Prior to landing, the pilot confirmed that the landing gear was down (three greens) on the downwind leg and again on final for landing. Approximately 2 to 3 seconds into the landing roll, the right landing gear collapsed allowing the right propeller, landing light and flaps to contact the runway. After the aircraft came to rest on the grass, the pilot and passengers egressed without injury.

Maintenance organisation inspection revealed several anomalies, which were not conducive to the continued proper functioning of the landing gear retraction system. The significant factors determined from the inspection were:

1. A lack of lubrication of the landing gear system.

2. A bush missing from the right main gear outboard drive tube.

3. Main landing gear system was out of rigging.

FACTUAL INFORMATION

An Airbus Industrie A340 registered as BHXI and operating flight number Cathay 104 (CPA104) had been flight-planned to operate a flight from Melbourne to Hong Kong. The crew of the A340 had been cleared to depart Melbourne on a KEPPA TWO standard instrument departure (SID) with a requirement to maintain 5,000 ft. The KEPPA TWO departure was able to be conducted from Melbourne runways 16, 27 or 34. The Melbourne Automatic Terminal Information service (ATIS) was "Information Sierra" with a variable easterly wind at 5 kts. Downwind on runway 27 was reported as 5 kts. The duty runway at Melbourne was runway 16 for arrivals and runway 27 for departures.

The departure of CPA104 was coordinated with both the Departures North controller and the Essendon aerodrome controller (ADC) by the Melbourne ADC. The crew of CPA104 was cleared for take-off and instructed to contact Departures airborne.

A Cessna C172 registered as VH-ZWR had been flight-planned from Essendon to Kyneton at 3,500 ft, flying under the visual flight rules. The Essendon ADC had cleared the pilot in command to depart the Melbourne CTR on an amended route via Rockbank at an amended level of 1,500 ft. The aircraft had departed from Essendon's runway 17 and had made a right turn to track via Rockbank. Because the C172 would transit only controlled airspace that was the responsibility of Essendon Tower, coordination for this aircraft with other control agencies was not required.

The Departures North controller identified CPA104 airborne and cleared the crew to climb to flight level 200. The controller then observed on radar an unidentified aircraft squawking code 4000, departing Essendon westbound and crossing the departure track of the A340. The controller initiated corrective action but the A340 passed behind the unidentified aircraft with 1 NM horizontal and 900 ft vertical separation. The separation standard was infringed: the required standard between these two aircraft was either 3 NM or 1,000 ft. The unidentified aircraft was subsequently confirmed to be VH-ZWR.

Air traffic control coordination procedures required the Melbourne ADC to obtain departure instructions for CPA104 from the Departures North controller, as the aircraft was planned to depart on a northerly track. The coordination between ADC and Departures was carried out and an "unrestricted" clearance was obtained. The use of the non-duty runway for departures from Melbourne was not unusual. Runway 16 was often used for aircraft tracking to southerly destinations or for the larger international aircraft requiring the longer runway.

Because CPA104 was departing from runway 16, additional coordination was required between the Melbourne ADC and the Essendon ADC in accordance with Local Instruction LOA2976 - Coordination for Non-Duty Departures Runway 16. Coordination with the Essendon ADC was attempted; however, due to conflicting traffic, the departure was not authorised by the Essendon ADC at the time.

The workload at Essendon was considered to be high with controllers working in all operational positions. Additional airspace had been negotiated and released to Essendon by the Melbourne Centre. The airspace configuration on this day was unusual. The usual configuration was for Essendon Tower to have the south-east quadrant of the Melbourne control zone (CTR) up to and including 2,000 ft. The south-east quadrant was from south of the extended centreline to runway 26 to east of the extended centreline from runway 17. For a planned calibration of the Essendon instrument landing system (ILS), an extension to the airspace was agreed that would encompass normal airspace, plus the airspace from the extended centreline of runway 26 to the western edge of the CTR up to and including 3,000 ft. This additional airspace included all airspace south of the extended centreline of Essendon's runway 26 up to and including 3,000 ft.

