The pilot was taking his passenger for a flight to demonstrate the aircraft. Following preflight and pre-take-off checks the take-off was commenced from runway 28. The aircraft accelerated normally until 60 knots when the aircraft was established in a 400 feet per minute climb. As the aircraft crossed the upwind threshold it began to sink. The pilot checked the performance and found that the airspeed was 60 knots, and the engine was developing full power. He lowered the nose of the aircraft to the straight and level attitude and the aircraft maintained level flight. However, as the nose was raised again to outclimb trees ahead, the aircraft again began to sink. The pilot turned the aircraft to the right towards a clear area but was unable to avoid the trees.

The aircraft came to rest upright in an area covered by 15 foot high regrowth. The pilot was able to extricate himself from the wreckage but because of his injuries could not free the passenger.

The pilot had not operated from Mareeba prior to this flight and was unaware that local pilots do not normally use runway 28 for take-off because of downdraughts near the upwind threshold.

At the time of the accident the weather was fine and clear with a temperature of 22 degrees Celsius and no wind.

The pilot had landed the aircraft and was decelerating on the runway when an object was seen in the grass directly ahead. Avoiding action was not possible and the left mainwheel hit the object, which was later identified as an old runway marker. The marker was thrown up and hit the tailplane, causing damage of the left horizontal stabiliser. The marker was partly rusty and was obscured from observation because of the long grass and the camouflaging effect of the surrounding colours.

The pilot elected to test fly the aircraft and then return to home base without first consulting an engineer.

The pilot was engaged on his second charter flight for the day from Darwin. A clearance for an immediate take-off was given but the pilot delayed on the taxiway until prompted by the tower controller.

The departure clearance was via Lee Point to the north, but the aircraft was observed tracking to the west. As there were three other aircraft in the circuit, the pilot was again instructed to track via Lee Point which he acknowledged. The aircraft continued to track west and was instructed to turn onto a heading of 360 degrees to avoid circuit traffic. A short time later the aircraft made a 180 degree turn and advised the tower he was returning to Darwin. A traffic alert was given by the tower controller and the other aircraft in the circuit altered course to prevent a breakdown in separation.

Being unfamiliar with the area, the pilot stated that he had confused East Point (west of Darwin) with Lee Point.

The previous evening, the pilot had worked at a part-time position until 0100. He then worked from 0600 until 1100 on the day of this flight before commencing his rostered flying duties.

VH-WIL was operating in the circuit area at Port Lincoln for the purpose of testing the installation of a Mogas conversion. The LAME who had carried out the work was the pilot-in-command. He was accompanied by the owner who was seated at the right hand control position. After entering downwind for a touch-and-go landing on runway 23, the pilot, while testing the new fuel pump switch, inadvertently selected the master switch off. When the master switch was reselected, the VHF radio, which had been set to the MTAF frequency, defaulted to 121.5 Mhz. The pilot then selected an incorrect frequency. At the same time, VH-LNB taxied and lined up on runway 19 for departure to Adelaide after making all the necessary radio calls. VH-WIL made an approach and landed just past the threshold of RWY 23. As the pilot applied power again for take-off, the passenger sighted VH-LNB rolling on RWY 19. The pilot of VH-WIL aborted his take-off well short of the intersection of the two runways, selected the correct frequency and called VH-LNB.

When the aircraft left the control area on its previous flight, it was noted by ATC staff that the transponder was not operational. The operator was informed that the equipment was unserviceable but that the aircraft would be allowed into the control area on its return flight. However, when the aircraft reported outside the control area (OCTA) for a clearance it was denied on the basis that the transponder was unserviceable. This left the aircraft crew with the option of proceeding OCTA or landing somewhere else. The crew continued OCTA but inadvertently infringed the 3,000 step north of Cairns due to unfamiliarity with VFR procedures in the area and difficulty with the radio navigation chart presentation. As a result of this investigation, ATS has modified their approach to this type of situation. Aircraft crews will no longer be forced OCTA under similar circumstances. One of the problems inherent in the present radar system in Cairns is that only transponder returns can be seen beyond 50nm to the north-west due to terrain shielding of the primary radar. ATC's first option should have been to reroute the aircraft to track in from the north to give primary radar coverage earlier. A second option was to bring the aircraft in on a procedural clearance.

The pilot was positioning the aircraft so that a left-handed shooter could take aim and shoot from the left seat. The aircraft was at about 40 feet above ground level and with minimal forward speed when the engine suddenly began running roughly and, after several back-fires, stopped. The pilot was unable to enter auto-rotation, and the aircraft landed heavily. The main rotor struck and severed the tail boom, and the aircraft skids were flattened during the impact.

Inspection of the wreckage revealed that the fuel selector was partially closed and that insufficient fuel, for normal operation, was able to reach the engine. An assessment of the sequence of events indicates that it is probable that, as the shooter was positioning the rifle for the shot, its butt made contact with the unprotected fuel selector lever and moved it to the partially closed position. The height at which the engine failure occurred prevented the pilot from cushioning the landing.

Safety Action

During the initial stages of the investigation, the Bureau issued Interim Recommendation IR930075 to the Civil Aviation Authority. It recommended:

That the Civil Aviation Authority advise R22 operators of the possibility for unintentional movement of the rear bulkhead mounted fuel selector and consider implementing a requirement for fuel selector protection to minimise inadvertent operation.

