Breakdown of co-ordination involving a Cessna 421C, VH-CMR and Beech Aircraft Corp C99, VH-OXC, 65 km south of Coffs Harbour, New South Wales, on 10 March 1993

Summary

Circumstances

VH-OXC was proceeding on a flight from Williamtown to Coffs Harbour at 9,000 ft outside controlled airspace [OCTA]. The pilot made all position reports as required and was estimating Coffs Harbour at 0734 hours EST. Sydney Flight Service 5 [FIS 5] co-ordinated these details with Coffs Harbour air traffic control [ATC] and at 0724 hours the pilot contacted Coffs Harbour ATC prior to the control area [CTA] boundary for an airways clearance. ATC issued the clearance for VH-OXC to enter CTA on descent to 5,000 ft.

VH-CMR was proceeding on a flight from Williamtown to Coffs Harbour and was maintaining Flight Level [FL] 130 in CTA. The crew used a standard flight plan and the time intervals indicated an estimated time of arrival [ETA] over Taree of 0710 hours and Coffs Harbour 0744 hours. Sydney Sector 2 [ATC] identified VH-CMR 20 NM south of Taree and therefore there was no requirement for the crew to report over Taree. The aircraft passed Taree at 0707 hours.

Sector 2 then co-ordinated VH-CMR with Coffs Harbour ATC and gave the ETA as 0744 hours as per the flight plan times. The crew of VH-CMR elected to descend prior to the Coffs Harbour CTA steps and this necessitated flight OCTA for approximately three minutes. Sector 2 therefore co-ordinated the aircraft's position with FIS 5 giving the Taree position as 0707 hours, but again gave the ETA Coffs Harbour as 0744 hours.

The crew of VH-CMR reported leaving FL 130 to Sector 2 and were instructed to contact area frequency at that time. However they elected not to call on area frequency as they only had approximately three minutes OCTA and would need to contact Coffs Harbour ATC for a clearance prior to entry into the CTA step.

The Sydney Flight Service Officer [FSO] took the position report on VH-CMR from Sector 2 and wrote the information on the flight strip, but did not make a check of the time interval from Taree to Coffs Harbour or on the difference in the ETA and the actual time at Taree. This resulted in the FSO having a ten minute time difference between VH-OXC and VH-CMR at Coffs Harbour when in fact the information received indicated a time difference of seven minutes. The time standard for passing traffic is, within ten minutes at any particular point and the FSO decided that as there was ten minutes at Coffs Harbour there was no need to pass traffic to the aircraft.

At 0725 hours VH-CMR contacted Coffs Harbour ATC at 35 NM [the CTA step] and on descent through 8,000 ft to request an airways clearance. The controller immediately took action to establish vertical separation but this was not achieved until 0727 hours. During this two minute period the vertical difference between the two aircraft reduced to a minimum of 100 ft and the horizontal difference to a minimum of 2.3 NM. As VH-CMR had waited until the exact location of the CTA step to contact Coffs Harbour ATC, the controller was unable to establish separation until after both aircraft had entered the CTA step and therefore a breakdown in separation occurred.

Significant Factors

1. The crew of VH-CMR contacted Coffs Harbour ATC at the CTA boundary and not prior to that boundary.

2. The crew of VH-CMR entered the CTA without an ATC clearance.

Occurrence summary

Investigation number 199300416
Occurrence date 10/03/1993
Location 65 km south of Coffs Harbour
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 Breakdown of co-ordination
Occurrence class Incident

Aircraft details

Manufacturer Beech Aircraft Corp
Model C99
Registration VH-OXC
Sector Turboprop
Operation type Air Transport Low Capacity
Departure point Williamtown NSW
Destination Coffs Harbour NSW
Damage Nil

Aircraft details

Manufacturer Cessna Aircraft Company
Model 421C
Registration VH-CMR
Sector Piston
Operation type Air Transport Low Capacity
Departure point Williamtown NSW
Destination Coffs Harbour NSW
Damage Nil

Near collision involving a Cessna 172M, VH-IRH and Cessna 172P, VH-JRB, Moorabbin Airport, Victoria, on 18 February 1993

Summary

VH-JRB approached the airport from the south and on right downwind for runway 17R was told he was number one in the sequence. VH-IRH came in via Point Ormond to the north, also for runway 17R, the pilot being told to report at Southland.

When he called at Southland the pilot of VH-IRH received an acknowledgement but no instructions or traffic information. The two aircraft came into close proximity at about the base leg position. Both pilots saw each other in just enough time to deviate and miss.

