Oil system event involving an Aerospatiale SA.365C-1, VH-PVA, 11 km north-east of Epping, Victoria, on 18 August 1999

Summary

The aircraft was enroute to Mount Buller on a medivac priority flight after having departed Essendon. During climb out to cruise level, the aircraft experienced a caution advisory indicating low oil pressure of the number two engine. The crew initiated emergency procedures and completed an uneventful precautionary landing near Thomastown.

Further investigation revealed oil leakage in the area of the number two engine deck. An engine magnetic particle detector receptacle was found loose and backing out, because of a failed lockwire, thereby causing the oil leakage. The engine number two and three modules were replaced as a precaution and the aircraft returned to service.

Occurrence summary

Investigation number 199904073
Occurrence date 18/08/1999
Location 11 km north-east of Epping
State Victoria
Report release date 28/09/1999
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Incident

Aircraft details

Manufacturer Aerospatiale Industries
Model SA.365C-1
Registration VH-PVA
Sector Helicopter
Departure point Essendon Vic.
Destination Mount Buller Vic.
Damage Nil

Loss of separation involving a Boeing 737-300, ZK-FDM and Airbus A320-211, VH-HYF, 13 km east-north-east of Sydney Aerodrome, New South Wales, on 5 July 1999

Summary

The crew had been issued a runway 34R MARUB2 SID with a requirement to maintain 5,000 ft and had confirmed this altitude on contact with Departures North. The aircraft was then observed on radar to climb above the assigned altitude. The controller confirmed the altitude requirement and passed traffic information on a crossing A320 at 6,000 ft.

The B737 crew immediately descended from 5,400 ft to 5,000 ft. Concurrently the crew of the A320 responded to a TCAS Resolution Advisory and climbed from 6,000 ft to 6,700 ft. A plot of the recorded radar data showed that the B737 had levelled at 5,400 ft and that the two aircraft had come within 600 ft of one another. The required standard was 1,000 ft and, therefore, an infringement of separation standards had occurred. The company operating the B737 conducted an investigation into the circumstances surrounding this incident and a copy of their report was duly lodged with the Bureau.

Their investigation found that a captain under training was flying the aircraft. A training captain occupied the right crew seat and performed the crew functions of the pilot not flying. The captain under training was hand-flying the aircraft at the time of the incident. Although he had correctly set the assigned altitude of 5,000 ft in the window of the Mode Control Panel, the Flight Director (FD) did not capture the 5,000 ft level-off altitude and, despite the training captain having alerted him to the approaching assigned altitude, he had allowed the aircraft to climb above the assigned 5,000 ft altitude. An intermittent fault in the altitude selection function of the FD had been detected a few days earlier but because the problem was not thought to be an aberrant operation, it was not reported. After this occurrence the problem was reported and a few days later manifested itself in a 'hard' failure.

The Mode Control Panel of the Flight Management System was subsequently replaced. The investigation concluded that the slow response of the captain under training had allowed the aircraft to exceed the assigned altitude. The company's Standard Operating Procedures were found to be adequate and, despite this event, did not require amendment. However, a recommendation was made that training captains require pilots under training to use greater levels of automation in busy flight phases in order to enhance their monitoring role.

Occurrence summary

Investigation number 199903458
Occurrence date 05/07/1999
Location 13 km east-north-east of Sydney Aerodrome
State New South Wales
Report release date 28/09/1999
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 Airbus
Model A320-211
Registration VH-HYF
Sector Jet
Operation type Air Transport High Capacity
Departure point Brisbane Qld
Destination Sydney NSW
Damage Nil

Aircraft details

Manufacturer The Boeing Company
Model 737-300
Registration ZK-FDM
Sector Jet
Departure point Sydney NSW
Destination Dunedin New Zealand
Damage Nil

ACAS warning involving a Boeing 767-277, VH-RMH and Boeing 737-476, VH-TJQ, 15 km north-north-west of Sydney Aerodrome, New South Wales, on 6 April 1999

Summary

No text.

