Wheels up landing involving a Cessna U206G, VH-MGK, Berowra Waters, New South Wales, on 7 June 1998

Summary

The pilot of an amphibious Cessna 206 had been chartered to fly two passengers from an aircraft landing area at Warnervale to Berowa Waters on the Hawkesbury River.

A gusty 20 kt westerly wind was blowing in the Warnervale area at the time of aircraft departure. The pilot recalls being concerned about making an approach into Berowa Waters and encountered turbulent and uncomfortable weather conditions enroute.

After making a normal approach to the landing area, the pilot closed the throttle and flared the aircraft. As the floats touched the water, the aircraft tipped forward and the nose of the aircraft dived under water, which caused the windscreen to shatter. Water flooded the cabin and the aircraft came to rest inverted. The pilot and the two passengers were not seriously injured and evacuated the submerged cabin through the door on the left side of the aircraft.

Immediately following this occurrence, the pilot observed that the float mounted landing gear was in the extended position and not correctly positioned for a water landing. He cannot recall any actions specific to the landing gear following the departure from Warnervale or on arrival at Berowa Waters.

Following recovery of the aircraft to dry land, the landing gear selector was observed to be in the neutral position.

Occurrence summary

Investigation number 199802029
Occurrence date 07/06/1998
Location Berowra Water
State New South Wales
Report release date 08/07/1998
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 Cessna Aircraft Company
Model U206G
Registration VH-MGK
Sector Piston
Operation type Charter
Departure point Warnervale NSW
Destination Berowra Waters NSW
Damage Substantial

Partial power loss involving a Piper PA-31, VH-UBA, Adelaide Aerodrome, South Australia, on 8 June 1998

Summary

The pilot of an arriving aircraft requested that emergency services be placed on standby, as his aircraft was experiencing engine surging in the right engine and he did not expect to make a normal approach. A short time later the aircraft made an uneventful landing and taxied to the general aviation terminal accompanied by a fire tender. An investigation was subsequently carried out by a maintenance organisation with no fault found. This included draining and testing 20 litres of fuel from both main tanks. No contamination problem that may have attributed to the engine surging could be identified. After engine ground runs to verify operations were within limits, the aircraft was returned to service.

Occurrence summary

Investigation number 199802036
Occurrence date 08/06/1998
Location Adelaide Aerodrome
State South Australia
Report release date 14/07/1998
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Incident

Aircraft details

Manufacturer Piper Aircraft Corp
Model PA-31
Registration VH-UBA
Sector Piston
Departure point Kingscote SA
Destination Adelaide SA
Damage Nil

Forced/precautionary landing involving a Piper PA-28-181, VH-NOR, 2 km north-west of Mittagong (ALA), New South Wales, on 18 April 1998

Summary

The pilot advised Flight Service (FS) that the engine had failed, and he was attempting a landing at the Mittagong airstrip. The aircraft subsequently landed approximately 2 km short of the airstrip damaging the left-wing tip and landing gear during the rollout. The pilot advised FS of the situation and that there were nil injuries. The initial maintenance investigation discovered that the crankshaft accessory drive gear positioning dowel had sheared. This in turn had ceased the drive to all the engine accessories and the camshaft, resulting in the engine stopping. The initial reason for the failure of the dowel could not be positively determined. 

Subsequent to the initial investigation, a detailed failure analysis of the failed engine components was carried out. This examination revealed that a significant factor in the failure of the crankshaft gear/crankshaft attachment had been a manufacturing irregularity on the bearing surface of the head of the attaching bolt. The manufacturing irregularity resulted in a reduced clamping force, between the gear and the crankshaft, being established during assembly. The loss of the clamping force had allowed relative movement between the gear and the crankshaft mounted gear positioning dowel. This eventually led to the fatigue failure of the dowel and the loss of integrity of the accessory gear drive assembly.