In nominating Southland as a reporting point for VH-IRH the controller selected a point close to the base position. He was initially unable to see VH-IRH when he called at Southland. As this was close to base leg position a conflict occurred before any further action was taken by him. Timely traffic information was not passed to both aircraft.

Occurrence summary

Investigation number 199300407
Occurrence date 18/02/1993
Location Moorabbin Airport
State Victoria
Report release date 10/06/1993
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 Cessna Aircraft Company
Model 172M
Registration VH-IRH
Sector Piston
Operation type Private
Destination Moorabbin VIC
Damage Nil

Aircraft details

Manufacturer Cessna Aircraft Company
Model 172P
Registration VH-JRB
Sector Piston
Operation type Flying Training
Damage Nil

Runway excursion involving a Piper PA-28-151, VH-HWN, Portland, Victoria, on 6 March 1993

Summary

During a touch and go landing, the student pilot lost directional control and the aircraft veered off the runway to the right. The aircraft hit part of the TVASIS installation.

Occurrence summary

Investigation number 199300392
Occurrence date 06/03/1993
Location Portland
State Victoria
Report release date 22/07/1993
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 Piper Aircraft Corp
Model PA-28-151
Registration VH-HWN
Sector Piston
Operation type Flying Training
Departure point Portland VIC
Destination Portland VIC
Damage Substantial

Hard landing involving a Beech Aircraft Corp 95-B55, VH-KMZ, Yea, Victoria, on 6 March 1993

Summary

The pilot elected was making a landing approach in light wind conditions. A higher sink rate than normal occurred on final, leading to a heavy touch down at the threshold. The aircraft bounced, and on the subsequent touchdown the nosewheel assembly separated.

Occurrence summary

Investigation number 199300391
Occurrence date 06/03/1993
Location Yea
State Victoria
Report release date 22/07/1993
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Hard landing
Occurrence class Accident

Aircraft details

Manufacturer Beech Aircraft Corp
Model 95-B55
Registration VH-KMZ
Sector Piston
Operation type Private
Departure point Moorabbin VIC
Destination Yea VIC
Damage Substantial

Control - Other involving a Cessna 402B, VH-BIZ, Kingscote, South Australia, on 22 February 1993

Summary

The aircraft was on final approach to land at night. At approximately 150 feet above the ground, it suddenly rolled to the left and a loud bang was heard.

The pilot applied full opposite aileron and rudder and was able to level wings prior to touchdown.

Investigation showed that the left "flap down" cable had snapped, allowing the left flap to retract rapidly while the right hand flap remained fully extended.

The right hand "flap down" cable was subsequently found to be corroded internally and failed on test even though it appeared serviceable.

Occurrence summary

Investigation number 199300386
Occurrence date 22/02/1993
Location Kingscote
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 Control - Other
Occurrence class Incident

Aircraft details

Manufacturer Cessna Aircraft Company
Model 402B
Registration VH-BIZ
Sector Piston
Operation type Charter
Departure point Adelaide SA
Destination Kingscote SA
Damage Nil

Loss of control involving an Extra EA 300, VH-OOE, Bankstown, New South Wales, on 4 March 1993

Summary

During the landing roll the right wheel brake failed to function. The pilot was unable to maintain directional control, resulting in a ground loop, during which slight damage to the left landing gear strut and right wingtip occurred.

Air in the right brake line rendered the right brake ineffective. It was not determined how the air was admitted to the system as no maintenance had been performed on the system since the aircraft had been delivered from the factory.

Occurrence summary

Investigation number 199300368
Occurrence date 04/03/1993
Location Bankstown
State New South Wales
Report release date 13/07/1993
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Landing gear/indication, Loss of control
Occurrence class Accident

Aircraft details

Manufacturer Extra-Flugzeugbau GmbH
Model EA 300
Registration VH-OOE
Sector Piston
Operation type Private
Departure point Bankstown NSW
Destination Bankstown NSW
Damage Substantial

ANSP info/procedural error involving a Boeing 737-377, VH-CZP, Hobart, Tasmania, on 29 January 1993

Summary

The pilot of the first aircraft in the sequence, from Australian Airlines, requested direct track from over Devonport to Hobart on the 320 radial. On co-ord with Hobart Air Traffic Control approval given for this and a second aircraft, this one from Ansett Airlines, to also track direct. The Sector 3 controller passed the clearance to the first aircraft but forgot to pass it to the second one. The second aircraft arrived in the Hobart area on the 301 radial, which was the original planned route, instead of the 320 radial as expected. No loss of separation occurred.

