Runway excursion involving a Cessna 172M, VH-RCK, 16 km west of Mount Augustus (IFR), Western Australia, on 23 May 1998

Summary

No text.

Occurrence summary

Investigation number 199801870
Occurrence date 23/05/1998
Location 16 km west of Mount Augustus (IFR)
State Western Australia
Report release date 27/07/1998
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 Cessna Aircraft Company
Model 172M
Registration VH-RCK
Sector Piston
Departure point Mt Augusta Station WA
Destination Mt Augusta Station WA
Damage Substantial

Loss of control involving a Kawasaki Heavy Industries 47G3B-KH4, VH-SUC, Bellburn Airstrip, Western Australia, on 23 May 1998

Summary

The pilot reported that he descended to approximately 150 ft AGL as he was approaching Bellburn airstrip, and decided to overfly the windsock. He noted that the wind was an easterly breeze of about 7 knots. The pilot then intended to carry out a left turn, fly a downwind leg, and terminate into wind. He then rolled on about 50 degrees of bank, and shortly afterwards the helicopter began shaking violently. The helicopter then rotated through 180 degrees and adopted a nose down attitude. The pilot said he applied full power and full collective control, but was unable to prevent the helicopter striking the ground.

A witness located near the parking area saw the helicopter bank steeply and then begin to descend. The tail rotor then hit a patio attached to an office building and the main rotor struck a tree just before the helicopter impacted the ground.

Occurrence summary

Investigation number 199801863
Occurrence date 23/05/1998
Location Bellburn Airstrip
State Western Australia
Report release date 16/06/1998
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Loss of control
Occurrence class Accident

Aircraft details

Manufacturer Kawasaki Heavy Industries
Model 47G3B-KH4
Registration VH-SUC
Sector Helicopter
Operation type Charter
Departure point Turkey Creek Roadhouse WA
Destination Bellburn Airstrip
Damage Substantial

Collision on ground involving a Airparts NZ Ltd FU-24-950, VH-KSF, 19 km north-east of Cumnock, New South Wales, on 18 May 1998

Summary

When the pilot entered the cockpit of the Fletcher, he observed the loading vehicle near the chemical dump. The pilot started the engine and allowed it to warm up for approximately four minutes. Unbeknown to the pilot, during this time, the loading vehicle moved to a position on the right side of the aft fuselage of the aircraft in preparation for loading. When the pilot commenced taxiing, the tailplane collided with the loading vehicle, causing substantial damage to the aft fuselage. No person was injured.

A significant factor in this accident was the driver positioning the loading vehicle near the aircraft without the approval of the pilot.

Occurrence summary

Investigation number 199801787
Occurrence date 18/05/1998
Location 19 km north-east of Cumnock
State New South Wales
Report release date 07/07/1998
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Accident

Aircraft details

Manufacturer Airparts NZ Ltd
Model FU-24-950
Registration VH-KSF
Sector Piston
Operation type Aerial Work
Departure point 'Allambie' NSW
Destination 'Allambie' NSW
Damage Substantial

Loss of separation involving a Boeing 737-33A, VH-CZV and Boeing 737-377, VH-CZK, 19 km north-west of Sydney Aerodrome, New South Wales, on 21 May 1998

Summary

The airport and associated airspace were being operated in accordance with Mode 7 of the Sydney Long Term Operating Plan (LTOP), in that runway 25 was being used for departures while runways 34L and 34R were being used for arrivals.

A Boeing 737 (B737), registration VH-CZV (CZV), had departed runway 25 at Sydney. When the aircraft was 6 NM north-west of Sydney airport, the crew was cleared to climb to flight level (FL) 280. When it was 10 NM north of Sydney, the Departures North controller instructed the crew to turn right onto a heading of 060 degrees. Shortly after, the controller recognised that CZV was not going to reach 9,000 ft in sufficient time to maintain separation with another B737, VH-CZK (CZK), which was on a LETTI 3 Arrival, standard arrival route (STAR) for runway 34R and maintaining 8,000 ft. The required separation standard was either 1,000 ft vertically or 3 NM horizontally.

The aircraft were approximately 3 NM apart when traffic information was passed to the crew of CZV. Subsequently, the crew of CZV reported sighting CZK and advised the controller that visual separation could be maintained. Analysis of the radar data indicated that a breakdown of separation had occurred when the lateral separation standard was infringed while the vertical displacement of the aircraft was 500 ft. The aircraft subsequently closed to within 1 NM, at which point 1,400 ft of vertical separation existed. The investigation revealed that the controller cancelled restrictions for CZV that had been imposed for the departure. The speed restriction was cancelled first, followed by the altitude restriction of 5,000 ft.

