The pilot reported that the engine stopped in the cruise at about 600 ft. He entered autorotation and landed in low trees and scrub. The engine stopped because the crank shaft drive gear bolt failed due to hydrogen embrittlement. When the bolt failed drive to the accessories was lost. The manufacturer has verbally assured CASA that this was an isolated instance of a bolt failure.

The pilot reported difficulty in maintaining directional control of the aircraft during the later stages of the landing roll. The pilot indicated that the left main gear collapsed, the left wing contacted the ground, and the nose wheel collapsed. The aircraft slid a short distance before coming to a stop. The pilot and his passenger were uninjured.

Following the accident, the pilot observed that the right-hand main tyre was partially deflated. Although the tyre was normally inflated prior to departure, it was unclear if this contributed to the pilot's difficulty in maintaining control of the aircraft during the landing roll.

On descent through 8,000 feet, the engine of VH-DBX started running rough. The pilot carried out the emergency check list procedures and found no response to throttle so he shut the engine down. Melbourne Flight Service (FS) was then informed by the pilot of his intention to land short of Goulburn. Another aircraft in the vicinity, VH-RPO, was diverted by FS to render assistance. The pilot of DBX did not declare an emergency, however FS initiate a Distress Phase. On short final to the selected landing site at approximately 20 feet AGL, the aircraft contacted a power line, rolled to the left and impacted the ground in a nose down attitude. The aircraft was then vacated with nil injuries. The pilot of RPO informed FS that an ambulance was in attendance and the Distress Phase was cancelled.

A report has been requested for the engine strip and inspection.

The pilot of the Hiller 12E helicopter had been tasked with spraying insecticide on a paddock of soybean plants. The pilot familiarised himself with the property layout and obstacles before starting treatment of the area. The paddock to be sprayed was crossed at its mid-point by powerlines running east-west. The southern boundary of the paddock was marked by a wire fence, a road and another set of powerlines.

The pilot reported commencing a spray run along the northern boundary but found that his GPS navigation system was not working. He landed on the western side of the paddock to re-enter data into the GPS system. On carrying out another run, the pilot found the system was still not operating, so he moved the helicopter away from the paddock to the south. He then elected to return to the paddock by flying over the powerlines. The pilot reported that at this time, he was mentally occupied with the problem with the GPS and forgot about the powerlines at the southern edge of the paddock. The helicopter spray gear contacted the powerlines, causing the helicopter to pitch nose down and contact the ground. The helicopter came to rest inverted, and the pilot climbed out of the wreckage, receiving only minor injuries. The helicopter did not catch fire.

A significant factor in this accident was the preoccupation of the pilot with the GPS navigation equipment at a time when he was flying close to obstacles.

The pilot was preparing to depart on a private flight from Cobden Vic. to Moorabbin. The Piper Cherokee aircraft was parked in front of the club house when the pilot found that the starter motor would not engage. After various attempts to get the starter motor to engage were unsuccessful the pilot decided to hand swing the propeller.

The pilot advised that he applied the parking brake, set the throttle to approximately half power and turned the magneto switches on. When he swung the propeller the engine started and ran at high RPM. The parking brakes did not stop the aircraft from rolling forward. The pilot grabbed the wing to try to arrest the aircraft's progress, however it continued to gather speed. When the pilot could no longer hang onto the wing he grabbed the tail plane. The pilot was carried 300 metres before he relinquished his grip and the aircraft sped away.

The aircraft continued south past the windsock and broke through the perimeter fence into a paddock. It ran across the paddock and through another fence and across the airfield access road. On the far side of the road, it demolished a gate before colliding with a shed and toilet, coming to rest against a farm plough. The aircraft had travelled in excess of 1 1/2 km.

The low time pilot had not been trained in hand starting aircraft engines. He said that he was not aware of the regulatory requirements surrounding the starting of aircraft engines, and did not ask a nearby pilot to sit on the brakes while he attempted the hand start. He stated was not aware that the operator from whom he rented the aircraft specifically banned unauthorised attempts to rectify defects when away from Moorabbin, including the hand starting of aircraft engines.

FACTUAL INFORMATION

Following a request from an Australian Army (Army) unit for the use of the Port Wakefield proof firing range (designated as restricted area R295 A to F), the Defence Corporate Support Centre (Support Centre) in Adelaide mailed notices to a number of organisations on 3 April 1998. These local procedures included notification to the Royal Australian Air Force (RAAF) at Edinburgh for the issue of a notice to airmen (NOTAM). R295 A, B and E were required for missile firings on 6 and 7 April 1998 and would be active from the surface to 33,000 ft. The lowest useable level by overflying aircraft was 34,000 ft. The letter to RAAF Base Edinburgh was not received prior to the period nominated for the activity and a NOTAM was not issued.

On Monday 6 April 1998 the Army unit arrived at the proof firing range and was cleared by the range control officer (RCO) to conduct their exercise from 1200 Central Standard Time. When the requesting unit arrived at the range, the RCO assumed that a NOTAM had been issued and that the other agencies had been notified.

