The pilot reported that he was taxiing for departure on runway 07. As he turned the aircraft to line up, the left main gear leg fractured. The left wingtip and the left horizontal stabiliser contacted the ground. Subsequent examination of the fracture showed a fatigue failure emanating from a small impression or dent on the leading edge of the leg. The leg appeared to have been cracked for some considerable time, and eventually failed longitudinally in a straight line. The aircraft had been operating for some years on rough runways, and had been engaged in parachuting operations continually. This type of operation generates an unusually high number of cycles (take-offs and landings) and would contribute to a fatigue failure of this nature.

While climbing through FL 210 on route from Broom to Perth, the aircraft's No 1 engine experienced a sudden failure. The crew shut the engine down and diverted the aircraft to Newman where it landed safely. The engine examination revealed extensive secondary damage to the High-Pressure Turbine (HPT) section caused by failure in the HPT Stage 2 area. All Stage 2 blades had failed.

The blade fracture surfaces contained small area of fatigue at the trailing edges. The fatigue area was not large enough the cause failure of the blades. It is suspected that the Stage 2 nozzle honeycomb abradable material partially separated from the nozzle, initiating a one per revolution vibration that resulted in fatigue propagating through majority of the Stage 2 blades. The engine failure was probably caused by a section of the honeycomb separating and causing blades failure.

FACTUAL INFORMATION

The crew of a Bell 212 helicopter, operating under instrument flight rules (IFR), contacted the controller and requested a clearance from Kooringal to the Royal Brisbane Hospital at 2,000 ft. The Bell 212 was required to transit airspace under the jurisdiction of the approach south controller. As the radar advisory service frequency was assigned to the approach north position, that controller coordinated a clearance for the Bell 212 with approach south.

Approach south initially instructed the approach north controller to track the Bell 212 via overhead Brisbane aerodrome and for it to transfer to the aerodrome control frequency. Approach north advised approach south that the Bell 212 was an aeromedical evacuation flight and consequently approach south agreed for the helicopter to track direct to the Royal Brisbane Hospital. Approach south advised approach north that an arriving Boeing 747 (B747), also operating under IFR, was being sequenced for runway 01 and would be manoeuvred clear of the Bell 212 if necessary. There was no further coordination between approach north and approach south with respect to the two aircraft.

The direct track from Kooringal to the hospital passed approximately 2 NM south of the threshold to runway 01. Approach north advised the aerodrome controller of the details of the Bell 212 in accordance with Local Operating Instructions. The aerodrome controller was not asked to provide separation between the Bell 212 and the B747. As the Bell 212 was about to cross the runway 01 extended centreline, approach north observed, on the radar display, the B747 turning onto a 5 NM final, about 6 NM from the Bell 212. Approach north instructed the crew of the Bell 212 to report sighting the B747 but did not receive a reply. Approach north then asked the aerodrome controller to separate the Bell 212 and the B747. As this coordination was being conducted, the crew of the Bell 212 advised approach north that they could see a heavy jet in their 12 o'clock position and requested approval to turn left and pass behind that aircraft.

Approach north approved the request. There was no infringement of separation standards. The approach south controller was undertaking his ninth consecutive shift without a rostered day free of duty. He advised that he felt slightly fatigued and, although he did not believe at the time that it unduly affected his performance, it was possible that fatigue may have had some effect. Traffic levels were moderate and approach south was aware of the potential conflict between arriving aircraft and the transiting Bell 212. However, based on his initial requirement for the Bell 212 to be handed over to the aerodrome controller, he had a mindset that separation would be provided by the aerodrome controller. Approach north did not initially request assistance from the aerodrome controller to separate the two aircraft because the approach south controller had indicated that he would manoeuvre the B747 clear of the Bell 212 if necessary.

The aerodrome controller was not asked to provide separation between the Bell 212 and B747 until very late, by which time the Bell 212 crew had sighted the B747 and had assumed responsibility to maintain their own separation from that aircraft. The investigation revealed that clear, concise and precise coordination was not conducted between the two approach controllers. In particular, standard procedures were not followed with respect to the assignment and acceptance of responsibility for the provision of separation between the Bell 212 and the B747. The investigation did not determine why standard coordination procedures were not followed.