The altitude restriction would have assured separation with the track of the inbound conflicting aircraft (CZK). When the altitude restriction was removed, the controller relied on monitoring the flight paths of the aircraft and his ability to implement any necessary action to maintain separation. The controller was undergoing a familiarisation period under the supervision of a suitably rated controller. The controllers were distracted, from the monitoring role, by coordination activities with flight service and the control tower. As a result of this investigation and a number of similar occurrences, the Bureau of Air Safety Investigation issued report B98/90 which covered the systemic investigation into factors underlying air safety occurrences in Sydney Terminal Area airspace.

Occurrence summary

Investigation number 199801779
Occurrence date 21/05/1998
Location 19 km north-west of Sydney Aerodrome
State New South Wales
Report release date 26/08/1998
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 The Boeing Company
Model 737-33A
Registration VH-CZV
Sector Jet
Operation type Air Transport High Capacity
Departure point Sydney NSW
Destination Maroochydore Qld
Damage Nil

Aircraft details

Manufacturer The Boeing Company
Model 737-377
Registration VH-CZK
Sector Jet
Operation type Air Transport High Capacity
Departure point Coolangatta Qld
Destination Sydney NSW
Damage Nil

Wheels up landing involving an Embraer EMB-820-C, VH-HVA, Scone (ALA), New South Wales, on 11 May 1998

Summary

After taking off from Scone, the pilot of an Embraer 820C aircraft reported that when retracting the landing gear, the landing gear selector failed to return to the neutral position, and the gear unsafe light remained on. The emergency checklist was actioned and the emergency hand pump was used by the pilot to extend the landing gear, however, the nose gear failed to lock down. The pilot requested emergency services to be in attendance prior to returning for a landing. When the aircraft subsequently landed, the nose gear collapsed during the landing roll. The pilot and passenger vacated the aircraft without injury.

An investigation revealed that the right engine driven hydraulic pump was leaking from a loose suction line fitting, and that most of the hydraulic fluid had been lost overboard. Inspection of the hydraulic hand pump found contamination of the check valve. This was probably enough to hold the valve off its seat so that insufficient pressure was available to lock the nose gear in the down position.

Further investigation determined that the right engine had been changed prior to the accident flight. As the engine had been supplied without a hydraulic pump, a serviceable pump was fitted. During engine ground running, the right hydraulic pump failed to pressurise the system and it was assumed that, because the left and right engines rotate in opposite directions, the pump was configured for left engine rotation. On completion of the engine run, the hydraulic pump lines were reconfigured for correct rotation. A very short engine run confirmed that the pump pressurised the system and that no leaks were apparent. However, the suction line had not been properly tightened, which was not detected. Sometime later, at about the time the aircraft departed, hydraulic fluid commenced to leak from the loose suction line fitting.

It is likely that whilst the pump was operating in the reverse rotation mode during the first engine run, the reversed hydraulic flow disturbed any sediment that was in the hydraulic system. The contamination then found its way into the hand pump when it was operated by the pilot during the emergency extension of the landing gear.

Occurrence summary

Investigation number 199801668
Occurrence date 11/05/1998
Location Scone (ALA)
State New South Wales
Report release date 02/07/1998
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Wheels up landing
Occurrence class Accident

Aircraft details

Manufacturer Embraer-Empresa Brasileira De Aeronautica
Model EMB-820-C
Registration VH-HVA
Sector Piston
Operation type Air Transport Low Capacity
Departure point Scone NSW
Destination Gunnedah NSW
Damage Substantial

Smoke involving a de Havilland Canada DHC-8-315, VH-JSQ, 172 km south of Moomba Aerodrome, South Australia, on 5 May 1998

Summary

While returning to Adelaide from Moomba, the crew of a Dash 8 detected smoke coming from around the weather radar. They immediately turned off the equipment, donned oxygen masks and made a PAN call requesting RFF services to be placed on standby. To dissipate the smoke, the crew requested a descent to 10,000 feet where the aircraft was depressurised and the forward outflow valve was opened. After ensuring that there was no smoke or flame coming from the radar unit, the crew made the decision to continue to their destination and briefed the passengers accordingly. Upon arrival in Adelaide the aircraft made a normal approach and an uneventful landing. The flight attendants were later sent for medical attention due to the effects of smoke inhalation. Maintenance investigation by the operator traced the fault to the radar indicator unit. This was replaced and the aircraft returned to service.

