Breakdown of co-ordination involving an Airbus A320-211, VH-HYG, Mount Hope Non-Directional Beacon, South Australia, on 13 February 1998

Summary

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Occurrence summary

Investigation number 199800486
Occurrence date 13/02/1998
Location Mount Hope Non-Directional Beacon
State South Australia
Report release date 01/05/1998
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Breakdown of co-ordination
Occurrence class Incident

Aircraft details

Manufacturer Airbus
Model A320-211
Registration VH-HYG
Sector Jet
Operation type Air Transport High Capacity
Departure point Melbourne Vic.
Destination Perth WA
Damage Nil

Loading related involving a Boeing 767-238, VH-EAJ, Sydney Aerodrome, New South Wales, on 13 February 1998

Summary

The Boeing B767 aircraft was operating an RPT passenger service from Sydney direct to Perth. As the aircraft was rotated for lift-off the co-pilot, who was the handling pilot for the flight, found that the aircraft was very nose heavy. The crew contacted load control and requested a loading check. The check disclosed that 400 kg of cargo had been loaded into position 11, the most forward bay, and this load had not been entered into the loading data. The crew received revised stabiliser trim settings which were confirmed during the arrival into Perth.

The investigation found that the load controller had established what load had to be loaded onto the aircraft and had made the relevant weight and balance computations. However, the load controller had not locked out the computer field related to freight as is required by the relevant procedures. This allowed the aircraft loaders to load the additional cargo and make an entry into the computer.

This entry did not become obvious to the load controller and, because the load controller thought there was no changes to the original computations, the crew were not advised to reconfigure the aircraft. The operator has instituted training procedures designed to improve discipline in the loading system.

Occurrence summary

Investigation number 199800517
Occurrence date 13/02/1998
Location Sydney Aerodrome
State New South Wales
Report release date 18/08/1998
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 The Boeing Company
Model 767-238
Registration VH-EAJ
Sector Jet
Operation type Air Transport High Capacity
Departure point Sydney NSW
Destination Perth WA
Damage Nil

Operational non-compliance involving a PZL Warszawa-Okecie M-18B, VH-PHO, Tamworth Aerodrome, New South Wales, on 10 February 1998

Summary

The pilot of VH-PHO was not familiar with procedures in the Tamworth Control Zone (CTR). He had obtained a clearance from the tower controller to enter the CTR at 3,000 ft and had been instructed to report at 5 NM. After reporting at this position, the pilot was instructed to maintain 3,000 ft and to join the circuit upwind for runway 12 Right. At this time, there were four aircraft in the circuit. The pilot of PHO was then asked by to report sighting an aircraft on the upwind leg one mile ahead. He reported that he had the traffic sighted and was instructed to follow that aircraft. A short time later, the controller observed PHO descending and tracking for a mid-downwind position. This action conflicted with VH-YTQ which was on the downwind leg.

The pilot of YTQ reported manoeuvring to avoid PHO. In response to a query from the controller, the pilot of PHO reported that he was below 2,500 ft. The pilot of PHO did not fully understand the procedure for upwind circuit entry. Further, he believed that the instruction to follow YTQ meant that he was cleared to descend from 3,000 ft. The pilot indicated that he operated inside controlled airspace infrequently. Investigation revealed that the relevant publications do not include a definition for the term 'follow'. SAFETY ACTION As a result of this occurrence, the Bureau of Air Safety Investigation is investigating a perceived safety deficiency relating to the use of "sight and follow" procedures by air traffic controllers. Any safety output issued as a result of this analysis will be published in the Bureau's Quarterly Safety Deficiency Report.

Occurrence summary

Investigation number 199800462
Occurrence date 10/02/1998
Location Tamworth Aerodrome
State New South Wales
Report release date 04/09/1998
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Operational non-compliance
Occurrence class Incident

Aircraft details

Manufacturer PZL Warszawa-Okecie
Model M-18B
Registration VH-PHO
Sector Piston
Destination Tamworth NSW
Damage Nil

Runway incursion involving a Boeing 767-338ER, VH-OGK, Brisbane Aerodrome, Queensland, on 7 February 1998

Summary

Prior to issuing a take-off clearance the controller checked that the runway was clear. Take-off was rejected when the crew of VH-OGK saw a vehicle on a taxiway and entering the runway. The aircraft exited via the next available taxiway and returned to the runway end for an uneventful departure.

A pest control contractor had been escorted to an aircraft parking area on the domestic apron to fumigate a number of aircraft. He was also informed that another aircraft to be treated was in the maintenance hangar on the other side of the airport. He indicated that he would travel to the hangar via the public roads outside the airport and that he would leave the airport via Gate 1, through which he had entered. He also indicated that he knew the location of the airline's operations office. No airline supervision was provided while the contractor did his work.