At approximately 1230 and 1445, Boeing 737 aircraft operating scheduled passenger flights from Sydney to Perth on air route Q32 passed through the northern portion of R295E at flight level (FL) 280 and FL310 respectively. During the period between the range opening and detection of the second B737 overflying the range, the unit had fired two target missiles. The B737s had flown through an active firing range.

Detection of the B737

The RCO heard the second B737 as it flew through the area and cancelled the exercise for the Army unit. At 1455, he rang Adelaide Air Traffic Control (ATC) to confirm that the range was active to 33,000 ft. Subsequently, ATC ascertained, and advised the RCO, that a NOTAM had not been issued for the activity.

Notification procedures

Army procedures required the unit intending to operate on the range to notify the Support Centre. The Support Centre was to advise the appropriate airspace authority prior to the activity for the issue of a NOTAM. The Support Centre used RAAF Edinburgh as the appropriate authority for the issue of a NOTAM for a range activity. The orders did not specify a minimum period of notice to the Support Centre. The Manual of Air Traffic Services (MATS) required a restricted area NOTAM to be issued a minimum of 8 hours prior to the commencement of operations.

There were no procedures requiring the unit intending to use the range to confirm that the activity had been notified in accordance with Army procedures. The RCO was not required to check that a NOTAM and notices to other authorities had actually been issued prior to approving operations on the range.

The procedures did not require the RCO or the unit to confirm the commencement or completion of operations with any air traffic service (ATS) agency.

Range surveillance

The RCO had radar to assist in the surveillance of that portion of the range over the Spencer Gulf. The radar was capable of detecting vessels on the water and persons on the tidal flats but was not designed to detect aircraft at high altitude. Because of these design and operating mode limitations, the radar did not detect the B737s. The range staff did not maintain a record of unauthorised entries to the range.

ANALYSIS

The process for requesting activation of the range was reliant upon staff members completing actions, which subsequently transferred the responsibility for completion to another person. Failure to complete an action by any one position in the required sequence of events would result in the notification process, for range activation, to stop. This process had no checks to ensure that subsequent actions had been completed or for feedback to occur if any action did not happen. Overall, the procedure was a fail-unsafe process. A final check with the relevant ATS agency prior to clearing the unit to operate on the range would have alerted the RCO to the fact that a NOTAM had not been issued.

The RCO was reliant on visual and limited electronic surveillance of the range area which was not conducive to the detection of high-flying aircraft. A check with the ATS agency would have established if any aircraft were operating within the range at high altitude.

SIGNIFICANT FACTORS

1. Range procedures did not require the Support Centre or the unit requesting the use of the range to confirm that a NOTAM had been issued.

2. The Support Centre did not allow sufficient time for the notice to be received and for a NOTAM to be issued.

3. Range procedures did not require the RCO to confirm, with the relevant ATS agency, that a NOTAM had been issued or whether there were any aircraft in the area prior to approving operations on the range.

4. Range surveillance facilities were unlikely to detect aircraft operating at high altitude within the range.

SAFETY ACTION

Local safety action

The Support Centre has amended procedures to require 21 days notice of range activities and will notify the appropriate authority 14 days prior to the activity for submission of a NOTAM. Additionally, the appropriate authority will fax a copy of the request for a NOTAM to the Support Centre as confirmation. Furthermore, the unit intending to operate on a range must access the aeronautical information service and obtain a copy of the current NOTAM for the activity prior to commencing operations. RCO clearance for operations on a range is subject to the unit providing a copy of the current NOTAM.

Bureau of Air Safety Investigation safety action

As a result of the investigation of this and another similar occurrence, the Bureau of Air Safety Investigation issued the following interim recommendations to the Australian Defence Force and to Airservices Australia on 30 June 1998:

"IR980086

The Bureau of Air Safety Investigation recommends that the Australian Defence Force, with the assistance of Airservices Australia, review airspace activation procedures to ensure that appropriate and fail-safe notification actions have been completed prior to the commencement of military activities.

IR980087

The Bureau of Air Safety Investigation recommends that Airservices Australia assist the Australian Defence Force to review airspace activation procedures to ensure that appropriate and fail-safe notification actions have been completed prior to the commencement of military activities".

The following response to the interim recommendation was received from Airservices Australia on 27 July 1998:

"I refer to your letter of 29 June enclosing Interim Recommendation IR980087. The subject of notification and activation of areas for Military activity will be referred to the National Airspace Management and Air Traffic Services Sub Committee (NAMPS) of the Air Coordinating Committee (ACC) for resolution. As a joint Australian Defence Force/Airservices Australia forum, NAMPS is the appropriate body to review airspace activation procedures relating to military activity".

Response classification: CLOSED - ACCEPTED

The commercial pilot pre-arranged to private hire a Robinson R22 for business purposes. When he arrived at Mangalore to collect the helicopter he spoke to the duty instructor who advised him to take VH-KKG after it returned from a training flight. Minutes later a solo student pilot landed KKG well away from the AVGAS refuelling facility because the flying school forbade student pilots to hover or land near the fuel bowsers. The student then applied the control frictions and reduced power, expecting to stop the engine after its cool down period. The commercial pilot planned to depart Mangalore with full fuel.