ANALYSIS

As the approach south controller was feeling slightly fatigued, he may not have been well placed to assess the effects of fatigue on his own performance. As such, although he did not believe that fatigue unduly affected his performance, it is possible that fatigue was a factor in this incident. As a result of the the coordination conducted between approach north and approach south shortly after the Bell 212 departed Kooringal, there was no apparent reason for approach north to conduct further coordination with approach south. However, had approach north provided a relay of radar identification or formal radar hand-off to approach south, it may have acted as a prompt for approach south as to the developing conflict and may have lead to approach south taking more positive control of the situation.

The use of non-standard and incomplete coordination procedures lead to a lack of understanding from all the controllers involved in the incident as to the assignment of responsibility for separation between the two aircraft. Separation between the Bell 212 and the B747 was achieved through conflict resolution, rather than through traffic planning and conflict avoidance to assure separation. As a result, the Bell 212 crew sighted and accepted responsibility for their own separation from the B747 as the two aircraft approached the minimum horizontal radar separation standard required.

SIGNIFICANT FACTORS

1. The use of non-standard coordination procedures lead to misunderstanding between the two approach controllers as to who was responsible for the provision of separation between the aircraft.

2. The approach south controller did not accept the Bell 212 on his radio frequency.

3. No controller took positive control of the situation. Consequently, separation assurance techniques between the aircraft were not applied.

4. The crew of the Bell 212 sighted the B747 prior to infringement of the required separation standard.

The aircraft was maintaining 10,000 ft enroute from Canberra, ACT to Albury, NSW. The weather was a south-westerly airstream, resulting in cloud and rain along the flight path. Consequently, the aircraft was being flown in accordance with the Instrument Flight Rules (IFR). At a position approximately 113km north east of Albury, the pilot reported that she had experienced problems with the right engine and had shut the engine down.

A PAN was declared. Due to a steady 50 kt headwind to Albury, and maintaining flight on only one engine, the pilot chose to divert the aircraft for a landing at Wagga. After holding south of Wagga, due to low cloud and inclement weather over the aerodrome, the pilot carried out an uneventful single engine landing.

The maintenance assessment carried out by the aircraft owner, determined that the right engine problem had occurred due to a failure of the impeller shaft bearing in the right turbocharger unit. This had resulted in a failure of the compressor impeller. The aircraft owner then sent the turbocharger to the manufacturer for examination. This examination found that the impeller and bearing damage had occurred as a result of the ingestion of soft foreign material from an unknown source. Such soft material was stated to include, shop towels, water, paper, filter media or some plastics. The owner reported that no soft material was found following the engine failure. Due to the conflicting examination reports, the reason for the turbocharger failure could not be determined.

During the investigation the passengers reported that some icing had been present on the aircraft wings. The investigation determined that some light icing had been present during the flight, however, the extent noted was insufficient to have had any significant effect on the aircraft's performance.

The pilot reported that the alternator failed while the aircraft was between Birdsville and Broken Hill. The pilot reduced the aircraft's electrical load to preserve battery power. On arrival at Broken Hill the battery was flat, and the pilot was unable to lower the landing gear either by normal or emergency methods. After emergency services were in position the aircraft was landed with the landing gear retracted.

When the aircraft was raised by engineers the landing gear was able to be extended normally. The investigation disclosed that the alternator body securing bolts had loosened thereby allowing the rotor to contact the windings, shorting out the electrical supply. The battery had depleted prior to arrival at Broken Hill; therefore, the electrically powered hydraulic pump that normally retracts and extends the landing gear was rendered inoperative. No fault was found with the landing gear system.

Upon reflection the pilot advised that he most probably did not hold the emergency gear extend lever down long enough to bleed off the hydraulic pressure and allow the landing gear to extend. The pilots operating handbook advises that under normal conditions the lever should be held down for approximately 10 seconds. However, industry experience is that it can take up to 20 seconds. The pilot advised that during his endorsement training on this aircraft he was taken through the emergency extend procedures but did not activate the system. He therefore did not have an appreciation of either the effort or the length of time the handle was required to be held down.

