Breakdown of co-ordination involving a The Boeing Company 737-476, VH-TJG, KAPNA, SA on 24 February 1993

Summary

The crew of VH-TJG, enroute to Perth, made a position report at Kapna. The Melbourne air traffic controller was required to co-ordinate details of this report to the Perth Sector Two controller. This was not done. There was opposite direction traffic which could have come into conflict but there was no loss of separation.

Occurrence summary

Investigation number 199300552
Occurrence date 24/02/1993
State South Australia
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Breakdown of co-ordination
Occurrence class Incident

Aircraft details

Manufacturer The Boeing Company
Model 737-476
Registration VH-TJG
Sector Jet
Departure point Sydney
Destination Perth
Damage Nil

Near collision involving an Embraer EMB-110P1, VH-LNB and Piper PA-28-181, VH-DRG, Port Lincoln, South Australia, on 14 February 1993

Summary

After making the necessary radio calls and arranging separation with an inbound aircraft, VH-LNB taxied for take-off from runway 19. While taxiing the crew were busy completing the pre-take-off checklist and giving a safety briefing to the passengers on the aircraft public address system. The pilot of another aircraft, VH-DRG, made a radio call to advise VH-LNB that he was inbound to Port Lincoln. There was no response from the crew of VH-LNB.

After take-off, when established in a turn to the left, the crew of VH-LNB observed VH-DRG pass from left to right in front of and about 80 ft below their aircraft.

The pilot of VH-DRG stated that communications with all other aircraft had been satisfactory. When the departing aircraft had not responded to his transmission, he kept a lookout and first sighted VH-LNB when it was about 500 metres away. He turned his aircraft away, but the other aircraft turned towards him, and he was unable to avoid the aircraft coming into close proximity with each other.

Occurrence summary

Investigation number 199300545
Occurrence date 14/02/1993
Location Port Lincoln
State South Australia
Report release date 11/03/1994
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Near collision
Occurrence class Incident

Aircraft details

Manufacturer Embraer-Empresa Brasileira De Aeronautica
Model EMB-110P1
Registration VH-LNB
Sector Turboprop
Operation type Air Transport Low Capacity
Departure point Port Lincoln SA
Destination Adelaide SA
Damage Nil

Aircraft details

Manufacturer Piper Aircraft Corp
Model PA-28-181
Registration VH-DRG
Sector Piston
Operation type Private
Departure point Parafield SA
Destination Port Lincoln SA
Damage Nil

Collision with terrain involving a Czechoslovak Automobile & A/C L40, VH-ENG, Benambra, Victoria, on 21 March 1993

Summary

The pilot reported that he was making an aerial inspection of the Benambra airstrip prior to landing. He overflew the strip at about 150 feet above the ground and then commenced a left turn at a bank angle of about 45 degrees. While turning, the pilot said he was looking at obstructions in the vicinity of the airstrip and neglected to monitor the airspeed. He felt the aircraft shudder and then it stalled. He managed to level the wings but was unable to arrest the descent. The aircraft struck the ground in a flat attitude in swampland immediately to the north of the strip.

The pilot said that the day was hot and the aircraft was heavier than usual, in that there were three persons on board. Usually he is the sole occupant. The elevation of the airstrip is 2250 feet.

Significant Factors

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

1. The pilot became distracted while manoeuvring in the circuit area and as a result the airspeed decayed and the aircraft stalled.

2. The pilot was operating the aircraft in a circuit area at a higher density altitude and higher weight than what he normally operated at.

Occurrence summary

Investigation number 199300562
Occurrence date 21/03/1993
Location Benambra
State Victoria
Report release date 28/07/1993
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Collision with terrain
Occurrence class Accident

Aircraft details

Manufacturer Czechoslovak Automobile & A/C
Model L40
Registration VH-ENG
Sector Piston
Operation type Private
Departure point Benambra VIC
Destination Benambra VIC
Damage Substantial

Loss of separation involving a Beech Aircraft Corp B200C, VH-AMS and British Aerospace PLC 3107, VH-TQK, Port Macquarie, New South Wales, on 15 March 1993

Summary

Circumstances

At 1635 hours VH-TQK departed Port Macquarie for Sydney via a track of 221 deg from Port Macquarie. An airways clearance was issued by RAAF Williamtown Air Traffic Control [ATC] for VH-TQK to enter controlled airspace [CTA] on this track on climb to Flight Level [FL] 160.