He proceeded to the right door of KKG where he tried to explain to the student that he wanted to swap seats with him without the engine being shut down, in order to hover-taxi to the bowser for fuel. The student, a Japanese national undergoing basic flying training in Australia, did not understand the request mostly because of the over-riding engine noise and because he was wearing a headset. He remained at the controls with the engine running. As the commercial pilot intended to reposition the helicopter only a short distance before shutting down the engine to refuel, he proceeded to the left side of the helicopter and occupied the left seat where there were dual flight controls.

He explained his intentions to the student who handed over the controls. The commercial pilot then checked that both his and the student's seat belts were fastened before releasing the control frictions. He then increased the engine/rotor RPM to the top of the green and raised the collective lever with the intention of stabilising in the hover momentarily before hover-taxiing to the bowser. He reported that as the helicopter became light on the skids, he applied light pressure to the anti-torque pedals and made minor cyclic control inputs as he further raised the collective.

As the landing gear skids left the ground the helicopter yawed quickly to the left. He cannot recall exactly what his following control inputs were as things happened very quickly and violently. However, his impressions were of yawing quickly and an unusual attitude which he attempted to correct. Then the helicopter skids contacted the ground and it lifted back into the air momentarily before settling onto the ground and rolling onto its left side. The weather was reported to be fine with a light and variable wind, CAVOK and temperature about 25 deg Celsius. The weather was not a factor in the accident.

No fault has been subsequently found with the helicopter which may have contributed to the accident. It had been functioning normally on its previous flight. The student reported that he made no flight control input after handing over the controls to the private pilot. The commercial pilot recalled that the student grabbed the cyclic at the end of the accident sequence but this action did not influence the outcome of the accident. The instructor did not give the commercial pilot approval for a engine-running seat swap with the student, nor did he authorise him to fly from the left seat.

Prior to the accident, the instructor had been very busy escorting a group of cadets who had arrived at the airport earlier than expected to visit the flying school. Except for dual check and training flights, the helicopter manufacturer requires that the R22 be flown from the right seat. There is a different visual perspective flying from the left seat versus the right seat. The R22 is also equipped with the RPM governor on the right throttle only. Normally only check and training pilots are given the additional dual instruction to enable them to fly from the left seat with another pilot occupying the right seat.

Commonly, when a pilot first attempts to hover a helicopter from the opposite seat, some degree of over-controlling will occur. The commercial pilot reported that he had previously controlled an R22 in flight from the left seat with a pilot-in-command occupying the right seat, but he had never before lifted a helicopter into the hover while flying from the non command seat. It is probable that the commercial pilot began to over-control the helicopter as it lifted into the hover. He was experienced at flying without a governor controlling RPM, so manipulating the left throttle was probably not a factor in the accident.

The yaw to the left probably resulted from inadvertent excessive left pedal input because a loss of anti-torque or insufficient left pedal would have caused the helicopter to yaw to the right. Over-controlling probably developed into an irretrievable roll-over condition as the left skid dragged on the ground as the helicopter yawed left.

The Boeing 737 (B737) was maintaining flight level (FL) 350 and the Melbourne Central controller had completed all the required tasks involving that aircraft. Although the aircraft had not yet reached the point at which it would normally be handed off to the next sector (Sector 4), the controller decided to proceed with an early hand-off which was accepted by the Sector 4 controller. The Airbus A320 was maintaining FL370 on a track which crossed that of the B737. The appropriate vertical separation standard of 2,000 ft was being maintained. As the tracks of the aircraft converged, the crew of the A320 was given descent to FL350 by the Melbourne Central controller, who momentarily forgot about the B737.

As soon as the crew of the A320 reported leaving FL370, the controller realised that he could not guarantee the required horizontal separation standard of 5 NM and immediately instructed them to return to FL370. The A320 had descended to FL368 before the crew were able to arrest the descent and commence climb back to FL370 and re-establish a vertical separation standard. The investigation revealed that the aircraft were at the same flight level, with a horizontal separation of 4.7 NM, resulting in a breakdown of separation standards. The practice of early hand-off is being reviewed by Airservices Australia as it can lead to a reduced level of awareness by controllers.

The pilot in command was demonstrating a 15-degree banked turn at a height of about 700 ft. The aircraft was travelling at 70 kts with 15 degrees of flap extended. However, control of the aircraft was affected by an unseen dust devil which caused it to roll further left to about 90 degrees angle of bank. The pilot applied full right rudder and aileron controls, righting the aircraft just above treetops in a stalled attitude, but was unable to arrest the descent. The aircraft struck trees and came to rest on the ground in an inverted position. Both the pilot and passenger vacated the aircraft, which was subsequently destroyed by an ensuing fire.

The pilot of the aircraft reported that the helicopter was being used to spray a sugarcane crop when he attempted to avoid a bird. As he banked the helicopter to the right, he heard two bangs and decided to land the helicopter in an adjacent fallow paddock. During the attempted landing, the helicopter yawed right, and the right skid dug into the ground, rolling the helicopter onto its right side. The pilot was not injured. Examination revealed that the right spray boom had struck the crop during the attempt to avoid the bird.

A portable ELT was carried in the cabin, but it was not activated by the pilot.