Total power loss involving a Jabiru ST, VH-SSC, 4 km east of Archerfield Aerodrome, Queensland, on 31 December 1997

Summary

The aircraft was returning from the training area when the pilot reported that he was experiencing engine problems. He then reported conducting a forced landing. Aircraft were dispatched by the controller to observe its progress. The pilot had elected to land in the grounds of a school. As he approached the area he found that it was too short for a normal landing and steepened his approach. The landing gear was torn off on touchdown and the aircraft stopped within the confines of the playground.

Examination of the engine disclosed failures of a number of connecting rods, which were protruding from the top of the engine block. The failure is being investigated by CASA, as part of its engine certification process.

Occurrence summary

Investigation number 199704210
Occurrence date 31/12/1997
Location 4 km east of Archerfield 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 Accident

Aircraft details

Manufacturer Jabiru Aircraft Pty Ltd
Model JABIRU ST
Registration VH-SSC
Sector Piston
Departure point Archerfield Qld
Destination Archerfield Qld
Damage Substantial

Airspace incursion involving a Boeing 767-338ER, VH-OGD and Cessna 172P, VH-ESO, Sydney Middle Marker, New South Wales, on 20 December 1997

Summary

A Boeing 767 (B767) was conducting an instrument landing system (ILS) approach to RWY 16R in instrument meteorological conditions (IMC). The aircraft had left 3,000 ft and the crew were in contact with the aerodrome controller (ADC). When some 11 NM from the airport the crew saw a target appear on their traffic collision and avoidance system (TCAS), 3.5 NM ahead, some 1,500 ft below, and climbing at 500 ft/min on a conflicting course. The crew of the B767 stopped their descent at 2,200 ft, and diverted slightly to the right of the ILS centreline to avoid the target. At about the same time the ADC observed a secondary surveillance radar (SSR) symbol from an unidentified aircraft in the Ryde bridge area. The SSR code was 2000, which was the appropriate code for civil aircraft flights in non-controlled airspace. The aircraft was west of the extended centreline of RWY16R, 8 NM north-west of the airport, and tracking north-east at an unconfirmed altitude of 1,500 ft. The crew of the B767 queried the ADC regarding the other aircraft and were advised that radar indicated the aircraft was ahead and below the B767. The two aircraft passed and the crew of the B767 subsequently encountered visual conditions and resumed their approach. The crew of the B767 did not see the other aircraft, which was later identified as a Cessna 172 (C172) that had departed Bankstown for Archerfield, tracking via the northern VFR route at 1,500 ft. Recorded data showed that the C172 had entered controlled airspace without a clearance and had subsequently passed below the B767 with 700 ft vertical separation and 0.75 NM lateral separation.

The required separation standard was 1,000 ft vertical, or 3 NM lateral. The pilot of the C172 had not previously flown in the Sydney area, and had only become aware he was off track when he realised he was too close to the city centre. At that point he had turned left to track north in order to leave controlled airspace. The progress of the B767 was the responsibility of the Director West (DIRW) controller until the aircraft landed. The DIRW had been engaged in a discussion with another controller when the C172 entered controlled airspace and consequently did not see the C172 conflict with the B767.

The ADC was provided with a radar display to assist him to appreciate the disposition of aircraft in the vicinity of the runway. However, the ADC was not responsible for separating traffic on the final approach path. Aircraft departing Bankstown to the north, outside controlled airspace, are required to track via the standard VFR route as depicted on the Visual Terminal Chart. This entails tracking 007 degrees from Bankstown, not above 2,000 ft, until reaching Pennant Hills, where climb can be continued to 2,500 ft. The VFR route passes below the approach/departure paths for aircraft using runways 16/34 at Sydney. The Manual of Air Traffic Services (MATS) states that; 'In providing radar services within controlled airspace, restricted areas, or designated restricted airspace, ATC has no responsibility to initiate avoiding action in respect of unknown aircraft which can reasonably be assumed to be outside controlled airspace. Nevertheless, if in the judgement of the radar controller, the action of an observed radar return or information received from other sources gives good reason to believe that the observed radar return of an unknown aircraft is likely to be a hazard to an aircraft under control, the controller has complete discretion to take such action as considered necessary to maintain the safety of the aircraft under radar control.