At 1537 hours VH-AMS departed Port Macquarie for Williamtown on a track of 200 deg from Port Macquarie. An airways clearance was issued by Williamtown ATC for VH-AMS to enter CTA on this track to FL 140.

The clearances were issued when neither aircraft was identified on radar and with no vertical or longitudinal separation requirement. In such circumstances the only separation standard available is lateral which required 30 deg between the departure tracks in question. As only 21 deg existed, a breakdown in separation occurred.

Radar analysis indicates that the aircraft were 7.6 NM apart when they were established in CTA and that this distance increased before radar identification was complete. It also shows that the vertical difference was a minimum of 500 ft which occurred prior to identification.

Significant Factors

1. The Williamtown air traffic controller issued procedural airways clearances that were not in accordance with the appropriate separation standard.

Occurrence summary

Investigation number 199300535
Occurrence date 15/03/1993
Location Port Macquarie
State New South Wales
Report release date 12/08/1993
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 Beech Aircraft Corp
Model B200C
Registration VH-AMS
Sector Turboprop
Operation type Medical Transport
Departure point Port Macquarie NSW
Destination Williamtown NSW
Damage Nil

Aircraft details

Manufacturer British Aerospace
Model 3107
Registration VH-TQK
Sector Turboprop
Operation type Air Transport Low Capacity
Departure point Port Macquarie NSW
Destination Sydney NSW
Damage Nil

Loss of separation involving a Boeing 747, and McDonnell Douglas F/A-18A, 70 km east of Sydney, New South Wales, on 15 March 1993

Summary

Singapore Airlines Flight 288 [SIA288] was maintaining Flight Level [FL] 310 on a flight from Auckland to Singapore. It had been cleared to transit Restricted Area R588 at FL 310 by Sydney Sector 5 who had correctly co-ordinated the clearance with Williamtown Approach control.

Four RAAF FA18A aircraft, operating as Shogun Section, had completed an exercise to the south of R588 and requested a clearance from Williamtown Approach control to return to Williamtown for a landing. The controller cleared Shogun Section to transit R588 at FL 310 from south to north on a course that was in conflict with SIA288.

As the aircraft approached each other, Williamtown Approach noticed the confliction and passed traffic information to Shogun Section, who then initiated evasive action by climbing above the level of SIA288.

The crew of SIA288 was not given traffic information by Sydney control but saw two FA18A aircraft and assessed that their own aircraft would pass behind. They therefore elected not to take any other action.

The aircraft passed within 2.7 NM of each other with 900 ft vertical difference. The required separation standard is 5 NM or 2,000 ft and, as such, a breakdown in separation occurred.

Significant Factors

1. The RAAF controller issued clearances for SIA288 and Shogun Section without correct application of the appropriate separation standards.

Occurrence summary

Investigation number 199300532
Occurrence date 15/03/1993
Location 70 km east of Sydney
State New South Wales
Report release date 26/07/1993
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 McDonnell Douglas Corp.
Model F/A-18A
Registration Unknown
Sector Jet
Operation type Military
Departure point Williamtown NSW
Destination Williamtown NSW
Damage Nil

Aircraft details

Manufacturer The Boeing Company
Model 747
Registration Unknown
Sector Jet
Operation type Air Transport High Capacity
Departure point Auckland NZ
Destination Singapore
Damage Nil

Ground handling involving a Fokker B.V. F28 MK 1000, VH-FKF, Geraldton, Western Australia, on 15 March 1993

Summary

A passenger reported that incorrect techniques were used when refuelling the aircraft, with respect to the earthing of the aircraft. The report was correct, however, investigations revealed that the petroleum company and the CAA were in the final stages of negotiation to change the relevant Civil Aviation Orders (CAO's). Although not in accordance with the CAO's, the procedure used was not dangerous, according to the petroleum company representative and was acceptable to the CAA.

