Loading related involving a Boeing 737-376, VH-TAF, Melbourne Aerodrome, Victoria, on 11 January 1998

Summary

After the aircraft had commenced taxiing for take-off the crew were advised that the aircraft had been loaded out of trim. The aircraft was returned to the gate while adjustments to the load were made. To enable the aircraft to be loaded within the weight and balance limits the load control officer planned for a nil uplift in hold 4. A load instruction report was prepared indicating a nil uplift for hold 4 and was handed to the ramp leading hand. After loading was completed the ramp leading hand presented a ramp clearance report to the load control officer.

It was noted that twenty bags had been loaded into hold 4. Accordingly, the load control officer recalculated the weight and balance, found that the aircraft was out of trim, and recalled the aircraft. The operators procedures require the ramp leading hand to advise the load control officer of any changes before the changes are made. These procedures were not followed and the company has initiated measures to improve discipline in the loading area. The aircraft was operating under a new centralised load control system that allows the aircraft to be released from the gate prior to obtaining a final load clearance.

The final loadsheet data is transmitted by radio to the aircraft and a hard copy is printed on the flight deck by the crew. System safety is assured as final loadsheet data cannot be transmitted by the load control officer until after the passenger and ramp clearances have been received and any loading adjustments made in the system. Also, the system will not produce a loadsheet if the weight or trim is outside limits, and the crew will not be able to configure the aircraft for takeoff without first having received the loadsheet data.

Occurrence summary

Investigation number 199800089
Occurrence date 11/01/1998
Location Melbourne Aerodrome
State Victoria
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 737-376
Registration VH-TAF
Sector Jet
Operation type Air Transport High Capacity
Departure point Melbourne Vic.
Destination Adelaide SA
Damage Nil

Collision with terrain involving a Robinson R22 Beta, VH-HFF, Canberra Airport, Australian Capital Territory, on 14 January 1998

Summary

The helicopter was engaged in a dual training exercise during which a number of autorotational approaches were conducted. These approaches were terminated in a hover using power. The student had completed a number of these approaches when the instructor introduced a 360-degree autorotational approach. The student completed this approach, however the standard to which it was flown was not consistent with the student's previous approaches. In an attempt to restore the student's confidence, the instructor asked the student to complete another normal autorotational approach.

This approach was flown in a similar fashion to the previous approaches, however when the helicopter was brought to the hover at the completion of the approach it began to yaw to the right. The instructor attempted to counter this yaw by application of anti-torque pedal however this was not successful. Despite the application of power, the helicopter contacted the ground firmly and rolled onto its left side. The instructor and student egressed from the helicopter without difficulty. The air traffic controller on duty did not witness the accident however he did notice that the helicopter was on its side and alerted the Rescue and Fire Fighting services who attended the accident site.

Examination of the accident site revealed that the helicopter came to rest approximately 3 m from the initial point of ground contact. There were only three rotor impact marks on the ground and one tail strike mark. The instructor commented that he had not heard the low rotor RPM warning horn during the approach and attempted hover.

The helicopter was fitted with a system that applied carburettor heat whenever the collective lever was lowered. This had functioned correctly during the normal after-start checks and examination of the system after the accident found no abnormalities.

Occurrence summary

Investigation number 199800099
Occurrence date 14/01/1998
Location Canberra Airport
State Australian Capital Territory
Report release date 10/07/1998
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 Robinson Helicopter Co
Model R22 Beta
Registration VH-HFF
Sector Helicopter
Operation type Flying Training
Departure point Canberra
Destination Canberra
Damage Substantial

Airframe event involving a Boeing 767-338ER, VH-OGD, Sydney Aerodrome, New South Wales, on 11 January 1998

Summary

The Boeing 767 had just departed from Sydney when a loud vibration was heard adjacent to the left overwing emergency exits. The aircraft returned to Sydney where the Rescue and Fire Fighting Services (RFFS) were placed on standby for the landing. The aircraft subsequently landed safely and taxied to the gate without incident.

The investigation determined that the hinge pin of the left rear overwing emergency exit door step piano hinge had migrated rearward about 15 cm and had been flapping against the fuselage skin in the airstream. The aircraft had undergone a 'C' maintenance inspection, which includes an inspection of the hinge, about two months prior to the incident.

The reason for the pin migration was not determined.