The aircraft conducting the calibration testing of the ILS was operating to and overshooting from Essendon's runway 26. The aircraft was an Astra 1125 jet aircraft operating under the callsign of Auscal 01 (ADA01). This was the first time that this type of aircraft had been used for calibration tests: previously the Airservices Australia Fokker F28 had conducted the testing. When the F28 did the testing, it was able to overshoot from the approach prior to crossing the runway intersection, which obviated the need to sequence the aircraft with other traffic. The Astra aircraft needed to conduct an overshoot from all approaches, which necessitated complex sequencing with all other traffic. It was this aircraft that precluded CPA104 getting airborne when the Melbourne ADC first attempted to coordinate a departure with the Essendon ADC.

When the Melbourne ADC next attempted to coordinate with the Essendon ADC the departure of CPA104, the Essendon controller pre-empted the request as soon as the "hotline" communication line was opened by issuing a clearance using the word "approved" for the Melbourne runway 16 departure. Melbourne Tower advised that "he (CPA104) would be after the one on short final". The Essendon ADC replied with the statement "OK, behind him, approved". The Essendon ADC stated during interview that he couldn't recall issuing the approval for the departure of CPA104.

Although not a documented procedure, the practice in Essendon Tower was to place a runway-16 departure designator strip in the bay containing departure strips. The designator strip was used to remind and alert controllers of aircraft cleared to depart from runway 16 at Melbourne. Essendon Tower did not hold individual flight progress strips for Melbourne's aircraft and the runway-16 designator strip was used to indicate a pending departing aircraft. Controllers were trained to scan the strip bay to identify conflicting aircraft prior to issuing a subsequent clearance to an aircraft that could potentially conflict with aircraft departing Melbourne's runway 16. The Essendon ADC stated during interview that although the designator strip was placed in the departure bay, he did not scan the strip bay prior to clearing VH-ZWR for departure and the right turn.

ANALYSIS

Although the Essendon ADC did not recall approving the departure clearance for CPA104, the designator strip was reputedly placed in the departure bay. Analysis of the audio recording indicated that the Essendon ADC issued the take-off clearance for VH-ZWR approximately 3 seconds after approving CPA104's departure. This action indicated that the Essendon ADC did not recognise the potential for conflict between the two aircraft when the judgement was made to clear VH-ZWR for take-off and make the right turn. An alternative hypothesis is that a judgement was made that there was no conflicting traffic for the departure of VH-ZWR, prior to issue of the take-off clearance and receipt of the hotline call from Melbourne. The controller's mind-set regarding VH-ZWR did not change because the implications of CPA104's departure did not register with the controller. Importantly, the potential for conflict was not recognised when the Essendon ADC approved CPA104's departure. The latter hypothesis is supported by the controller's failure to scan the strips prior to the take-off transmission being made because his mind-set was that VH-ZWR was clear for take-off.

The traffic density and complexity on this particular day was reported to be unusually high. This additional workload may have increased the cognitive demands on the controller, unbeknown to other members of the team. The other controllers were also busy and the ADC was reputedly a very experienced controller. These two factors may have been the reason that the performance of the ADC was not monitored more closely.

Analysis of the radar data indicated that when the 3-NM radar separation standard was infringed, vertical separation indicated that CPA104 was 500 ft below VH-ZWR and climbing. When the aircraft were at the same level of 1,300 ft, radar separation had reduced to 2.2 NM. When CPA104 passed behind VH-ZWR, vertical separation had increased to 900 ft and radar separation had reduced to 1.25 NM. A vertical separation standard of 1,000 ft was re-established when the aircraft were 1.4 NM apart.

SAFETY ACTION

The Airservices Australia investigating officer made the following two recommendations:

"1. Amend LOA 2976 to:

a. Give better examples of the approval process for Melbourne runway 16 departures; and

b. Promulgate usage and the process to be followed by Essendon tower of the runway 16 designator strip.

2. Consider releasing all control zone airspace to Melbourne and Essendon towers".

Melbourne ATC management agreed to implement Recommendation 1 at the next revision of Local Instructions. Management will consider Recommendation 2 following consultation with terminal control unit staff.

The pilot reported that before landing he had obtained the appropriate cockpit indications that the landing gear was locked down. However, the nose gear collapsed during the landing roll. The main landing gear also collapsed after the aircraft had been inspected and was being moved. Subsequent examination and testing of the landing gear system failed to identify any fault.