Occurrence summary

Investigation number 199801584
Occurrence date 05/05/1998
Location 172 km south of Moomba Aerodrome
State South Australia
Report release date 27/05/1998
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Smoke
Occurrence class Incident

Aircraft details

Manufacturer De Havilland Canada/De Havilland Aircraft of Canada
Model DHC-8-315
Registration VH-JSQ
Sector Turboprop
Operation type Charter
Departure point Moomba SA
Destination Adelaide SA
Damage Nil

Air-ground-air involving a Beech Aircraft Corp 76, VH-AZX and British Aerospace PLC BAe 146-200, VH-NJU, Mackay Aerodrome, Queensland, on 28 April 1998

Summary

CIRCUMSTANCES

VH-AZX, a Beech 76, was taxiing for take-off at the same time as VH-NJU, a British Aerospace 146. Both aircraft had made the appropriate mandatory broadcast zone (MBZ) calls. While lining up for take-off, the crew of NJU noticed AZX at taxiway E approaching the runway. The crew of NJU broadcast "rolling" and AZX stopped. Immediately, another voice broadcast that AZX had infringed the flight strip and suggested that the pilot should take off. This broadcast was acknowledged by the pilot of AZX, who taxied onto the runway and took off.

The crew of NJU had only just commenced the take-off roll and rejected the take-off. The other voice was that of the airport safety officer, who was in a vehicle near taxiway E. He saw AZX cross the holding point and enter the flight strip. He believed that the crew of NJU had not seen AZX, and that a dangerous situation existed. This was the basis for his radio transmission to the pilot of AZX. The investigation found that there were no published procedures or guidelines for airport safety officers to follow in situations perceived to require immediate action. On this occasion, the safety officer made a radio transmission which the pilot of AZX interpreted as an air traffic control instruction and which he subsequently followed.

SAFETY ACTION

The Bureau of Air Safety Investigation is currently investigating a perceived safety deficiency that has been identified as a result of this occurrence. The deficiency involves the lack of published information available to airport safety officers on recommended radio usage. This information is necessary in order to provide safety officers with phraseology they can use to alert pilots to safety hazards, without using terms that could be interpreted as controlling or suggesting. Any recommendation issued as a result of this investigation will be published in the Bureau's Quarterly Safety Deficiency Report.

Occurrence summary

Investigation number 199801530
Occurrence date 28/04/1998
Location Mackay Aerodrome
State Queensland
Report release date 19/11/1998
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Air-ground-air
Occurrence class Incident

Aircraft details

Manufacturer Beech Aircraft Corp
Model 76
Registration VH-AZX
Sector Piston
Departure point Mackay Qld
Destination Unknown
Damage Nil

Aircraft details

Manufacturer British Aerospace
Model BAe 146-200
Registration VH-NJU
Sector Jet
Departure point Mackay Qld
Destination Brisbane Qld
Damage Nil

ACAS warning involving a Cessna P206, VH-SIR and Airbus A320-211, VH-HYA, 74 km south-east of Perth Aerodrome, Western Australia, on 3 May 1998

Summary

FACTUAL INFORMATION

The pilot of the Cessna 206 was conducting repetitive parachute jumping exercises at the Dale River drop zone. He was operating in Class C airspace and communicating with the air traffic controller at Perth Approach on the radar advisory frequency. He advised his intention for the parachutists to jump and was cleared by the controller to operate to a ceiling of flight level (FL) 110. Soon after the pilot of the Cessna received his clearance to drop, the pilot of an Airbus A320 contacted Perth on the approach frequency, advising that he was on descent to FL120. The Airbus was inbound to Perth from the south-east on a track that passed close to the Dale River Drop Zone. The Cessna pilot reported that he had the Airbus sighted. The air traffic controller then assigned the pilot of the Cessna responsibility for maintaining separation visually from the Airbus but the Cessna pilot did not respond. Because the two aircraft were on different frequencies, the pilot of the Airbus was unaware of the Cessna and that the pilot of the Cessna had been assigned a requirement to remain visually clear of the Airbus.