Occurrence summary

Investigation number 199801979
Occurrence date 18/04/1998
Location 2 km north-west of Mittagong (ALA)
State New South Wales
Report release date 22/01/1999
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Forced/precautionary landing
Occurrence class Accident

Aircraft details

Manufacturer Piper Aircraft Corp
Model PA-28-181
Registration VH-NOR
Sector Piston
Departure point Bankstown NSW
Destination Bankstown NSW
Damage Substantial

Runway incursion involving a Beech Aircraft Corp C90, VH-FDP, Cairns Aerodrome, Queensland, on 2 June 1998

Summary

The pilot of FDP had been instructed to taxy to the holding point at taxiway A2 for departure. The Surface Movement Controller then diverted his attention to other traffic. The Aerodrome Controller then noticed that FDP was holding at the intersection of runway 15 and taxiway A3 , partially inside the holding point.

The pilot advised that the aircraft was slightly inside the holding point and asked for approval to conduct engine checks in that position. As there was no immediate traffic, the aircraft was cleared onto the runway. The pilot reported that he did not see the holding point marking until he had passed over it. He added that the marking did not extend across the full width of the taxiway, and felt that this contributed to the incident. In addition, he had not operated into Cairns for more than 2 years, so he was not completely familiar with the aerodrome layout.

The comments by the pilot on the holding point marking were discussed with the local Airservices manager and the airport owner. Both these agencies indicated that there had been other instances of pilot confusion concerning taxiway markings in the same area. It was agreed that Airservices would arrange for a 'Caution' note to be inserted in the En-route Supplement advising pilots to exercise caution when approaching the taxiway A3 holding point. The airport owner was completing arrangements to repaint the holding point marking to extend the full width of the taxiway, and to repaint the holding point and frequency information on the associated gable marker.

Occurrence summary

Investigation number 199801976
Occurrence date 02/06/1998
Location Cairns Aerodrome
State Queensland
Report release date 16/06/1998
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 Beech Aircraft Corp
Model C90
Registration VH-FDP
Sector Turboprop
Operation type Medical Transport
Departure point Cairns Qld
Destination Kowanyama Qld
Damage Nil

Loading related involving a McDonnell Douglas DC9-33F, VH-IPC, Melbourne, Victoria, on 13 May 1998

Summary

The aircraft was being prepared for a freight flight with newspapers included as part of a standard load for this service. Normally the newspaper publisher informed the operator of the weight of the consignment and the newspapers would arrive at the airport in sufficient time to ensure an on time departure. However, on this occasion, the consignment was delayed. The duty manager decided to delay the flight's departure to await the arrival of the newspapers.

The aircraft's upper deck and Compartment 1 of the lower deck had been loaded, and the manager intended to load the newspapers in the rear compartment of the lower deck in which 670 kg of weight allowance was available. The duty manager had the newspapers weighed and found them to be heavier than normal at a weight of 1,070 kg. He reported that he had informed the captain that the consignment was 400 kg overweight but the captain later stated that he had not been told of the discrepancy. The newspapers were loaded and the aircraft departed 20 minutes later than its scheduled departure time. The loading crew at the destination opened Compartment 1 and noted the Universal Loading Device (ULD) tag as showing the weight of an item of cargo as 87 kg.

The crew did not believe this figure and checked the weight at 277 kg. The loading crew then opened the rear compartment and noted a ULD tag showing a cargo weight of 607 kg. They again checked the weight and found 1,172 kg of newspapers and 78 kg of other freight. The net effect of these discrepancies was that the aircraft was heavier than its maximum zero fuel weight limit and that the centre of gravity was aft of its computed position, although within limits. The flight crew reported that the flight was normal and free from any noticeable abnormalities in aircraft performance or handling.

Since the occurrence, the operator has replaced the ULD tags with new "user friendly" tags designed to reduce the probability of error. The reason the crew were unaware of the excess load could not be determined.

Occurrence summary

Investigation number 199801956
Occurrence date 13/05/1998
Location Melbourne
State Victoria
Report release date 11/07/1998
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Loading related
Occurrence class Incident

Aircraft details

Manufacturer McDonnell Douglas Corp.
Model DC9-33F
Registration VH-IPC
Sector Jet
Operation type Air Transport High Capacity
Departure point Melbourne Vic.
Destination Launceston Tas.
Damage Nil

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