Occurrence summary

Investigation number 199300346
Occurrence date 29/01/1993
Location Hobart
State Tasmania
Report release date 29/06/1993
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category ANSP info/procedural error
Occurrence class Incident

Aircraft details

Manufacturer The Boeing Company
Model 737-377
Registration VH-CZP
Sector Jet
Operation type Air Transport High Capacity
Departure point Melbourne VIC
Destination Hobart TAS
Damage Nil

Operational event involving a Druine, Avion Roger D31, VH-PWH, Warracknabeal, Victoria, on 29 January 1993

Summary

The pilot inspected part of strip 17 and found it to be dry and firm. He took off on sealed strip 08. Later he landed on 17. Near the end of the landing roll the main wheels sank in a softer area and the aircraft overturned. This happened in an area the pilot had not checked on his inspection.

Occurrence summary

Investigation number 199300355
Occurrence date 29/01/1993
Location Warracknabeal
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 Loss of control
Occurrence class Incident

Aircraft details

Model Druine, Avion Roger D31
Registration VH-PWH
Sector Piston
Operation type Private
Departure point Warracknabeal VIC
Destination Warracknabeal VIC
Damage Minor

Operational non-compliance involving a Bell Helicopter Co 206B, VH-EPQ, Richmond, NSW on 1 February 1993

Summary

VH-EPQ was cleared into the Richmond Control Zone on track to Riverstone, not above 500 feet on QNH. VH-EPQ was observed by the control tower supervisor proceeding north of Riverstone. When challenged by the tower controller, he reported 2 nautical miles (nm) south of Oakville. VH-EPQ proceeded to Oakville from Riverstone without a clearance, breaking down separation with Stal Thunder One on Tacan One final. No Holding instructions were given to VH-EPQ by the tower. The pilot of VH-EPQ was contacted and he said that he had complied with the terms of his clearance and that at no time was he anywhere near the C130 which he saw about 2000 feet above and one and a half to two miles away.

Occurrence summary

Investigation number 199300345
Occurrence date 01/02/1993
State New South Wales
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Operational non-compliance
Occurrence class Incident

Aircraft details

Manufacturer Bell Helicopter Co
Model 206B
Registration VH-EPQ
Sector Helicopter
Departure point BANKSTOWN
Destination OAKVILLE
Damage Nil

Collision on ground involving an Aerospatiale AS355F2, VH-PHM, 1 km south of Little Beach, New South Wales, on 5 March 1993

Summary

The Police rescue helicopter was being flown for the purpose of conducting the search for and rescue of a seriously injured rock fisherman in the MacMasters Beach area, south of Terrigal. It departed Bankstown at about 0555 ESuT and arrived at the command post at Little Beach at about 0620. Shortly after, a paramedic was embarked and a search initiated. The injured person was located about 650 metres south of the command post.

The helicopter was flown back to Little Beach, where a crewmember disembarked and returned to the location of the injured person. It then was landed on a nearby rock ledge near the water's edge, where both the paramedic and the observer left the helicopter to assist the fisherman. The helicopter then took off and moved away to minimise noise and rotor wash in the immediate area. The pilot reported that at that time the wind was calm, the visibility unlimited, and there was some wave action against the lower of two rock shelves. He asked the ground party by radio if a 'Stokes' litter was required for the retrieval of the fisherman but was advised by the paramedic that this would be unnecessary as the fisherman could be carried down to the rock shelf, close to the original landing point.

The helicopter was brought to a low hover to allow the patient and observer to board. After receiving a clearance to depart from the paramedic, who remained on the ground, the pilot commenced a take-off. At a skid height of about 12 ft above the rock shelf, the entire aircraft was engulfed by a very large wave. The take-off was aborted, and the helicopter was stabilised in a hover. Almost immediately, it was struck by a second wave, resulting in a double engine flameout. The helicopter was landed on the rock shelf, where it was then struck by a third wave, which rolled it onto its side and forced it against a low rock face. After the helicopter had come to rest, all three persons on board were able to escape, assisted by the paramedic.

The pilot reported that the sea state then returned to its original, relative calm. However, after a further 80 minutes, another series of very large waves struck the helicopter, resulting in further damage.

Significant Factors

1. Deceptive sea state.

2. Desirability of rescuing injured person with minimum delay.

Occurrence summary

Investigation number 199300342
Occurrence date 05/03/1993
Location 1 km south of Little Beach
State New South Wales
Report release date 14/09/1994
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Accident
Highest injury level Minor

Aircraft details

Manufacturer Aerospatiale Industries
Model AS355F2
Registration VH-PHM
Sector Helicopter
Operation type Aerial Work
Departure point 1 km S Little Beach NSW
Destination Little Beach NSW
Damage Destroyed