At the time of the incident, the Cessna was tracking southbound and had just turned left with the Airbus passing about 1.25 NM to the North. The controller then cleared the Airbus to descend to 8,000 ft. As the Airbus left FL120 on descent, the crew received a traffic alert and collision avoidance system (TCAS) traffic advisory (TA) closely followed by a resolution advisory (RA) instruction to reduce sink rate with which the crew complied. The crew of the Airbus reported sighting the Cessna 400 ft below their aircraft and climbing. Radar evidence indicated that the nearest the aircraft came to each other was approximately 700 ft vertically and 1.25 NM laterally.

The Aeronautical Information Publication (AIP) Air Traffic Rules and Services (RAC) noted that air traffic control (ATC) will provide separation between instrument flight rules (IFR) and visual flight rules (VFR) flights. In this situation, ATC would have normally been expected to direct the aircraft such that a minimum separation of 5 NM laterally or 2,000 ft vertically between the aircraft was maintained. However, it also stated that "under certain conditions, the pilot of one aircraft may be given the responsibility for separation with other aircraft". The Manual of Air Traffic Services (MATS) section 8 prescribed the application of visual separation and there was no requirement for the pilots of aircraft that had not been assigned separation responsibility to be advised that visual separation standards applied. There was also no requirement for the aircraft to be on the same frequency.

Whilst Civil Air Regulation 163 stated that an aircraft must not be flown so close to another aircraft as to create a collision hazard, it did not prescribe a minimum separation requirement. Therefore, the pilot given the responsibility for maintaining visual separation was at liberty to fly close to another aircraft so long as no collision hazard was created.

Although the air traffic controller had assigned a visual separation requirement in accordance with the AIP and MATS, he had not sought confirmation from the Cessna pilot regarding the assignment of the separation responsibility. However, there was no evidence to indicate that the Cessna pilot did not maintain such separation from the Airbus. Because the aircraft were on different frequencies and the air traffic controller had not advised the Airbus pilot that the Cessna was assigned separation responsibility, the Airbus pilot was unaware of the Cessna and the reduced separation standard being applied. He had no opportunity to accept or reject the reduced separation standards and his first indication of the presence of the Cessna was the TCAS alert to which he properly responded.

SAFETY ACTION

In 1996, a similar event occurred involving a Boeing 767 departing from Darwin and a Partenavia P68C which was conducting aerial work at Darwin. As a result of the investigation into that incident, the Bureau issued interim recommendation IR970027 to Airservices Australia. The interim recommendation stated, in part, that "Airservices Australia should introduce a requirement for a controller to advise the crew of an IFR-category aircraft that the pilot of another aircraft has been assigned visual separation responsibility and to pass traffic information on the other aircraft". On 31 October 1997, the Bureau received a response from Airservices Australia which stated, in part, that "Airservices will seek a review, in conjunction with CASA, of the visual separation standards applicable to aircraft operating below FL125, at the earliest opportunity. On completion of the review, BASI will be advised of any outcomes".

Response classification: OPEN

As at 11 July 1998 the Bureau had received no further advice on the proposed review. As a result of this occurrence (9801510), the Bureau is investigating further safety aspects related to visual separation procedures and responsibilities. Any safety outputs resulting from this investigation will be published in the Quarterly Safety Deficiency Report.

Occurrence summary

Investigation number 199801510
Occurrence date 03/05/1998
Location 74 km south-east of Perth Aerodrome
State Western Australia
Report release date 13/07/1998
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 Airbus
Model A320-211
Registration VH-HYA
Sector Jet
Operation type Air Transport High Capacity
Departure point Adelaide SA
Destination Perth WA
Damage Nil

Aircraft details

Manufacturer Cessna Aircraft Company
Model P206
Registration VH-SIR
Sector Piston
Departure point Dale River WA
Destination Dale River WA
Damage Nil

Loss of separation involving a Beech Aircraft Corp B200C, VH-AMM and Aeronautica Macchi S.p.A MB-326, Unknown, Williamtown Aerodrome, New South Wales, on 19 March 1998

Summary

FACTUAL INFORMATION

The crew of an instrument flight rules (IFR) Beech 200 (B200) was conducting a base check which would entail a practice non-directional beacon (NDB)/distance measuring equipment (DME) approach to runway 12 at Williamtown aerodrome. The pilot under check (handling pilot) and the checking pilot briefed for an approach to the minima, followed by a missed approach to 1,500 ft and then join the circuit for circuit training. The missed approach was to be conducted with the aircraft configured to simulate asymmetric operation. While inbound to Williamtown, the handling pilot briefed the approach controller of their intentions and was subsequently cleared to make the NDB/DME approach. The handling pilot then advised the approach controller that, after the NDB, the aircraft would conduct a go around. The check pilot did not hear this transmission due to the aircraft's communications configuration, which prevented his hearing any air/ground transmission by the handling pilot.