This may comprise the provision of:

a. traffic information; or

b. controller initiated traffic avoidance advice; or

c. a safety alert' Local safety action taken as a result of this occurrence included;

1. Providing a video recording of the occurrence to highlight to controllers the implications of not maintaining an adequate scan of the radar display.

2. Amending radar controller refresher training to include situations in which aircraft infringed controlled airspace, and

3. Reminding aerodrome controllers that while they are not responsible for the separation of aircraft on the final approach path they are, in conjunction with the Directors, responsible for monitoring the approach and departure areas for infringing aircraft.

Occurrence summary

Investigation number 199704172
Occurrence date 20/12/1997
Location Sydney Middle Marker
State New South Wales
Report release date 15/07/1998
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Incident

Aircraft details

Manufacturer Cessna Aircraft Company
Model 172P
Registration VH-ESO
Sector Piston
Departure point Bankstown NSW
Destination Archerfield Qld
Damage Nil

Aircraft details

Manufacturer The Boeing Company
Model 767-338ER
Registration VH-OGD
Sector Jet
Operation type Air Transport High Capacity
Departure point Melbourne Vic.
Destination Sydney NSW
Damage Nil

Forced/precautionary landing involving a Piper PA-32R-300, VH-DAH, 22 km north of Essendon Aerodrome, Victoria, on 20 December 1997

Summary

The Piper Cherokee Lance (PA32R-300) was prepared for departure from runway 35 at Essendon for a flight to Moorabbin, Phillip Island and return. The outside air temperature was 29 degrees C and the wind was from 320 degrees, gusting between 15 and 25 kt. This resulted in a crosswind of 12 kt and a density altitude of approximately 2,000 ft.

The pilot decided to conduct a flapless take-off. He had used this take-off configuration successfully on previous departures from Essendon. The pilot reported that during the take-off roll the aircraft accelerated normally and the engine reached its maximum power indications of 2,700 rpm and 27 in of manifold pressure. As the aircraft lifted off at an airspeed of approximately 65 kt the right wing dropped suddenly, and the aircraft yawed to the right. The pilot corrected the wing drop and the yaw but then realised that the aircraft was not climbing normally. With maximum power still being applied, the airspeed was still indicating 65 kt.

The pilot retracted the landing gear when he had insufficient runway remaining on which to land and advised ATC that he had a problem. When the tower controller observed the aircraft at a very low altitude and flying towards a series of high-tension powerlines, he activated the 'common-crash' alarm.

The pilot was able to fly the aircraft over the high-tension powerlines at the lowest point of the span, which meant that the aircraft was below the height of the pylons. He stated that he felt the aircraft seemed to be having difficulty remaining airborne and that it only felt normal when he lowered the nose attitude. However, he then had to raise to nose attitude to climb over obstacles. He carried out relevant checks but was not able to identify any problems that may have affected the aircraft's performance.

The pilot was able to keep the aircraft flying until he reached a large paddock suitable for a forced landing. He applied two stages of flap and extended the landing gear for the landing. The surface of the paddock was very rough and sloped downhill from the touchdown point. The pilot was not able to stop the aircraft before it continued across a low embankment and through a fence. The aircraft was substantially damaged. The pilot and his two passengers were not injured and were able to evacuate the aircraft without assistance.

The investigation did not find any evidence of a malfunction with the aircraft, the engine, or associated systems. However, it was found that the elevator trim was in the full nose down position and that the rudder trim was full nose left. This flight was the first after a periodic maintenance check had been carried out. It is likely that the trims were not returned to neutral following the maintenance, and this was not noticed by the pilot during his pre-take-off checks.

At the take-off weight of approximately 1500kg the PA32R-300 flight manual charts indicate that the take-off safety speed (TOSS) for the aircraft is 72 knots. The nose attitude is required to be raised smoothly for a flapless take-off, and the aircraft accelerated to a minimum of 72 knots, before the pilot adopts the appropriate attitude to attain a climb speed of 92 knots.

It is likely that the aircraft was adversely affected by a gust of wind as it lifted off. In addition, the incorrect trim tab settings would have resulted in the aircraft flying in an unbalanced condition. This imbalance would have produced extra drag with a resulting reduction in airspeed. To correct the wing drop and yaw the pilot would have had to promptly apply coarse control inputs. Drag would have further increased, with a corresponding reduction in airspeed. It is probable that the aircraft did not have sufficient power to overcome the drag resulting from the low speed and high nose attitude - a condition commonly known as 'flying on the back of the drag curve'. The density altitude and high temperature on the day would have also adversely affected the aircraft's performance.