Occurrence summary

Investigation number 199800073
Occurrence date 11/01/1998
Location Sydney Aerodrome
State New South Wales
Report release date 25/03/1998
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-OGD
Sector Jet
Operation type Air Transport High Capacity
Departure point Sydney NSW
Destination Singapore
Damage Nil

Collision on ground involving a Lake A/C Div. Of Consolidated Aeronautics Inc. LA-4-200, VH-FTB, King Fisher Bay, Queensland, on 9 January 1998

Summary

During the take-off run, the aircraft struck an unseen, submerged object. The impact launched the aircraft out of the water prematurely. The pilot placed the aircraft back on the surface of the water and continued the take-off run. The pilot then noticed that water was entering the cabin behind the front seats and that the aircraft began to vibrate. He rejected the take-off and stopped the engine before evacuating his passengers and himself. The aircraft sank approximately 15 minutes later.

Occurrence summary

Investigation number 199800069
Occurrence date 09/01/1998
Location King Fisher Bay
State Queensland
Report release date 15/01/1998
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Accident

Aircraft details

Manufacturer Lake A/C Div. Of Consolidated Aeronautics Inc.
Model LA-4-200
Registration VH-FTB
Sector Piston
Operation type Charter
Departure point King Fisher Bay Qld
Destination King Fisher Bay Qld
Damage Substantial

Forced/precautionary landing involving a Hughes Helicopters 369D, VH-HWD, Ulan State Mines, New South Wales, on 7 January 1998

Summary

The MD500 helicopter was engaged in a sling operation to lift a powerline to the top of a transmission tower. The pilot was hovering the helicopter about 60 ft above the 30-ft tower, and had just passed the powerline to the linesman when the engine began to "spool down", resulting in a total loss of power.

The pilot immediately banked the helicopter to the right to avoid personnel on and below the tower, and attempted a landing in light scrub. However, the helicopter came to rest on its right side, incurring substantial damage, and slightly injuring the pilot. The maintenance investigation found that the engine fuel system was contaminated with water, discoloured fuel, and particle debris. After the engine fuel system was cleaned, the engine was successfully ground-run.

The helicopter had spent 45 hours on firefighting duties in the 60 hours since the last maintenance inspection. During the firefighting operations, refuelling was routinely undertaken from an assortment of drum and mobile bowser fuel sources. "Hot" refuelling also accounted for a significant proportion of these refuelling operations. It is probable that the fuel system was contaminated during those refuelling operations.

SAFETY ACTION STATEMENT

As a result of this occurrence, the Bureau of Air Safety Investigation is currently analysing a possible safety deficiency. The deficiency identified involves the manufacturer-instigated modification of the fuel filtration system which removed the ability to do water/contamination tests at the engine driven fuel pump and filter assembly. Any recommendation issued as a result of this analysis will be published in the Bureau's Quarterly Safety Deficiency Report.

Occurrence summary

Investigation number 199800067
Occurrence date 07/01/1998
Location Ulan State Mines
State New South Wales
Report release date 14/07/1998
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Forced/precautionary landing
Occurrence class Accident
Highest injury level Minor

Aircraft details

Manufacturer Hughes Helicopters
Model 369D
Registration VH-HWD
Sector Helicopter
Departure point Charm Haven NSW
Destination Ulan State Mine NSW
Damage Substantial

Collision with terrain involving a Cessna A188B/A1, VH-HWE, 7 km south-south-east of St George, Queensland, on 3 January 1998

Summary

The day before the accident, the pilot had made some modifications to the aircraft's spray equipment. Approximately 180 lts of water was then loaded to test the equipment.

Early the next morning, the pilot decided to test spray over a paddock. After checking the paddock for hazards, he commenced a spray run from west to east with the sun still below the horizon. The pilot noticed a loss of spray pressure and as he looked down inside the cockpit to adjust the pressure, the main landing gear struck the ground. The aircraft nosed over and slid upside down for approximately 40 m before coming to rest. The pilot was not injured and was able to extricate himself without outside assistance.

An emergency locator transmitter (ELT) was not fitted to the aircraft.

Occurrence summary

Investigation number 199800065
Occurrence date 03/01/1998
Location 7 km south-south-east of St George
State Queensland
Report release date 15/01/1998
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 Cessna Aircraft Company
Model A188B/A1
Registration VH-HWE
Sector Piston
Operation type Aerial Work
Departure point St George Qld
Destination Aspen ALA Qld
Damage Substantial

Loss of separation involving a Israel Aircraft Industries Ltd 1124, VH-AJJ and The Boeing Company 747, 9M-MPG, 4 km south-south-east of Sydney Aerodrome, New South Wales, on 6 January 1998

Summary

VH-AJJ, a Westwind, departed Sydney runway 16L on a COOKS ONE standard instrument departure (SID) for a maintenance test flight. The SID required the aircraft to turn left on reaching 500 ft. Radar observation, however, indicated that the aircraft remained on runway heading and did not comply with the SID. The departures controller instructed the pilot to turn left immediately as there was an international B747 departing from runway 16R on a GUEST TWO SID. The tower had both aircraft in sight at all times but there was a breakdown in separation.