Prior to the missed approach point the handling pilot commenced an asymmetric missed approach and reported to the aerodrome controller. The aerodrome controller (ADC) instructed the crew to go around, to maintain runway heading and to maintain an altitude not above 500 ft. The transmission from the ADC was broken and both pilots believed that the assigned altitude was 1,500 ft. The handling pilot readback the requirement to maintain runway heading but did not readback the altitude, which was contrary to Aeronautical Information Publication (AIP) procedures. The ADC did not challenge the lack of the readback of the altitude by the pilot, which was contrary to air traffic control procedures.

The ADC's intention was to limit the altitude of the B200 to establish 500 ft vertical separation with a formation of Macchis that was entering the circuit via the initial point. The Macchi pilots had sighted the B200 as they tracked from the initial point and pitched into the circuit. During the missed approach, at approximately 1,200 ft, the B200 pilots saw the formation of Macchis pass from their left to right in front of and slightly below the level of their aircraft. The Macchi formation passed with approximately 200 ft vertical separation.

ANALYSIS

The misunderstanding by the handling pilot of the B200 in relation to a "go around" and a "missed approach", and the fact that the check pilot did not hear the transmission, created a developing situation that was appreciated differently by the two pilots and the ADC. The minima for the "missed approach" was 570 ft, whereas a "go-around" could have been commenced from a lower altitude.

While the radio transmission quality made communication difficult, the lack of radiotelephony discipline by both the handling pilot and the ADC ensured that the opportunity to resolve any misunderstanding was lost.

SIGNIFICANT FACTORS

1. The pilot of the B200 requested a "go around" instead of a "missed approach"

2. The check pilot could not hear the handling pilot's air/ground transmissions.

3. The pilot did not readback the requirement to maintain 500 ft to the ADC.

4. The ADC did not challenge the pilot to readback the altitude requirement.

Occurrence summary

Investigation number 199801484
Occurrence date 19/03/1998
Location Williamtown Aerodrome
State New South Wales
Report release date 03/03/1999
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 Aeronautica Macchi S.p.A
Model MB-326
Registration Unknown
Sector Jet
Operation type Military
Departure point Williamtown NSW
Destination Williamtown NSW
Damage Nil

Aircraft details

Manufacturer Beech Aircraft Corp
Model B200C
Registration VH-AMM
Sector Turboprop
Departure point Sydney NSW
Destination Williamtown NSW
Damage Nil

Control - Other involving a Fairchild SA227-DC, VH-OYB, Broome Aerodrome, Western Australia, on 7 April 1998

Summary

The crew of a Fairchild Metro 23 aircraft report experiencing difficulty in maintaining directional control as they applied power during the take-off roll. The aircraft seemed to be sluggish in accelerating and was pulling to the left. The difficulty in controlling the aircraft was exacerbated due to the inadvertent deactivation of the nose wheel steering button on the left power lever.

This system had been checked during taxi and was confirmed as serviceable. The crew indicate that this switch was "on" at completion of the pre-take-off checklist but had somehow been released during the early stages of the take-off roll.

The crew detected that the left propeller had not released the start locks, resulting in asymmetric power being produced. A non-standard call made by the pilot not flying is reported to have delayed the crew's recognition of the problem. The crew were in the process of abandoning the take-off when the aircraft veered off the left side of the runway, stopping prior to the runway 10 T-VASIS. The crew taxied the aircraft back onto the runway, switched the nose wheel steering system "on" and taxied normally back to the hangar for maintenance investigation.

The aircraft was not damaged during the incident and all aircraft systems checked out as serviceable. The crew briefed themselves on aspects of the previous incident before departing on the planned flight.

Occurrence summary

Investigation number 199801382
Occurrence date 07/04/1998
Location Broome Aerodrome
State Western Australia
Report release date 06/07/1998
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 Fairchild Industries Inc
Model SA227-DC
Registration VH-OYB
Sector Turboprop
Operation type Air Transport Low Capacity
Departure point Broome WA
Destination Derby WA
Damage Nil