On completion of the work on the apron the contractor decided to travel to the hangar via the perimeter road inside the airport. He ultimately arrived at the hangar and completed the task there. No supervision was provided by hangar staff as they were not aware the contractor did not have an airside licence. The contractor departed the hangar intending to return to gate 1 via the perimeter road. While driving along the taxiway from the hangar he missed the turn to the perimeter road and crossed the holding point to the runway. This was when the aircraft crew observed the vehicle and rejected the take-off. A short time later, the vehicle was intercepted by an airport safety officer.

Procedures required that all persons who do not hold an 'Airside Drives Authority' be escorted and supervised at all times while airside. This requirement was not complied with in this instance. As an additional safety measure, a 'Safety Information Note' has been prepared for issue to all airside visitors.

Occurrence summary

Investigation number 199800460
Occurrence date 07/02/1998
Location Brisbane Aerodrome
State Queensland
Report release date 22/06/1998
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 The Boeing Company
Model 767-338ER
Registration VH-OGK
Sector Jet
Operation type Air Transport High Capacity
Departure point Brisbane Qld
Destination Bangkok, Thailand
Damage Nil

Passenger related involving a Boeing 747-238B, VH-EBQ, 800 km north-east of Sydney Aerodrome, New South Wales, on 2 February 1998

Summary

The cabin service manager came to the flight deck to advise the pilot in command of an intoxicated passenger who was in the galley and making intimidating threats towards three flight attendants. The pilot in command was then advised that the passenger had punched two other passengers.

A short time later, the pilot in command was informed that a female passenger was alleging that she had been indecently assaulted by the passenger. The pilot in command directed that the passenger be restrained and requested that Police meet the aircraft on arrival at Sydney.

On arrival at Sydney, the passenger was arrested, charged with assault and subsequently sentenced to 6 months jail.

Occurrence summary

Investigation number 199800447
Occurrence date 02/02/1998
Location 800 km north-east of Sydney Aerodrome
State New South Wales
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 The Boeing Company
Model 747-238B
Registration VH-EBQ
Sector Jet
Operation type Air Transport High Capacity
Departure point Honalulu Hawiia USA
Destination Sydney NSW
Damage Nil

Operational non-compliance involving a Boeing 767, JA8970, 6 km south-east Sydney Aerodrome, New South Wales, on 9 February 1998

Summary

The Boeing 767 had departed from runway 16R at Sydney, NSW and the crew were tracking via a GUEST 2 standard instrument departure (SID) with an initial altitude restriction of 5,000 ft. The SID required the aircraft to track via the 163 radial of the Sydney very high frequency omni-directional radio range beacon (VOR) for 10NM before turning right to track for Glenfield. On first radio contact with Departures Control, the crew were instructed to climb to flight level (FL) 280 but, incorrectly, read back "to heading 280" and commenced a turn to the right when approximately 2 NM south of the runway.

The air traffic controller did not realise that the crew had read back heading 280 and replied using the word "affirm". He also re-iterated the instruction to climb to FL280, which the crew correctly read back. This situation resulted in the crew believing that they had been cleared to climb to FL280 and to turn right to Glenfield, while the controller believed that the crew were climbing to FL280 via the SID track. The turn was observed on radar and, although there were several other aircraft in the general area, radar vectors by air traffic control ensured that no breakdown of separation standards occurred.

Occurrence summary

Investigation number 199800444
Occurrence date 09/02/1998
Location 6 km south-east Sydney Aerodrome
State New South Wales
Report release date 21/07/1998
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Operational non-compliance
Occurrence class Incident

Aircraft details

Manufacturer The Boeing Company
Model 767
Registration JA8970
Sector Jet
Operation type Air Transport High Capacity
Departure point Sydney NSW
Destination Kensai Japan
Damage Nil

Wheels up landing involving a Cessna 210L, VH-TCR, Darwin Aerodrome, Northern Territory, on 11 February 1998

Summary

When the pilot selected the landing gear down he found that the gear was not indicating down. He could see that the main gears were extended and the control tower confirmed that the nose gear was not extended. The pilot diverted to a clear area and gained altitude to conduct further attempts to lower the landing gear. All attempts were unsuccessful. A landing was later conducted on the main gears, with the pilot shutting down the engine during the landing roll prior to the aircraft settling on its nose.

Examination of the nose landing gear found that a pin had fallen from a shaft associated with the uplock mechanism. As a result, the nose gear was locked up, with no way to release the lock. The pin was recovered when the aircraft was lifted. The reason for the pin becoming loose has not been established. It is located in an area which cannot be checked during a daily inspection. The aircraft had flown about 65 hours since the previous periodic inspection.