Occurrence summary

Investigation number 199901827
Occurrence date 06/04/1999
Location 15 km north-north-west of Sydney Aerodrome
State New South Wales
Report release date 05/05/1999
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category ACAS warning
Occurrence class Incident

Aircraft details

Manufacturer The Boeing Company
Model 737-476
Registration VH-TJQ
Sector Jet
Departure point Melbourne Vic.
Destination Sydney NSW
Damage Nil

Aircraft details

Manufacturer The Boeing Company
Model 767-277
Registration VH-RMH
Sector Jet
Departure point Cairns Qld
Destination Sydney NSW
Damage Nil

Collision with terrain involving a Cessna 402C, VH-UBB, Gove Aerodrome, Northern Territory, on 5 April 1999

Summary

During the initial climb after take-off, the pilot of the Cessna 402 observed that the nose landing gear had failed to retract. While orbiting clear of the airfield, the pilot commenced troubleshooting and found that the hydraulic system circuit breaker had tripped. After resetting the circuit breaker, several further retraction attempts failed to resolve the problem. The pilot then attempted to lower the landing gear using the emergency function. These attempts were also unsuccessful. After briefing the passengers on emergency procedures and with RFFS in position, the pilot commenced the landing with an unlocked nose gear. During the approach, the pilot shut down both engines and turned off the fuel. He then realised that the aircraft would land short of the runway.

The aircraft came to rest 10 metres outside of the airport boundary fence. The pilot and passengers were uninjured. Engineering inspection of the aircraft revealed a wire in the electrical loom to the left main landing gear which had shorted to structure. When a selection was made with the landing gear selector lever, power applied to move the electro-hydraulic shuttle valve from the idle position to either up port or down port would pop the circuit breaker. This prevented the nose gear from completing the cycle to the fully down position and also prevented the return of all the gears to the up and locked position. The emergency blow down bottle was removed and examined. It was found to require a force well in excess of the maintenance manual requirement to operate the mechanism. These two defects prevented the landing gear from being locked down.

Occurrence summary

Investigation number 199901762
Occurrence date 05/04/1999
Location Gove Aerodrome
State Northern Territory
Report release date 30/08/1999
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 Cessna Aircraft Company
Model 402C
Registration VH-UBB
Sector Piston
Departure point Gove NT
Destination Lake Evella NT
Damage Substantial

Runway incursion involving a Cessna 172M, VH-MGZ and Cessna 172RG, VH-CSH, Canberra Airport, Australian Capital Territory, on 11 April 1999

Summary

The pilot of VH-MGZ was instructed to taxi for runway 30 and to hold short of runway 35. The aircraft was later observed approaching the holding point and taxiing at a considerable speed. The pilot was instructed to stop immediately. The aircraft came to a halt just within the flight strip of runway 35. VH-CSN was sent around from short final approach. The pilot reported that he had been distracted by his preparation for a navigation exercise and by the two passengers on board his aircraft.

Occurrence summary

Investigation number 199901643
Occurrence date 11/04/1999
Location Canberra Airport
State Australian Capital Territory
Report release date 16/04/1999
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 Cessna Aircraft Company
Model 172M
Registration VH-MGZ
Sector Piston
Departure point Canberra ACT
Destination Tumut NSW
Damage Nil

Aircraft details

Manufacturer Cessna Aircraft Company
Model 172RG
Registration VH-CSH
Sector Piston
Departure point Unknown
Destination Canberra ACT
Damage Nil

Airspace incursion involving a McDonnell Douglas F/A-18A, 370 km north-north-west of Perth Airport, Western Australia, on 28 March 1999

Summary

Occurrence summary

Investigation number 199901286
Occurrence date 28/03/1999
Location 370 km north-north-west of Perth Airport
State Western Australia
Report release date 01/10/1999
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Incident

Aircraft details

Manufacturer McDonnell Douglas Corp.
Model F/A-18A
Registration Unknown
Sector Jet
Operation type Military
Departure point USS Carl Vinson
Destination USS Carl Vinson
Damage Nil

Flight control systems involving a Cessna 402C, VH-UCD, 9 km south-east of Palm Island (ALA), Queensland, on 26 February 1999

Summary

During the pre-flight inspection, the pilot of the Cessna 402 noticed an unusual amount of free play in the elevator trim tab system. A maintenance inspection did not detect any abnormality. During the subsequent flight, while in the cruise, the aircraft suddenly pitched nose down without any input from the pilot. He disconnected the autopilot but this did not remedy the pitch problem. Re-trimming the aircraft also made no difference to the pitch down tendency. After an uneventful landing at the destination, an inspection by a licenced aircraft maintenance engineer revealed that the bolt attaching the trim tab actuator rod to the trim jack could not be located.