The operator of VH-AJJ reported that the flight test was to observe the operation of the aircraft's pressurisation system. The pilot was aware of the departing B747 from the parallel runway but was intent on cabin and engine instruments during the initial climb. He realised he had failed to comply with the SID when he was instructed to turn left.

Occurrence summary

Investigation number 199800051
Occurrence date 06/01/1998
Location 4 km south-south-east of Sydney Aerodrome
State New South Wales
Report release date 25/03/1998
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 Israel Aircraft Industries Ltd
Model 1124
Registration VH-AJJ
Sector Jet
Departure point Sydney NSW
Destination Sydney NSW
Damage Nil

Aircraft details

Manufacturer The Boeing Company
Model 747
Registration 9M-MPG
Sector Jet
Operation type Air Transport High Capacity
Departure point Sydney NSW
Destination Melbourne Vic.
Damage Nil

Collision with terrain involving a Cessna 172M, VH-WTG, Dubbo Aerodrome, New South Wales, on 8 January 1998

Summary

The aircraft was on final approach to Dubbo aerodrome when it suddenly descended, collided with power lines and cartwheeled to the ground. The aircraft was destroyed in the accident but the solo student pilot managed to escape with minor injuries.

The pilot subsequently reported that he had the aircraft configured for a short field landing with full flap and 60 kts approach speed. At about 400 ft on mid final, a sudden wind gust lifted the nose and right wing to a high attitude. The pilot applied full power and opposite aileron but the aircraft failed to recover before colliding with the power lines.

It is likely that the high nose attitude resulted in the aircraft stalling at a height which was insufficient to effect a recovery.

Occurrence summary

Investigation number 199800049
Occurrence date 08/01/1998
Location Dubbo Aerodrome
State New South Wales
Report release date 23/02/1998
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Collision with terrain
Occurrence class Accident
Highest injury level Minor

Aircraft details

Manufacturer Cessna Aircraft Company
Model 172M
Registration VH-WTG
Sector Piston
Operation type Flying Training
Departure point Dubbo NSW
Destination Dubbo NSW
Damage Destroyed

Oil system event involving a Short Bros Pty Ltd SD360, VH-MVW, 46 km south of Bundaberg Aerodrome, Queensland, on 1 January 1998

Summary

A passenger alerted the crew to fluid leaking from the left engine cowling. Several minutes later, the oil pressure began fluctuating. The crew reduced power on the affected engine as stipulated in the Abnormal Procedures checklist. They declared an emergency and advised the sector controller of their intention to divert to Bundaberg. Emergency services were alerted and in place for an uneventful landing.

Company maintenance staff found an engine oil leak. The leak was traced to the failure of an oil seal at the gas generator tachometer gear.

Occurrence summary

Investigation number 199800011
Occurrence date 01/01/1998
Location 46 km south of Bundaberg Aerodrome
State Queensland
Report release date 07/01/1998
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Incident

Aircraft details

Manufacturer Short Bros Pty Ltd
Model SD360
Registration VH-MVW
Sector Turboprop
Operation type Air Transport Low Capacity
Departure point Brisbane Qld
Destination Rockhampton Qld
Damage Nil

Collision with terrain involving a Maule Aircraft Corp M-7-235, VH-JLU, Lady Musgrave Island, Queensland, on 5 January 1998

Summary

The pilot reported that while taking off from Lady Musgrave lagoon, just after the aircraft became airborne, a gust of wind caused the right wing to drop. The wing contacted the water surface, and the aircraft cartwheeled to the right. The windscreen was shattered and the cockpit filled with water immediately. The aircraft came to rest inverted under the floats in approximately 8 metres of water.

The rear seat passengers egressed safely from the right side of the aircraft with cuts and bruises. The pilot's door was jammed but the pilot kicked out the side window and egressed with the front seat passenger from the left side of the aircraft. The aircraft was eventually washed onto the reef and destroyed by wave and tide action. An attempt to salvage the aircraft was unsuccessful.

The pilot reported that the wind at the time was a 20-25 knot south-easterly, the general weather was squally conditions with wind gusts to 30 knots, and the sea state was choppy with waves to one metre.

Occurrence summary

Investigation number 199800002
Occurrence date 05/01/1998
Location Lady Musgrave Island
State Queensland
Report release date 28/01/1998
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 Maule Aircraft Corp
Model M-7-235
Registration VH-JLU
Sector Piston
Operation type Charter
Departure point Lady Musgrave Lagoon Qld
Destination Bundaberg Qld
Damage Substantial