Collision on ground involving a Robinson R22 Beta, VH-LKK, Louisa Downs, (ALA), Western Australia, on 20 February 1998

Summary

The helicopter was refuelled from a drum positioned approximately one metre from the left hand side of the aircraft. The helicopter was parked facing north with an approximate 15 knot wind from the east. Pilot and passenger then boarded the helicopter and commenced normal start procedures before lifting into the hover. The helicopter was close to maximum all up weight. After coming into the hover the helicopter was weather cocking and difficult to stabilise.

Due to the proximity of the fuel drum, out of sight on the left side of the aircraft, and the aircraft weather cocking in the cross wind, the pilot decided to do a hovering left hand circuit of the fuel drum to enter into wind. As the pilot looked to his right to check the area was clear the aircraft yawed to the right. The pilot pushed full left pedal and applied left cyclic to stop the yaw at the same time pushing forward cyclic to clear the drum. The rear of the left hand skid came into contact with the fuel drum and the helicopter rolled onto its left-hand side.

Occurrence summary

Investigation number 199800537
Occurrence date 20/02/1998
Location Louisa Downs, (ALA)
State Western Australia
Report release date 26/02/1998
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Accident

Aircraft details

Manufacturer Robinson Helicopter Co
Model R22 Beta
Registration VH-LKK
Serial number 1625
Sector Helicopter
Operation type Aerial Work
Departure point Louisa Downs Station WA
Destination Louisa Downs Station WA
Damage Substantial

Airspace incursion involving a Beech Aircraft Corp E55, VH-OMD, Avalon Aerodrome, Victoria, on 20 February 1998

Summary

FACTUAL INFORMATION

The pilot of the Beech 55 Baron advised that he made a transmission to Avalon Tower while taxiing at Ceres. This transmission was neither heard nor recorded by Avalon, and no acknowledgment was received by the pilot.

Avalon Tower was staffed by a trainee air traffic controller under the supervision of a rated aerodrome controller. The trainee was performing the aerodrome control tasks at the time.

The Baron subsequently departed Ceres. The pilot remained clear of the Avalon control zone until radio communication was established with Avalon Tower, when he requested an airways clearance to Bairnsdale on climb to 9,000 ft. The reply from the Avalon controller was spoken in a soft voice and was intended only to confirm the details of the request but used the words "...cross the zone, confirming on climb to 9,000 to Bairnsdale ...". The pilot advised that he did not hear the full transmission. He interpreted the communication as an airways clearance and initiated a climb to 9,000 ft. The pilot only acknowledged this perceived clearance with the word "affirmative" and did not read back the full clearance.

This situation resulted in the pilot believing that he had a clearance to enter controlled airspace on track to Bairnsdale and on climb to 9,000 ft, whereas the controllers believed that no clearance had been issued.

The Avalon controllers then coordinated the details of the Baron's intended flight with Melbourne radar control which resulted in an agreed altitude limit of 2,000 ft for the Baron. The coordination included an assessment of the relative position of the Baron with a Boeing 767 conducting training in the Avalon airspace. The radar controller was unable to provide any radar separation between the two aircraft.

During the ensuing radio exchange between the Avalon controller and the pilot of the Baron, the controller did not mention the word "clearance" when instructing the pilot to maintain 2,000 ft and track to Portarlington. He did, however, specifically instruct the pilot to maintain his own separation with the Boeing 767. The pilot accepted both instructions and proceeded to Portarlington.

The pilot of the Baron now believed that the original (perceived) clearance was still current but that he had a temporary restriction to maintain 2,000 ft until reaching Portarlington. This belief was further validated in his mind when he was instructed to Squawk Code 3000, a code used to radar identify aircraft.

During the transit of the Avalon control zone, the pilot of the Baron made radio contact with Melbourne Flight Service and passed his position and departure time.

The Melbourne radar controller had expected the Baron to remain outside controlled airspace but observed the aircraft passing through 4,500 ft after passing Portarlington. He issued a different squawk code via Flight Service and made a positive identification. A violation of controlled airspace had occurred but there was no breakdown of separation standards.