Occurrence summary

Investigation number 199704134
Occurrence date 20/12/1997
Location 22 km north of Essendon Aerodrome
State Victoria
Report release date 07/01/1998
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-32R-300
Registration VH-DAH
Sector Piston
Departure point Essendon Vic
Destination Essendon Vic
Damage Substantial

Wheels up landing involving a Cessna 210K, VH-MJD, Ranku, Northern Territory, on 17 December 1997

Summary

The aircraft landed with the landing gear retracted. The pilot said that he had forgotten to extend the gear.

Occurrence summary

Investigation number 199704125
Occurrence date 17/12/1997
Location Ranku
State Northern Territory
Report release date 09/01/1998
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 210K
Registration VH-MJD
Sector Piston
Operation type Charter
Departure point Darwin NT
Destination Ranku NT
Damage Substantial

Hard landing involving a Cessna 210L, VH-BEC, Bankstown Aerodrome, New South Wales, on 17 December 1997

Summary

The Cessna 210 aircraft had completed a local flight in the Bankstown area and was returning to land on runway 29 right. On final approach the pilot noticed that the windsock was indicating a crosswind from the left and elected to complete the landing using flap 20. The pilot reported crossing the runway threshold at an airspeed of approximately 80 knots, although the aircraft seemed to have a higher ground speed than would be normally associated with this approach speed.

The aircraft was flared and touched down briefly, before becoming airborne again. The pilot attempted an unsuccessful recovery from the initial bounce, but the aircraft continued to porpoise down the runway. As the nose wheel contacted the runway for the fourth or fifth time, a loud bang was heard and the nose of the aircraft settled onto the runway.

The aircraft slid to a stop and the occupants vacated the aircraft without assistance. The Aerodrome Safety Officer extinguished a small fire that had broken out in the wheel well.

Occurrence summary

Investigation number 199704123
Occurrence date 17/12/1997
Location Bankstown Aerodrome
State New South Wales
Report release date 10/03/1998
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Hard landing
Occurrence class Accident

Aircraft details

Manufacturer Cessna Aircraft Company
Model 210L
Registration VH-BEC
Sector Piston
Operation type Private
Departure point Bankstown NSW
Destination Camden/Hoxton Park NSW
Damage Substantial

Wirestrike involving a Cessna 150F, VH-EMH, Biloela, Queensland, on 18 December 1997

Summary

The pilot reported that had commenced the take-off run with no flap selected but felt that the aircraft was slow to accelerate to take-off speed. He then selected flap and the aircraft became airborne. There were trees and high ground beyond the end of the strip and the pilot turned the aircraft right to avoid this area.

As the aircraft turned, it struck a powerline and then impacted the ground in a nose down attitude. The pilot and passenger were uninjured. The pilot stated that the aircraft was about 100 lb under maximum weight with the centre of gravity within the envelope. He believed that the aircraft encountered wind shear and a downdraft leading to loss of performance. The ambient air temperature was 34 degrees C, with less than 5 kts wind at the time of the accident.

Occurrence summary

Investigation number 199704117
Occurrence date 18/12/1997
Location Biloela
State Queensland
Report release date 19/01/1998
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Wirestrike
Occurrence class Accident

Aircraft details

Manufacturer Cessna Aircraft Company
Model 150F
Registration VH-EMH
Sector Piston
Operation type Private
Departure point Biloela Qld
Destination Biloela Qld
Damage Substantial

Runway excursion involving a de Havilland Canada DHC-2, VH-AAJ, 37 km south of Walcha (ALA), New South Wales, on 16 December 1997

Summary

The pilot was conducting topdressing operations from a property airstrip located in undulating terrain. He reported that he had refuelled the aircraft after 11 flights, and that the accident occurred on the seventh take-off after refuelling. The aircraft appeared to be operating normally but failed to gain flying speed before reaching the end of the strip.

During the subsequent collision with the terrain, both wings, both elevators, the engine, and the main landing gear were torn from the aircraft. The aircraft came to rest facing back towards the airstrip, about 200 m beyond and 100 ft below the level of the airstrip. The pilot stated that he had observed indications of localised whirlwinds and considered it likely that as he attempted to lift the aircraft from the strip, the aircraft's performance had been adversely affected by one. Weather conditions at the time were fine with a north-westerly wind of 6 to 10 kts.