During climb, the crew noticed an odour in the cabin which was suspected to have resulted from bleed air system cleaning during earlier maintenance. Further checks carried out by the crew identified a strong smell of petrol, increasing in intensity towards the rear of the cabin. As the aircraft was carrying dangerous goods, detailed as a petrol engine in the forward hold, an immediate return to Los Angeles was initiated. During the return the smoke/fumes removal drill was carried out and fuel was jettisoned. The cabin crew were instructed to switch off any non-essential electrical equipment and the aircraft was descended to 20,000 ft. Oxygen masks were not deployed and the return to Los Angeles was completed without further incident.

A subsequent ground inspection of the forward hold revealed that a motorcycle had fallen onto its side and petrol had leaked from its fuel tank. The petrol spill had been contained within the hold. The motorcycle was offloaded, the petrol spill was cleaned up and the service continued. The operator carried out an investigation into the incident and determined that the motorcycle fuel tank had been drained to the reserve level for shipment. This complied with the dangerous goods regulations for transportation of the motorcycle in an upright position. However, the motorcycle had been inadequately restrained on its transport stand. Only two securing straps had been used instead of five, and no timber had been used between the motorcycle and the pallet floor. This had resulted in the motorcycle falling over, probably during take-off, and the remaining fuel leaking out.

Safety action

The operator, in conjunction with the overseas freight handling agent, instigated an immediate retraining program for all staff involved in export handling procedures. In addition, new instructions have been issued for the handling of dangerous goods.

The pilot advised the Bureau that while flying his Quickie Q2 aircraft in the circuit at Shepparton Vic. he felt that the aircraft was not responding as usual to control inputs. The pilot said that during the roll out after a smooth landing the right canard failed. The propeller was damaged when it contacted the runway after the canard failed.

Arrangements were made for examination of the failed components by the Civil Aviation Safety Authority's structures specialists. It was determined that the upper surface of the canard had failed under a single application of a compression load parallel with the plane of the skin. The inner structure of the section showed damage that was consistent with the upper surface being under compression. Examination of the composite materials indicated that there was no apparent degradation of the matrix. Given these features it was considered that the wing had failed as a result of a large sudden upward force on the wing.

There were many witnesses to the events on the day. It was determined that when the pilot arrived at the airfield and declared his intention to fly the Q2, a highly experienced local pilot advised the Q2 pilot to take some instructional flying in a Pitts Special aircraft that was available. The Q2 pilot declined the offer even though he had only very limited recent flying experience, non of which was in an aircraft comparable to the Q2. Witnesses advised that during the take-off the aircraft had been lifted off too early at a very low airspeed. Immediately after lift off the pilot encountered control difficulties, however these were overcome and the aircraft was flown out of the circuit towards the training area.

Ten minutes later the aircraft was observed overhead the airfield and was manoeuvred to join crosswind for runway 18. The aircraft was observed to be flying very slowly on the final approach and after touch-down commenced porpoising. The aircraft veered to the left, continued to porpoise, and then veered right, back across the runway. The pilot applied considerable power and lifted the aircraft off the runway at very low speed with a high nose attitude. At approximately 3 metres above the runway the aircraft stalled, dropped to the right and impacted on the right canard which fractured. The aircraft slewed and came to rest. The pilot evacuated without assistance.

The investigation determined that this was most probably the pilot's first flight in the aircraft. He had purchased it 28 months before the accident, and, while he informed the Bureau that he had flown the aircraft for 5 hours, changes and deletions in his pilot's log book precluded verification. The investigation was told that the pilot had been observed taxiing the aircraft but this was the first time the pilot had been observed to fly the aircraft. Witnesses stated that on one occasion while taxiing fast the pilot lost control and the aircraft was damaged.

This accident was not reported and the repairs were not reflected in the aircraft's logbooks. It is probable that the accident occurred because the pilot had no experience on the type, had very limited recent flying experience, and lost control of the aircraft on landing.

A military Hercules aircraft, operating under visual flight rules, was conducting an airdrop exercise at low level onto Tumbarumba airfield. Due to a delay in the airdrop, the aircraft was holding in a right orbit east of the airfield at an altitude of 1,000ft above ground level. A Piper Chieftain aircraft, on an instrument flight rules charter flight, was on descent to Tumbarumba.

