The club was carrying out joy flights in VH-WVQ and earlier in the day another pilot had flown these. A second pilot then took over this task. He flew his first flight with an adult passenger and no operating anomalies were noted. For his second flight a 12 year old boy was carried in the front seat, along with 13.5 kilograms of ballast.

On aero tow take off the pilot noted the stick had to be pushed fully forward to lift the tail. He said the handling felt a little "strange" in the air, but he elected to continue. Release was at 2800 feet, and he commenced circling in the Gap area to try and obtain lift. Positive two stages of flap was set, with a speed of 42 knots and 30 degrees of bank.

Lift conditions were poor; they were just maintaining height. At about 300 feet above a ridge the glider stalled with the left wing going down and the tail also dropping slightly. Recovery seemed slow even though the stick was pushed completely forward. It became impossible to avoid trees and on contact these pulled the wings backward. The glider came to rest in the trees with the canopy dislodged and the nose pointing down at the ground some 30 feet below.

The pilot was unable to prevent the passenger from undoing his belt and attempting to get out onto a branch. In the process the passenger slipped, then managed to briefly hold on to the branch with a hand before falling to the ground. He was injured but managed to walk to a nearby road where a motorist picked him up. The pilot got out of the aircraft onto a branch but could not get down to the ground which was still some 25 feet below. He remained there until rescued about 1.5 hours later.

It was a fine day with virtually no surface wind. Other glider pilots who flew either before or at about the time of the accident said that lift conditions were poor and intermittent. One of those who flew in the Gap area commented that he had to circle close to the mountain to get lift. As his turn took him out from the side of the mountain he lost the lift, with the variometer indicating -1. Post accident calculations indicated that the position of the centre of gravity was at 38.7 per cent Mean Aerodynamic Chord (MAC). The approved range was 22-40.6 per cent MAC.

Significant Factors

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

1. The conditions were unfavourable for obtaining adequate lift for prolonged flight.

2. The pilot continued the flight in marginal lift conditions.

3. The pilot allowed a severe stall to develop at a low height above the terrain.

Whilst enroute Barracouta to Snapper Oil Platform the number 2 engine oil pressure began to fluctuate. At Snapper the fluctuations became worse. The pilot-in-command decided to return the helicopter to Longford. Enroute Longford the oil pressure fell below minimum allowable. The pilot shut down number 2 engine and subsequently carried out a safe single engine landing at Longford. It was discovered by the engineers that the starter generator oil seal had popped out on the number 2 engine. Several quarts of oil had been pumped overboard in flight. It was found that only one quart of oil was left in number 2 engine when the pilot elected to shut down the engine.

Significant Factor

The following factor was considered relevant to the development of the incident:

1. The starter generator oil seal failed.

VH-ANA [B727] was enroute from Brisbane to Sydney at Flight Level [FL] 330. At 0949 hours EST the crew were authorised by Sydney air traffic control [ATC] to descend, when ready, to FL 280. One minute later this clearance was cancelled by ATC and VH-ANA was required to maintain FL 330. The aircraft had not commenced descent.

All Nippon Airways 914 [B747] had departed Sydney for Narita [Japan] and was climbing to an initial altitude of FL 280. The track of this aircraft would cross that of VH-ANA approximately 120 NM north of Sydney.

All Nippon Airways 914 was given climb to FL 310 at 0946 hours and, due to a busy period of air traffic, this change of level was not co-ordinated until 0949 hours. On receiving the notification of the level change, the controller responsible for VH-ANA took immediate action to reintroduce procedural separation before radar separation was lost.

The aircraft passed at 0951 hours with 2,000ft vertical difference. There was no breakdown in separation standards.

VH-LBA was maintaining FL 270 and northbound from Meekatharra. VH-FKI was southbound to Meekatharra and was cleared to descend from FL 310 to FL 260 through the level assigned to VH-LBA. The duty air traffic controller was advised of this error by the pilot of VH-LBA and VH-FKI was assigned a new clearance which should have provided lateral separation for the descent. However, the controller's calculations were in error and the distance between the aircraft was reduced below the minimum separation standard.

The controller had just completed a hand-over/take-over when he was presented with this slightly more complicated separation problem. Coupled with this was a reduction in currency due to administrative tasks associated with being a team leader. Flight progress strip management practices at Perth may have contributed to the occurrence. Strip procedures have since been modified to be consistent with an apparent national standard developed from discussions with other check control staff.

VH-UOP was on descent from Broken Hill to Mildura. The pilot of VH-UOP made appropriate radio calls on the Mildura mandatory traffic advisory frequency (MTAF) and took note of traffic. He copied 238 degrees as the outbound track for one of the aircraft from Mildura. VH-SFQ advised VH-UOP that there was another aircraft just ahead. At the same moment the pilot of VH-UOP saw a single engine Cessna within 500 metres diving off to the left in a right hand descending turn. The pilot of VH-UOP took no evasive action. He made a general broadcast directed to any aircraft in the Dareton area. VH-RFB responded. VH-RFB's track ex Mildura was 338 degrees direct for Broken Hill, not 228 degrees as earlier copied by VH-UOP.

Some of the radio transmissions from VH-RFB were muffled, which brought about the misunderstanding.