Occurrence summary

Investigation number 199300530
Occurrence date 15/03/1993
Location Geraldton
State Western Australia
Report release date 30/10/1993
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Ground handling
Occurrence class Incident

Aircraft details

Manufacturer Fokker B.V.
Model F28 MK 1000
Registration VH-FKF
Sector Jet
Operation type Air Transport High Capacity
Departure point Exmouth WA
Destination Geraldton WA

Hydraulic involving a Cessna 404, VH-BPO, Ararat, Victoria, on 29 January 1993

Summary

In the circuit area at Ararat the landing gear failed to extend. After two attempts to recycle, both hydraulic flow lights illuminated indicating loss of hydraulic fluid. The aircraft returned to Essendon where the landing gear was extended by the emergency system and the aircraft landed safely.

Hydraulic oil was leaking from the right wing root area. Investigation showed that an aluminium high-pressure pipe had fractured due to fatigue. The pipe was replaced with a flexible hose in accordance with a locally approved modification.

Occurrence summary

Investigation number 199300529
Occurrence date 29/01/1993
Location Ararat
State Victoria
Report release date 26/05/1993
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Hydraulic
Occurrence class Incident

Aircraft details

Manufacturer Cessna Aircraft Company
Model 404
Registration VH-BPO
Sector Piston
Operation type Medical Transport
Departure point Warrnambool VIC
Destination Ararat VIC
Damage Nil

Wheels up landing involving a Beech Aircraft Corp 58, VH-SMW, Adelaide Airport, South Australia, on 16 March 1993

Summary

The flight proceeded normally until on approach to Adelaide Airport, when the pilot found he could not extend the landing gear. The emergency system was also tried but still no gear down indication could be obtained.

A wheels up landing was then made on runway 30.

Later inspection of the gear system revealed that on the last gear up selection a gear motor over-run had occurred. This caused the gear to be jammed in the up position and for the emergency gear extension mechanism to be damaged. The reason for the gear motor over-run was a defect in the dynamic brake relay which prevented the motor operation from ceasing in the normal up position.

Significant Factors

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

1. A dynamic brake relay was defective.

2. The emergency gear extension system became damaged as a result of the defective dynamic brake relay.

Occurrence summary

Investigation number 199300526
Occurrence date 16/03/1993
Location Adelaide Airport
State South Australia
Report release date 27/10/1994
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Wheels up landing
Occurrence class Accident

Aircraft details

Manufacturer Beech Aircraft Corp
Model 58
Registration VH-SMW
Sector Piston
Operation type Charter
Departure point Port Lincoln SA
Destination Adelaide SA
Damage Substantial

Runway excursion involving a Thorp Engineering T-18, VH-CMC, Kalgoorlie, Western Australia, on 24 February 1993

Summary

After an uneventful landing, the aircraft veered to the left and ran off the side of the runway, despite the correcting control inputs from the pilot. The left wheel entered soft dirt and swung the aircraft further to the left, causing it to head towards an earthen bank. The pilot prevented the aircraft from hitting the bank by ground looping the aircraft, which damaged the aircraft by placing excessive side loads on the undercarriage. The pilot was familiar with the aircraft, and the wind was light and variable.

Occurrence summary

Investigation number 199300525
Occurrence date 24/02/1993
Location Kalgoorlie
State Western Australia
Report release date 29/06/1993
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Runway excursion
Occurrence class Accident

Aircraft details

Manufacturer Thorp Engineering Company
Model T-18
Registration VH-CMC
Sector Piston
Operation type Private
Departure point Unknown
Destination Kalgoorlie WA
Damage Substantial

Electrical systems involving a Fokker B.V. F28 MK 4000, VH-EWD, Melbourne, Victoria, on 16 January 1993

Summary

Shortly after take-off the warning annunciator for the 26V AC bus supply illuminated followed by a strong electrical burning smell. Power was removed from the bus and the smell diminished. After a successful landing the investigation disclosed that a power supply diode had overheated and failed.

Occurrence summary

Investigation number 199300524
Occurrence date 16/01/1993
Location Melbourne
State Victoria
Report release date 26/05/1993
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Electrical system, Fumes
Occurrence class Incident

Aircraft details

Manufacturer Fokker B.V.
Model F28 MK 4000
Registration VH-EWD
Sector Jet
Operation type Air Transport High Capacity
Departure point Melbourne VIC
Destination Launceston TAS
Damage Nil