The pilot of the Chieftain made transmissions on the area frequency at the top of descent and on arrival in the circuit area but heard no replies from other aircraft. While flying on downwind for a left circuit to runway 19, the Chieftain pilot, and his passengers, observed the Hercules aircraft on their right side on a parallel track and at about the same altitude. When the Chieftain pilot specifically addressed a radio transmission to the Hercules aircraft in the Tumbarumba area, the Hercules crew replied that they had visual contact with the Chieftain and would remain clear.

The Chieftain completed its landing on runway 19 and the Hercules departed the Tumbarumba area at low level. The operator of the Hercules reported that the crew had received the broadcasts from the Chieftain pilot but had replied on the wrong frequency due to the incorrect positioning of the copilot's radio transmit selector. After receiving the call directed at their aircraft type, the crew discovered their error and transmitted on the correct frequency.

The minimum distance between the two aircraft could not be established. The minimum separation reported by the Chieftain pilot varied from that reported by the crew of the other aircraft. Radar data was unable to reconcile the discrepancy as the Tumbarumba circuit area is shielded from all nearby radar heads by undulating terrain. However, neither pilot believed that a collision risk existed. Although the Hercules crew transmitted on the wrong frequency, they were monitoring the correct frequency and were aware of the Chieftain. They maintained visual separation with the other aircraft throughout the occurrence.

The pilot of the Piper Pawnee glider tug reported that soon after take-off, at about 200ft AGL the engine lost power. The pilot of the glider being towed realised there was a problem and released the tow line. The glider was able to return to the airfield for a normal landing. The Pawnee collided with the tops of trees as the pilot attempted to force land into a paddock. The aircraft subsequently landed heavily and suffered substantial damage. The aircraft was fitted with one 84 litre fuel tank in each wing.

The investigation found that the left tank was empty while the right tank was approximately three quarters full. The fuel selector was found selected to the empty left tank. The pilot advised that he had refuelled the aircraft the previous night with 55 litres of fuel. He was unable to recall whether he had put any of that fuel in the left tank. He said that he did not physically check the fuel quantities after the refuelling or during the daily inspection on the morning of the accident. He advised that he conducted the first flight of the day with the fuel selector to the right tank. He noticed during that flight that the aircraft appeared to fly right wing heavy.

For the next flight, the accident flight, the pilot changed the fuel selector to the left tank. He was unable to explain why he had selected the left tank when he knew that the right wing was heavy. He did not check the fuel quantity gauges when he changed the selection. It was reported that a fuel stain had been noted under the aircraft while it was in the hangar prior to the day's operation.

No investigation was carried out to determine if the stain was as a result of a fuel leak. The gliding club has required the pilot to undertake a flight review with an emphasis on fuel management and pre-flight inspection procedures. The club is also to require all tug pilots to undertake a session on tug operating procedures as a part of their biennial flight review.

The Cessna 206 floatplane was on a charter flight taking passengers from Kimberley Coastal Camp to Lake Kununurra. During descent 25 NM from Lake Kununurra, the aircraft's engine lost power. The pilot reported that he immediately switched the fuel selection from the left to the right fuel tank. He also selected full throttle, full rich fuel mixture, boost pump to low prime and full fine on the propeller pitch control. The engine did not respond so he elected to conduct an emergency landing on the Ord River. The pilot reported that the descent took about five minutes, during which he selected high prime on the boost pump for several seconds.

The engine did not recover power throughout the descent. The landing was conducted without further incident. The aircraft was undamaged, and the passengers were uninjured. The pilot reported that he filled the tanks before leaving Lake Kununurra for the Camp. Because of the amount of fuel he thought was in the left tank, the pilot had intended to select the right tank at 15 NM from Lake Kununurra. However, the engine lost power before he could do so. After the landing, the aircraft's left fuel tank was found to have about 8 L of fuel remaining, approximately 20 L less than the pilot had planned. The right tank had about 60 L. The operator reported that the only fuel system fault was three clips that secured the left fuel tank bladder to the wing were found undone. No fault could be found with the engine.