Significant Factors

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

1. Some of the radio transmissions from VH-RFB were hard to understand.

2. The pilot of VH-UOP misunderstood a radio transmission from VH-RFB.

During agricultural operations, one propeller blade moved to coarse pitch while the aircraft was flying at a height of 50 feet. Power was reduced, the load dumped and the pilot carried out a forced landing in a nearby paddock.

Investigation revealed that one counterweight roller bearing shaft had failed in fatigue across the split-pin hole. The split-pin hole is drilled close to where the bearing shaft exits the hub flange. The hub has now been modified to locate the split-pin in the threaded section at the opposite end of the shaft.

Approaching Cairns the crew received the automatic terminal information service which gave the following information: "runway 15, wet, wind 170 degrees 12 knots, QNH 1014, temperature 22, 3 okta (cloud) at 2,500ft, lower patches, showers in area." Following a Distance Measuring Equipment (DME) arrival, the crew reported visual with the field at four nautical miles. They flew a visual circuit, tracking via a left downwind for runway 15.

During the base turn, the crew lost visual contact with the runway lights because a rain shower was positioned across the final approach path. The flying pilot (first officer) initiated an overshoot and commenced a right turn towards high terrain. The turn continued through some 250 degrees to 090 degrees magnetic, heading out to sea. The crew then conducted an instrument approach to runway 15 followed by a normal landing.

The right turn conducted by the crew allowed the aircraft to track outside the circling area limit of 4.2nm (7.8km). During the turn the lowest altitude of the aircraft was approximately 1,400ft in an area where the radar lowest safe altitude is 3,300ft.

The investigation revealed that the crew were under two misapprehensions. Both pilots believed that they would stay in visual meteorological conditions during the missed approach by conducting a right turn, although they had no way of assuring this on a dark night. The crew also thought that they were further off the coast (hence clear of high terrain) than they were. Prior to commencing the circuit the crew did not foresee the possibility of a missed approach and did not brief for that eventuality.

The procedures laid down in the Aeronautical Information Publication indicate that the crew should have remained inside the manoeuvring area for the DME arrival procedure following the loss of visual reference with the runway approach lights at night. This could best have been accomplished by continuing the left turn to intercept the 040 degree radial, whilst at the same time commencing a climb to the lowest safe altitude of 5,000ft (the procedure laid down for a missed approach off a DME Arrival).

FACTORS

1. The crew did not brief for the possibility of a missed approach in the circuit considering that rain showers were in the area.

2. They made a spontaneous, inappropriate decision to turn right thus tracking near high terrain.

Circumstances

Canberra approach/departures control was being operated on combine due to training requirements. The training officer had confidence in the trainee's ability to handle the situation as the traffic level was light and the trainee was in his final two weeks of training prior to a rating proficiency check.

VH-WNK [Cessna 210] was maintaining 9,000ft on a flight from King Island to Bankstown and was established on the 210 radial of the Canberra VOR.

VH-EWF [Fokker F28] departed Canberra for Melbourne at 0906 hours and was instructed to maintain 8,000ft due to an expected confliction with VH-WNK.

When the trainee controller identified VH-EWF he expected that the aircraft would climb sufficiently quickly to be able to reach a level above VH-WNK before the radar separation standard of 5nm was infringed. On this basis he climbed VH-EWF to Flight Level 190 with a requirement to report leaving 10,000ft.

As the distance between the two aircraft reduced, the training officer asked the trainee what action he intended to take. The trainee was considering his reply when the training officer instructed him to turn VH-EWF so that radar separation would be maintained. At that precise moment the trainee commenced a transmission to another aircraft on an unrelated matter and a few seconds delay occurred before a radar vector was issued to VH-EWF. The training officer elected not to use the override system as he judged that the time taken to activate the system would be similar to that taken by the trainee to complete the transmission. As the crew of VH-EWF were complying with the instruction the separation reduced to 3nm before the flight paths diverged. As vertical separation had not been established, a breakdown in separation occurred.

Significant Factors

1. The trainee approach/departures controller misjudged the climb performance of VH-EWF.

2. The rated approach/departures controller allowed the situation to develop to the stage where there was insufficient time to guarantee that separation standards would be maintained.

3. The training officer's override facilities were not conducive to immediate correction of a trainee's error.

After the pilot selected the landing gear down, no gear locked down indication was received. The pilot elected to remain in the circuit area and attempted to rectify the problem. He observed that the right main gear was "dangling" and attempts to lower it by both the normal and emergency methods were unsuccessful.

After about 45 minutes when no solution could be found the pilot was advised that a landing with the landing gear retracted was the recommended course of action. The aircraft was subsequently landed on runway 12 with the gear retracted.

Inspection of the landing gear system found that a casting attached to the right gear actuator had failed. As a result, the right gear leg could not be driven to the down position.

The pilot of VH-WSA was carrying out training at the Casino navaid. The pilot of VH-CFQ reported inbound to Casino, also for training at the navaid. VH-CFQ had arranged a 500 feet vertical separation with the pilot of VH-WSA. However, the pilot of VH-CFQ reported that the radio transmissions from VH-WSA were difficult to read and that he was not aware that VH-WSA also intended training at Casino. When he lost sight of VH-WSA the pilot of VH-CFQ assumed that VH-WSA had departed the area and continued descending. Both pilots next sighted each other when their aircraft passed nose to nose with about 100 metres lateral separation and with VH-CFQ at a slightly lower altitude.