The use of non-standard phraseology had resulted in confusion between the pilot of the Baron and Avalon Tower. Air traffic control had not specifically mentioned the word "clearance" at any time, leaving the pilot to misinterpret the transmissions as an airways clearance.

Had the pilot read back the perceived clearance in full, the controllers may have realised that the misinterpretation had occurred.

Occurrence summary

Investigation number 199800541
Occurrence date 20/02/1998
Location Avalon Aerodrome
State Victoria
Report release date 21/09/1998
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Incident

Aircraft details

Manufacturer Beech Aircraft Corp
Model E55
Registration VH-OMD
Sector Piston
Departure point Ceres Vic
Destination Bairnsdale Vic.
Damage Nil

Collision with terrain involving a Grob G-115C2, VH-ZTE, Hyden North, Western Australia, on 18 February 1998

Summary

The student was briefed by his instructor for a solo flight as part of the CPL training Block. The published route is Merredin - Wagin - Hyden - Merredin. The planned landing point for this exercise is Wagin, which has an adequate runway for the purpose. To meet the operational requirement of a 2.5 hour flight, students are permitted to divert en route Wagin to Hyden, direct to Merreden, after considering such factors as ground speed and fuel remaining.

This student elected to divert in the Merredin to Wagin leg, and proceeded to Hyden where he then conducted an unauthroised landing at a private airfield to the North of the town, not the Shire strip as published in the WA Country Airfield Guide. The student later reported that on his final approach for a landing to the South he was distracted by something close to the threshold, possibly a fence, which prompted him to change his original aiming point.

This action lead to a bounce on touch down followed by an attempted go around, during which the aircraft departed the runway centreline to the left towards some trees. He then tried to manoeuvre the aircraft back to the runway and then could not remember hearing the stall warning prior to the impact of the nose and right wing into the ground. The aircraft came to rest 10m from the runway edge sustaining considerable damage to the propellor, engine, nose and right undercarriage plus sundry damage to the airframe including the tailplane.

Occurrence summary

Investigation number 199800536
Occurrence date 18/02/1998
Location Hyden North
State Western Australia
Report release date 25/02/1998
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Collision with terrain
Occurrence class Accident

Aircraft details

Manufacturer Grob - Burkhart Flugzeugbau
Model G-115C2
Registration VH-ZTE
Sector Piston
Operation type Flying Training
Departure point Merredin WA
Destination Wagin WA
Damage Substantial

Avionics system event involving a Airbus A320-211, VH-HYB, Melbourne Aerodrome, Victoria, on 14 January 1998

Summary

The pilot reported that he discontinued take-off on runway 27 due to severe nosewheel aquaplaning. The departure was changed to runway 34 and during this time the inertial reference systems lost alignment. Re-alignment was not possible, and the aircraft was returned to the terminal.

Occurrence summary

Investigation number 199800533
Occurrence date 14/01/1998
Location Melbourne Aerodrome
State Victoria
Report release date 25/02/1998
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Incident

Aircraft details

Manufacturer Airbus
Model A320-211
Registration VH-HYB
Sector Jet
Operation type Air Transport High Capacity

Freight related event involving a Boeing 767-338ER, VH-OGJ, 185 km east of Sydney Aerodrome, New South Wales, on 15 January 1998

Summary

As the aircraft commenced descent, the crew heard and felt a loud thump. On final approach, the crew heard and felt a second thump and concluded that a container in the forward hold was incorrectly restrained.

When the hold was opened at the ramp, an engineer confirmed that the aft restraint on one pallet was not engaged, permitting the pallet to move approximately 15 cm forward and rearward.

Occurrence summary

Investigation number 199800523
Occurrence date 15/01/1998
Location 185 km east of Sydney Aerodrome
State New South Wales
Report release date 06/07/1998
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Incident

Aircraft details

Manufacturer The Boeing Company
Model 767-338ER
Registration VH-OGJ
Sector Jet
Operation type Air Transport High Capacity
Departure point Auckland New Zealand
Destination Sydney NSW
Damage Nil

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

Summary

No text.

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