They subsequently advised that the Authority was in agreement with the recommendation and had issued an appropriate letter to all R22 operators on the matter. The Robinson Helicopter Company had also been advised of the accident and would be forwarded a copy of the letter.

Hudson 587 [HS748] was proceeding on a flight from East Sale to East Sale via Dubbo at Flight Level [FL] 170. While under the control of Melbourne Sector 2 the pilot requested a climb to FL190 and a diversion east of track for weather avoidance. The request was approved by air traffic control who then co-ordinated the changes with Sydney Flight Information Service [FIS] 6 as the track would take the aircraft outside controlled airspace [OCTA] for 8nm before entering Sydney Sector 6 airspace.

Some confusion arose as to which FIS position was responsible for the airspace because officers were still unfamiliar with recent boundary changes. The FIS 6 position was the wrong position to which to direct the co-ordination as FIS 2 had responsibility for that portion of airspace. The FIS 6 operator misjudged the actual track of Hudson 587 believing that the aircraft would remain in controlled airspace and, as such, the Melbourne Sector 2 controller would co-ordinate directly with the Sydney Sector 6 controller. On that basis the FIS 6 operator decided that no further action by him was required.

The Melbourne Sector 2 controller, although co-ordinating with the wrong FIS, instructed Hudson 587 to call Sydney on the correct frequency, which the crew did. The FIS 2 operator heard the call but was not expecting the aircraft as no co-ordination had been received by him. He immediately commenced co-ordination checks with Melbourne Sector 2, FIS 6 and Sydney Sector 6 to establish the current status of Hudson 587. Finally, Sydney Sector 6 issued an airways clearance for Hudson 587, but, as the aircraft was only OCTA for approximately three minutes, the clearance was not issued in time to prevent Hudson 587 penetrating controlled airspace without a clearance.

Significant Factors

1. The co-ordination procedures for the revised airspace boundaries were not adequately documented.

2. The Melbourne Sector 2 controller co-ordinated with the wrong FIS operator.

3. The FIS 6 operator miscalculated the track of Hudson 587.

4. The FIS 6 operator did not co-ordinate the position of Hudson 587 after accepting the report from Melbourne Sector 2.

5. There was no breakdown in separation.

Circumstances

The Canberra air traffic control approach and departures functions were being performed by one controller because of the low traffic density. VH-ILL departed Canberra for the local training areas and intended to transit at 4,000 feet which was the normal altitude for such transit. The approach/departures controller had a flight progress strip and notated this altitude on the strip in the normal manner.

The pilot of VH-ILL then requested a climb to 5,000 feet which was approved as there was no conflicting traffic. The flight progress strip was annotated correctly with this change.

At this time air traffic levels were increasing and it was decided to separate the approach and departures functions. During this transition, control of VH-ILL was taken over by the oncoming departures controller who was given the flight progress strip. The approach controller then replaced this conflict alert tool with another, a red plastic rectangle referred to as a "shrimp boat", which was placed on the radar screen to indicate that there was traffic en route to the training areas. However the controller did not notate an altitude on this shrimp boat.

VH-TAH was arriving at Canberra from Sydney and the approach controller was radar vectoring that aircraft for an approach to runway 35. During this vectoring process the controller descended VH-TAH to 5,000 feet without providing horizontal separation with VH-ILL. The radar screens at Canberra do not show Secondary Surveillance Radar [SSR] Mode C altitude readout, and the controller evidently forgot the height of VH-ILL.

The aircraft came within half a nautical mile and 300 feet of each other. The required separation standard is five nautical miles or 1,000 feet.

Significant Factors

1.The approach controller gave up his main conflict alert reminder when he passed the flight progress strip to the oncoming departures controller.

2.The approach controller did not notate the altitude assigned to VH-ILL on the red shrimp boat.

3. SSR Mode C altitude information is not available at Canberra.

Safety Action

Deficiencies were identified during this investigation and appropriate safety recommendations are being formulated.

The right engine failed on descent into Devonport. The engine was shut down and the aircraft landed without incident.

The engine was disassembled, and it was found that the gas generator second stage cooling plate had disintegrated. Extensive foreign object damage had affected the remaining components of the gas generator turbine.

Failure of the second stage cooling plate was a problem known to the manufacturer. A modified plate of improved durability had been introduced by SB72-352. The failed unit was of pre-modification status. As well as progressive introduction of the improved plates into the fleet when the engines are overhauled, the area is subject to regular borescope inspections.

The pilot said that after he had reported ready for take-off at the holding point for runway 11 centre, he was told that there would be a 5-minute delay in obtaining an airways clearance. After about 10 minutes he was advised that he could depart Bankstown, remaining outside controlled airspace (OCTA). He decided to proceed because he was obstructing other traffic.

The aircraft was observed to track directly through the centre of restricted area R505 which was activated. Mode C radar readout showed the aircraft on climb to 3000 feet, confirming that the pilot had penetrated the restricted area and the control area without clearance.

The pilot said he was unfamiliar with Sydney airspace boundaries and had Jeppesen charts for reference. He said in hindsight he should not have departed under the circumstances but decided to do so as he felt he was impeding other traffic on the ground at Bankstown.