Infrastructure - ATM involving a Boeing 767-200, ZK-NBB, Melbourne, Victoria, on 11 February 1993

Summary

Melbourne air traffic control received co-ordination details on Air New Zealand Flight NZ114 from Perth air traffic control. This indicated the route shown on the flight progress strips held in Melbourne was different to tracking details co-ordinated from Perth. It was discovered that the Computer Aided Strip Printing System (CASPS), which automatically prints flight progress strips from the flight plan had made an error. This was partly due to a complicated route description in the plan message and a software error in the CASPS system. The strips should have been checked by the flight data officer against the flight plan. The error was not detected by the flight data officer.

Occurrence summary

Investigation number 199300343
Occurrence date 11/02/1993
Location Melbourne
State Victoria
Report release date 10/06/1993
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Incident

Aircraft details

Manufacturer The Boeing Company
Model 767-200
Registration ZK-NBB
Sector Jet
Operation type Air Transport High Capacity
Departure point Perth WA
Destination Auckland NZ
Damage Nil

Collision with terrain involving a Bell 47G-3B1, VH-KHY, Bindoon, Western Australia, on 28 February 1993

Summary

The aircraft was conducting joy-flights near a Rock Festival. The pilot aborted a take-off attempt when it became clear to him that he would not obtain translational lift in time to clear trees at the end of the selected take-off area. He chose to air-taxi to a more suitable pad. To get to the pad, he had to air-taxi between two large trees. Whilst passing between the trees the pilot concentrated on rotor clearance and did not notice a wind gust which moved the aircraft towards the tree on the left. The main rotor hit a branch, forcing the pilot to take immediate recovery action. The aircraft landed heavily.

Occurrence summary

Investigation number 199300338
Occurrence date 28/02/1993
Location Bindoon
State Western Australia
Report release date 26/05/1993
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Collision with terrain, Hard landing
Occurrence class Accident
Highest injury level Minor

Aircraft details

Manufacturer Bell Helicopter Co
Model 47G-3B1
Registration VH-KHY
Sector Helicopter
Operation type Charter
Departure point Bindoon WA
Destination Bindoon WA
Damage Substantial

Fuel exhaustion involving a Cessna 177A, VH-TXU, Birdwood, 55 km west of Port Macquarie, New South Wales, on 21 February 1993

Summary

The aircraft struck an obstacle during an attempted forced landing.

Inspection found that the engine had stopped when the fuel on board had been exhausted after 40 minutes flying. The pilot reported that the tanks were half full prior to departure. This should have been sufficient fuel for about two and a half hours flying. No evidence was found of any fuel leaks.

Occurrence summary

Investigation number 199300323
Occurrence date 21/02/1993
Location 55 km west of Port Macquarie
State New South Wales
Report release date 01/06/1993
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Collision with terrain, Forced/precautionary landing, Fuel exhaustion
Occurrence class Accident
Highest injury level Minor

Aircraft details

Manufacturer Cessna Aircraft Company
Model 177A
Registration VH-TXU
Sector Piston
Operation type Private
Departure point Port Macquarie NSW
Destination Birdwood NSW
Damage Substantial

Runway incursion involving a Boeing 737-476, VH-TJO and Partenavia P.68C-TC, VH-TCU, Sydney, New South Wales, on 26 February 1993

Summary

The Partenavia was being flown from Essendon to Sydney. During the final stage of the flight the aircraft was radar vectored for an approach and landing on runway 34, which was accomplished normally.

After landing, the aircraft vacated left into taxiway 'Alpha' and contacted Surface Movement Control (SMC), which cleared the aircraft to cross runway 34 via taxiway 'Hotel' and hold short of runway 07. Although this was acknowledged by the pilot, the aircraft continued past the holding point on taxiway 'Charlie' and infringed the runway 07 flight strip, despite being queried by SMC. When the pilot of the Partenavia recognised the aircraft had entered the flight strip he immediately carried out a 180 degree turn to vacate, during which the runway surface itself was slightly infringed.

In the meantime, a Boeing 737, VH-TJO, which had been cleared to take-off on runway 07, was instructed by the Aerodrome Controller (ADC) to stop immediately. This was accomplished safely from a reported speed of 100 knots. The aircraft was able to vacate the runway via taxiway 'Charlie'.

Occurrence summary

Investigation number 199300322
Occurrence date 26/02/1993
Location Sydney
State New South Wales
Report release date 14/08/1996
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Runway incursion
Occurrence class Incident

Aircraft details

Manufacturer Partenavia Costruzioni Aeronautiche S.p.A
Model P.68C-TC
Registration VH-TCU
Sector Piston
Operation type Private
Departure point Essendon
Destination Sydney
Damage Nil

Aircraft details

Manufacturer The Boeing Company
Model 737-476
Registration VH-TJO
Sector Jet
Operation type Air Transport High Capacity
Departure point Sydney
Destination Brisbane
Damage Nil

Animal strike involving a Beech Aircraft Corp 58, VH-EGM, The Monument, Queensland, on 1 March 1993

Summary

After touchdown, the pilot observed two kangaroos run onto the runway. He was unable to avoid the animals and one struck and collapsed the nosegear. The other struck the right flap.