Occurrence summary

Investigation number 199800430
Occurrence date 11/02/1998
Location Darwin Aerodrome
State Northern Territory
Report release date 23/02/1998
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 210L
Registration VH-TCR
Sector Piston
Operation type Charter
Departure point Peppimenarti NT
Destination Darwin NT
Damage Substantial

Collision with terrain involving a Cessna A188B/A1, VH-DDW, Jandowea, Queensland, on 12 February 1998

Summary

The aircraft was conducting spraying operations in a paddock bounded by a power line. Due to the nearness of the paddock to the power line, it was necessary for the pilot to fly the aircraft under the line at the commencement of each spray run. At the beginning of the accident run, the pilot rolled the aircraft right to clear a small tree. As he did this, the left wing contacted the power line. The aircraft then rolled inverted and struck the ground left wing first, cartwheeling several times before coming to rest inverted. The pilot was able to exit the aircraft before fire consumed the majority of the wreckage.

The pilot confirmed that the aircraft was operating normally at the time of the accident. While maneuvering to avoid the small tree, he had momentarily forgotten about the power line and did not correct quickly enough to prevent the wing contacting it.

Occurrence summary

Investigation number 199800421
Occurrence date 12/02/1998
Location Jandowea
State Queensland
Report release date 23/03/1998
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Collision with terrain
Occurrence class Accident
Highest injury level Minor

Aircraft details

Manufacturer Cessna Aircraft Company
Model A188B/A1
Registration VH-DDW
Sector Piston
Operation type Aerial Work
Departure point Kapunn, near Jandowea Qld
Destination Warra - Janoowie Qld
Damage Destroyed

Electrical systems involving a Boeing 767-204, VH-RMO, 222 km north-north-east of Melbourne Aerodrome, New South Wales, on 12 February 1998

Summary

Approaching the top of the climb out of Melbourne, enroute to Brisbane, the Boeing 767 suffered a standby DC bus failure. The crew elected to return to Melbourne.

Investigation by the operator discovered a faulty circuit breaker. The circuit breaker was replaced and the standby system functionally tested as serviceable. The aircraft was then returned to service.

Occurrence summary

Investigation number 199800417
Occurrence date 12/02/1998
Location 222 km north-north-east of Melbourne Aerodrome
State New South Wales
Report release date 11/05/1998
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Incident

Aircraft details

Manufacturer The Boeing Company
Model 767-204
Registration VH-RMO
Sector Jet
Operation type Air Transport High Capacity
Departure point Melbourne Vic.
Destination Brisbane Qld
Damage Nil

Air-ground-air involving a Airbus A310, 9V-STA, 93 km north-west of BIDAP, Western Australia, on 4 February 1998

Summary

The crew of the foreign registered Airbus A310 were maintaining the aircraft at FL370 on air route A585 and were estimating the BIDAP position at 0234 WST. BIDAP was the boundary between the Perth and Melbourne Air Traffic Control areas of responsibilities and Perth Sector Control had instructed the crew to contact Melbourne Sector Control at BIDAP. As their aircraft approached BIDAP, the crew observed a weather return on radar along their proposed track just passed the reporting point.

The crew decided to make a diversion to the north, left of track, to avoid the storm. As they were approaching BIDAP, the pilot-in-command commenced a 15-degree track change and instructed the co-pilot to advise Melbourne Sector that a diversion to the left was required. The co-pilot made a radio transmission to Melbourne Control indicating their position as abeam BIDAP and "up to 15NM left of track due weather". The aircraft was actually only 2 - 3NM off track at that time. Melbourne Control replied with an instruction for the crew to limit their diversion to 15NM due to conflicting traffic. A short time later, Melbourne Control informed Perth Control that the crew had reported 15 NM left of track due weather and established that this diversion had not been requested by the crew from either Melbourne or Perth Control.

Melbourne Control were able to ensure separation from an Australian registered Boeing 747 that was on a conflicting air route. The tracks were laterally separated at the point at which the A310 crew reported their position, and the direction of travel ensured that the aircraft were diverging. The co-pilot believed he was reporting the position at BIDAP with a request for a diversion left of track and believed that the response from Melbourne Control was a clearance to conduct the diversion. Melbourne Control believed they were limiting the possibility of conflict for a diversion that had already taken place.

The co-pilot's first language was not English and this may have contributed to a misunderstanding between the controller and the crew It was not established at which point the crew of the A310 commenced their diversion but, as the crew reported that it was only "a few miles prior to BIDAP", it was probably outside the lateral separation points for the two routes and, therefore, no infringement of the separation standards was likely to have occurred.

Occurrence summary

Investigation number 199800416
Occurrence date 04/02/1998
Location 93 km north-west of BIDAP
State Western Australia
Report release date 21/07/1998
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 Airbus
Model A310
Registration 9V-STA
Sector Jet
Operation type Air Transport High Capacity
Departure point Singapore
Destination Adelaide SA
Damage Nil