When the copilot rotated the aircraft through 17 degrees on the way towards the lift off body angle of 19 degrees the stick shaker activated. Concurrent with the stick shaker activation, the leading edge flaps extend light on the forward panel extinguished and the amber leading edge flaps transit light illuminated. As soon as the stick shaker activated the rotation was stopped. Almost immediately the leading edge flaps transit light extinguished, the leading edge flaps extend light illuminated, and the stick shaker stopped. The activation period was very brief and occurred at approximately 174 knots. 

The take-off and climb were continued normally and no other discrepancies were noted. Maintenance investigation disclosed that one of the leading edge slat position micro switches had failed. The failure of the switch caused the logic system to sense that the leading edge slats were retracted rather than extended. This resulted in the stall warning system being reset and the stick shaker to activate at normal take-off speeds. The operator advised that the manufacturer is considering a change that will ensure that failure of only one switch is insufficient to cause the system to be reset.

The aircraft departed Parafield for Renmark on a private flight. He could not land at Renmark when he arrived due to low stratus cloud. He then elected to return to Parafield. En route he flew above cloud to remain in VMC. North-east of Parafield, while still on top of cloud at 3,000 ft, the pilot contacted Adelaide approach and requested navigational assistance. The controller vectored the aircraft to the vicinity of Edinburgh where the pilot was able to resume his own navigation and commenced a descent to 1,500 ft. Shortly thereafter, the pilot called 'Mayday' because the engine had failed. During the forced landing the aircraft landed heavily and crashed through a fence.

The pilot subsequently reported that before leaving Parafield, both fuel tanks had been filled to the tab. He flew with the right tank selected all the time from Parafield until the engine lost power. At no stage had he leaned the fuel mixture. Sometime during the descent from 3,000 ft the right fuel tank ran dry and the engine starved of fuel. The pilot did not realise that the engine had lost power until he tried to increase power at about 1,100 ft. He then changed the fuel selector to the left tank. He also switched on the electric fuel boost pump but the engine still did not regain power except for one quick burst while the boost pump was selected to high.

At about 200 ft AGL, he reselected the right fuel tank but the engine never regained power. After the accident engineers inspected the aircraft and reported that both the right wing tank and the right reservoir tank were empty and had not leaked fuel as a result of the accident. The left wing tank contained about 135 litres, after fuel had spilled from it due to the accident. A subsequent engine run proved that there was no fault with the engine; nor was fault found with the airframe fuel system. No evidence was found that the engine had flooded; the exhaust showed no signs of soot. It is probable that the pilot inadvertently ran the right tank dry while under stress of flying in marginal weather.

When he changed to the left tank, he probably did not persist long enough with the electric boost pump selected on for the air to be purged from the fuel lines to the engine. When the pilot reselected the right tank there was no chance that the engine could regain power.

SAFETY ACTION

After the accident, a flying operations inspector retested the pilot's knowledge of flight planning, fuel management and the Cessna 210N fuel system.

When the aircraft arrived in the Broken Hill circuit area, the pilot observed the airfield covered in fog. After failing to become visual during an instrument approach, he decided to divert to Wilcannia. The pilot declared an emergency during the diversion, as he expected to arrive at Wilcannia with less than minimum fuel. The aircraft landed at Wilcannia with about 25 minutes of fuel remaining. Investigation showed that the Terminal Area Forecast (TAF) requested by the pilot prior to the flight did not include a forecast of fog or any other significant weather at Broken Hill.

At the time of issue of the forecast (1850 Z), the conditions at Broken Hill were considered to be too dry for fog to develop. Satellite images did not show any fog on the ground. At 2125Z, after receiving advice of increased moisture levels at Broken Hill and reports of fog at Mildura, the TAF for Broken Hill was amended to include a 30% probability of fog. The incident aircraft arrived overhead Broken Hill aerodrome at 2128 UTC and began an instrument approach. Another company aircraft had landed at Broken Hill approximately 30 minutes earlier, and had advised the pilot of the incident aircraft that there was no fog.

A DeHavilland Canada DHC-8 (Dash 8) had been cleared to take-off on runway 30, with a request to make an early right turn to track to Point Lookout. The aircraft was rolling when the crew heard traffic information being issued by the aerodrome controller to an inbound formation of three McDonnell Douglas F-18A (Hornet) fighter aircraft. The Dash 8 crew also heard the controller advise the formation pilots that an early "pitch" (a 180 degree turn onto downwind) was available. The Dash 8 crew subsequently commenced a right turn at about 350 ft. At an altitude of about 700 ft they saw a Hornet to their right, passing from left to right about 300 ft higher than them.

