, Sydney, New South Wales, on 28 October 1992

Summary

Approaching the top of climb the left engine began to surge moderately. Engine temperature and pressure appeared normal. Although the pilot carried out trouble checks the surging continued and moderate vibration was noticed. The pilot decided to return to Sydney, but two minutes later an audible 'crack' was heard from the engine. The propeller was feathered, the engine secured, and the aircraft continued to Sydney for an uneventful single engine landing.

It was later determined that the left engine crankshaft had suffered a fatigue failure at the forward crankweb. The shaft was on its second life and had completed 265 hours since the engine was last reconditioned. No rework had been performed on the shaft during reconditioning.

Occurrence summary

Investigation number 199202509
Occurrence date 28/10/1992
Location Sydney
State New South Wales
Report release date 03/08/1994
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-31-350
Registration VH-NDU
Sector Piston
Operation type Air Transport Low Capacity
Departure point Sydney NSW
Destination Forbes NSW
Damage Nil