Occurrence summary

Investigation number 199901176
Occurrence date 26/02/1999
Location Palm Island (ALA)
State Queensland
Report release date 20/07/1999
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Flight control systems
Occurrence class Incident

Aircraft details

Manufacturer Cessna Aircraft Company
Model 402C
Registration VH-UCD
Sector Piston
Departure point Townsville Qld
Destination Palm Island Qld
Damage Nil

Ground injury involving a Fairchild SA226-TC, VH-UZQ, Bankstown Aerodrome, New South Wales, on 10 March 1999

Summary

The pilot reported that he had started the right engine and was about to select the generator ON when he inadvertently touched the left engine start switch momentarily. The pilot was aware that the left door was open, and loaders were completing last-minute loading. Shortly afterwards, the pilot was advised by the senior base pilot who was in attendance that the left propeller had rotated briefly and struck a loader who was walking towards the front of the aircraft. The loader was uninjured, and the flight proceeded as planned.

As the result of an inquiry by the freight company, the following recommendations were made and have been accepted by the aircraft operator:

1. Development of a documented training program on tarmac operations and procedures.

2. Implementation of a recurrent training program for tarmac personnel.

3. Loading personnel to be certified or "signed up" for single-engine turn-around and loading procedures with engines running.

The operator has included training on "error types" and prevention strategies as part of the company's in-house human factors management on initial and recurrent training courses. During the regular monthly safety meetings pilots have been alerted to the need for propeller and personnel awareness.

Occurrence summary

Investigation number 199901143
Occurrence date 10/03/1999
Location Bankstown Aerodrome
State New South Wales
Report release date 13/09/1999
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Incident

Aircraft details

Manufacturer Fairchild Industries Inc
Model SA226-TC
Registration VH-UZQ
Sector Turboprop
Departure point Bankstown NSW
Destination Unknown
Damage Nil

Abnormal engine indications involving a British Aerospace PLC 3107, VH-TQK, 56 km south-west of Williamtown, New South Wales, on 4 February 1999

Summary

While conducting a regular public transport operation between Williamtown and Sydney, the pilot of a British Aerospace J31 secured the right engine of the aircraft after it auto shut down. He informed the air traffic controller who then issued a clearance to proceed direct to Sydney. The investigation revealed that a support bearing in a gear shaft had failed within the engine gearbox, disconnecting the gear shaft. This deprived the oil pump, fuel control unit, and fuel pump of drive, thereby shutting down the engine. The bearing failure is the subject of a major defect report to the Civil Aviation Safety Authority.

Occurrence summary

Investigation number 199900580
Occurrence date 04/02/1999
Location 56 km south-west of Williamtown
State New South Wales
Report release date 20/07/1999
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Abnormal engine indications
Occurrence class Incident

Aircraft details

Manufacturer British Aerospace
Model 3107
Registration VH-TQK
Sector Turboprop
Departure point Williamtown NSW
Destination Sydney NSW
Damage Nil

Runway excursion involving a Piper PA-28-161, VH-CWW, Lilydale (ALA), Victoria, on 20 February 1999

Summary

The pilot advised that during the engine run prior to take-off the windscreen fogged up both internally and externally. She shut down the engine and wiped both surfaces free of moisture. There was light fog present in the area. During the subsequent take-off run the windscreen again fogged over and she lost visual reference. The pilot closed the throttle and rejected the take-off. However, the aircraft diverged off the runway and impacted trees before coming to rest substantially damaged. The four occupants were able to evacuate unaided and were not injured.

Occurrence summary

Investigation number 199900691
Occurrence date 20/02/1999
Location Lilydale (ALA)
State Victoria
Report release date 03/03/1999
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-28-161
Registration VH-CWW
Sector Piston
Departure point Lilydale Vic.
Destination Avalon Vic.
Damage Substantial