The Dash 8 crew arrested their rate of climb as the Hornet passed over them and was lost from view. It was subsequently determined that the Hornet pilots had sighted the Dash 8 prior to entering the circuit at 1,500 ft. The first two aircraft were able to "pitch" early, passing behind the Dash 8. The third Hornet commenced to "pitch" just astern of the Dash 8 but overtook that aircraft during the turn. The Hornet pilot assessed that the Dash 8 was at approximately 700 ft, with a moderate rate of climb, and that adequate vertical separation would be maintained. The aerodrome controller did not use separation assurance techniques to establish separation between the departing Dash 8 and the arriving fighters. As a result, separation became reliant on the judgement of the Hornet pilots, rather than by the use of air traffic control traffic conflict strategies.

Prior to the aircraft departing Lord Howe Island, the Terminal Area Forecast (TAF) for Norfolk Island did not require the pilot in command to arrive with fuel for holding or for diversion to an alternate airfield. During the course of the flight, the weather at Norfolk Island deteriorated. The TAF was initially amended to require 30 minutes holding and later amended to require 60 minutes of holding fuel. The pilot advised that he became aware of the deteriorating weather at his destination only after he had passed the point of no return (PNR).

When the aircraft arrived in the Norfolk Island circuit area, the pilot assessed the conditions as unsuitable to land and commenced holding at low level over the water, but within visual range of the island. Approximately 45 minutes later, the weather conditions improved sufficiently for the pilot to make a visual approach and landing. The aircraft landed with required fuel reserves. Investigation of this incident did not reveal any deficiencies in the conduct of this flight. The airline has advised that as a result of this incident, they have changed their fuel policy to require the carriage of additional fuel where possible.

During take-off from runway 16 at Melbourne the pilot of the Airbus A320 aircraft experienced inadequate directional control. The take-off was rejected and the aircraft returned to the gate. The investigation determined that six days prior to this report the pilot in command's nose wheel steering transmitter had been found to be faulty. Because a spare was not immediately available, the aircraft had been cleared to operate under the conditions of the minimum equipment list. Because of that deficiency the crew did not have nose wheel steering available through the rudder pedals. Up to 70 kts nosewheel steering is through the tiller steering system, but the tiller is deactivated beyond 70 kts. The rudder becomes fully effective at about 100 kts.

Therefore between 70 kts and 100 kts pilots must apply a larger than normal rudder deflection if the rudder pedal steering system is not available to assist with directional control. The flight data recorder showed that as the aircraft commenced to diverge slightly to the left, the pilot applied right rudder. Subsequent analysis has shown that while the degree of rudder deflection applied by the pilot would have been sufficient to correct the swing had rudder pedal steering been available, without the rudder pedal steering the applied deflection was approximately half of what was required. It was determined that the pilots had not received training in the effects of the loss of rudder pedal steering. Safety action. The operator has initiated a simulator training sequence that will address the effects of failure of the rudder pedal steering system.

The pilot of the Fokker 50 was tracking the 168 degree radial from Carnarvon enroute to Perth. Whilst passing FL183 on climb to FL190, the pilot of the Fokker observed a Jetstream pass beneath and to the left on the reciprocal track. The Jetstream was enroute from Perth to Carnarvon and was maintaining FL180. FS had not provided traffic information to either pilot. Airservices Australia reported that a new manning roster was being trialled at the Flight Service Centre and that there were a small number of teething problems being experienced with staff and supervisors becoming familiar with the new hours and rotation of staff within the roster.

On this occasion, insufficient staff was available to provide relief to the operating positions. The flight service officer had just commenced duty but due to the staffing restrictions being experienced through the new roster, he did not have time to complete his normal familiarisation with the activities of the centre before he was required to assume the operating position. The workload at the time of the incident was high and the handover from the officer previously occupying the position was reported as being rushed and incomplete. The flight service officer who had assumed the operating position was, therefore, unfamiliar with the traffic situation.

LOCAL SAFETY ACTION

Airservices Australia has reported that it has identified the problems with the new roster and these will be rectified pending a review.