Occurrence summary

Investigation number 199300336
Occurrence date 01/03/1993
Location The Monument
State Queensland
Report release date 30/08/1993
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Animal strike
Occurrence class Accident

Aircraft details

Manufacturer Beech Aircraft Corp
Model 58
Registration VH-EGM
Serial number TH-730
Sector Piston
Operation type Charter
Departure point Mt Isa QLD
Destination The Monument QLD
Damage Substantial

Operational non-compliance involving a Piper PA-31-350, VH-ATP, 15 km north-west of Sydney, New South Wales, on 2 February 1993

Summary

The aircraft was issued with an airways clearance to climb straight ahead from runway 34 and maintain 3000 feet. The pilot called airborne and reported on climb to 3000 feet. There was no Secondary Surveillance Radar (SSR) altitude readout evident. The pilot was then cleared to climb to 4000 feet but still no SSR readout was displayed. At approximately 10 nautical miles north of the airport the height readout appeared, indicating 4400 feet. When the pilot was queried he reported on descent to 4000 feet.

The pilot later reported that he had set 4000 feet on the assigned altitude indicator and subsequently noticed that he had inadvertently climbed to 4200 feet.

The pilot also reported that he had noticed the encoding altimeter on the co-pilot panel had not been set to QNH and was indicating 200 feet higher than the pilot's altimeter.

Occurrence summary

Investigation number 199300317
Occurrence date 02/02/1993
Location 15 km north-west of Sydney
State New South Wales
Report release date 30/08/1993
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 Piper Aircraft Corp
Model PA-31-350
Registration VH-ATP
Sector Piston
Operation type Air Transport Low Capacity
Departure point Sydney NSW
Destination Coonabarabran NSW
Damage Nil

Operational non-compliance involving a Piper PA-31-350, VH-WAD, 25 km north of Sydney, New South Wales, on 26 February 1993

Summary

The aircraft was issued with a take-off clearance, with a requirement to maintain 3000 feet. On departure, the pilot reported on climb to 3000 feet. The aircraft was then observed on radar to be approaching 3800 feet. When queried, the pilot confirmed his altitude was 3800 feet. The aircraft was then cleared to maintain 4000 feet to ensure separation with crossing traffic arriving at Sydney. The pilot later stated that he understood his initial clearance limit to be 4000 feet.

Occurrence summary

Investigation number 199300313
Occurrence date 26/02/1993
Location 25 km north of Sydney
State New South Wales
Report release date 29/07/1993
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 Piper Aircraft Corp
Model PA-31-350
Registration VH-WAD
Sector Piston
Operation type Air Transport Low Capacity
Departure point Sydney NSW
Destination Maitland NSW
Damage Nil

Collision with terrain involving a Let Blanik L13, VH-GVS, 0.5 km north of Tocumwal, New South Wales, on 1 March 1993

Summary

The pilot, who was relatively inexperienced, had a series of dual check flights prior to going solo. On his second solo flight he allowed the glider to drift too far downwind and on returning was committed to landing short of the airfield. During the landing the glider was substantially damaged when it ran through a drainage ditch.

Significant Factors

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

1. The pilot had limited flying experience.

2. The pilot misjudged his distance from the runway while on downwind.

3. Landing on unsuitable terrain.

Occurrence summary

Investigation number 199300311
Occurrence date 01/03/1993
Location 0.5 km north of Tocumwal
State New South Wales
Report release date 22/07/1993
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 Let National Corporation
Model Blanik L13
Registration VH-GVS
Sector Other
Operation type Flying Training
Departure point Tocumwal NSW
Destination Tocumwal NSW
Damage Substantial

Forced/precautionary landing involving a Cessna 182C, VH-BXW, Tully, Queensland, on 20 February 1993

Summary

At about 400 feet on climb after take-off the engine began to run roughly and lose power. The pilot was forced to attempt a landing in a cane field. During the landing one wing struck the cane and the aircraft nosed over coming to rest inverted.

Inspection of the aircraft found that the internal timing of the magneto was incorrect and that the magneto was also in a poor state of repair. In addition, the spark plugs were of different types and in varying condition. It was the opinion of the maintenance engineers who inspected the ignition system that the loss of power was a result of the overall condition of the system.

Occurrence summary

Investigation number 199300307
Occurrence date 20/02/1993
Location Tully
State Queensland
Report release date 19/10/1993
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Collision with terrain, Engine failure or malfunction, Forced/precautionary landing, Loss of control
Occurrence class Accident
Highest injury level Minor

Aircraft details

Manufacturer Cessna Aircraft Company
Model 182C
Registration VH-BXW
Sector Piston
Operation type Sports Aviation
Departure point Tully QLD
Destination Tully QLD
Damage Substantial

Forced/precautionary landing involving a Bell 47G-3B1, VH-JWI, 7.5 km north-east of Woolner Station, Northern Territory, on 20 February 1993

Summary

The helicopter was hovering about 30 feet over a swamp when the pilot heard a noise and the helicopter began to vibrate. The pilot flew the helicopter towards dry land, but it began to rotate around the main rotor mast. A tail rotor failure procedure was carried out and the machine landed in the water.

The helicopter suffered damage to the tail boom, drive shaft, uprights and cross tubes.

Subsequent examination revealed that the tail rotor extension shaft drive pin had failed at the tail rotor gearbox.

Occurrence summary

Investigation number 199300308
Occurrence date 20/02/1993
Location 7.5 km north-east of Woolner Station
State Northern Territory
Report release date 11/03/1994
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Forced/precautionary landing, Transmission and gearbox
Occurrence class Accident

Aircraft details

Manufacturer Bell Helicopter Co
Model 47G-3B1
Registration VH-JWI
Sector Helicopter
Operation type Aerial Work
Departure point Woolner Station NT
Destination Woolner Station NT
Damage Substantial