Occurrence summary

Investigation number 199704108
Occurrence date 16/12/1997
Location 37 km south of Walcha (ALA)
State New South Wales
Report release date 11/07/1998
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 De Havilland Canada/De Havilland Aircraft of Canada
Model DHC-2
Registration VH-AAJ
Sector Piston
Departure point 'Glen Collen', NSW
Destination 'Glen Collen', NSW
Damage Destroyed

Breakdown of co-ordination involving a Boeing 767-338ER, VH-OGI and Boeing 747, JA8190, VIPAM (IFR), on 7 December 1997

Summary

Port Moresby ATC passed coordination to Brisbane Centre on ANA923 and QFA 114 but the flight levels coordinated were incorrect. ANA 923 was coordinated at flight level 390 and QFA114 at flight level 370. At 1700, the pilot of ANA923 reported at VIPAM at flight level 370. When this was passed to Brisbane sector 11, confirmation of the flight level was requested, and this was confirmed by the pilot. Sector 11 contacted Port Moresby by telephone, and Port Moresby confirmed flight level 390.

At approximately 1710, Port Moresby called back to apologise and advise that the level coordinated should have been flight level 370, and QFA 114 should have been flight level 390.

Occurrence summary

Investigation number 199704074
Occurrence date 07/12/1997
Location VIPAM (IFR)
State International
Report release date 22/12/1997
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 The Boeing Company
Model 767-338ER
Registration VH-OGI
Sector Jet
Operation type Air Transport High Capacity
Departure point Osaka Japan
Destination Brisbane Qld
Damage Nil

Aircraft details

Manufacturer The Boeing Company
Model 747
Registration JA8190
Sector Jet
Operation type Air Transport High Capacity
Departure point Narita Japan
Destination Brisbane Qld
Damage Nil

Ground strike involving a Robinson R22/A1, VH-IXM, Jandakot Aerodrome, Western Australia, on 2 December 1997

Summary

The helicopter was being used for flight training. The student had been experiencing some problems in stabilising the hover so the instructor placed the helicopter light on the skids to allow the student to practice use of the cyclic control. Because the student had a tendency to allow the helicopter to drift right as the helicopter came light on the skids, the instructor gave the student control of the cyclic and yaw pedals whilst he retained control of the collective.

After several attempts, the student's cyclic control had apparently improved sufficiently that the instructor was confident to bring the helicopter into the hover. However, during the following three attempts the student found hover control difficult and after several seconds in the hover, the instructor had to take control. During the fourth attempt, the student allowed the helicopter to drift right slightly. With the helicopter approximately 1 ft off the ground, the student unexpectedly made a large right cyclic input and allowed the helicopter to yaw left. The instructor did not respond quickly enough to prevent the helicopter sinking and the right rear skid struck the ground. As the ground contact was firmer than normal, the instructor decided to air taxi the helicopter to the parking area. The helicopter's airframe, right skid and tailboom were found damaged.

Occurrence summary

Investigation number 199704044
Occurrence date 02/12/1997
Location Jandakot Aerodrome
State Western Australia
Report release date 18/02/1998
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Ground strike
Occurrence class Accident

Aircraft details

Manufacturer Robinson Helicopter Co
Model R22/A1
Registration VH-IXM
Sector Helicopter
Operation type Flying Training
Departure point Jandakot WA
Destination Jandakot WA
Damage Substantial

Partial power loss involving a Saab SF-340B, VH-LIH, Point Lookout VOR, New South Wales, on 5 December 1997

Summary

The pilot reported that during a flight from Sydney to Lismore the right engine suffered two "rollbacks". Rollback is a phenomenon in which aircraft engines lose power. On the subsequent flight to from Lismore to Sydney the right engine suffered one "rollback". The problem is a known fault and can be caused by icing at the inlet cowl area.

Occurrence summary

Investigation number 199704062
Occurrence date 05/12/1997
Location Point Lookout VOR
State New South Wales
Report release date 22/12/1997
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Incident

Aircraft details

Manufacturer Saab Aircraft Co.
Model SF-340B
Registration VH-LIH
Sector Turboprop
Operation type Air Transport Low Capacity
Departure point Sydney NSW
Destination Lismore NSW
Damage Nil