Loss of control involving a Cessna A185E, VH-FLU, Peterborough (ALA), Victoria, on 29 December 1997

Summary

The pilot was flying a Cessna 185 aircraft on a VFR charter flight from Moorabbin to Peterborough with 2 passengers. On arrival at Peterborough he overflew the strip and estimated the wind to be from 220 degrees at 5 to 7 kts. The strip has an uphill gradient to the east, and, even though this would result in a slight tailwind from the right quarter for the landing, the pilot elected to accept this and make use of the uphill gradient.

The landing was reported to have been smooth and light and was accomplished with a trickle of power and full flap (4 stages). During the roll out the aircraft diverged slightly left and then made a rapid and increasing swing to the right. Application of rudder and brake was not able to stop the developing ground loop. The aircraft left the mown strip with the group loop tightening until the left main landing gear collapsed. The aircraft came to rest pointing back down the strip towards the touchdown point.

After shutting down the engine the pilot and passengers evacuated without assistance or injury.

The pilot considered that he should have used a different technique when landing. A powered approach with 2 stages of flap, raising the flaps as soon as possible after landing, and using power to ensure adequate rudder authority during roll out would have result in control of the aircraft being maintained.

Occurrence summary

Investigation number 199704267
Occurrence date 29/12/1997
Location Peterborough (ALA)
State Victoria
Report release date 12/01/1998
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Loss of control
Occurrence class Accident

Aircraft details

Manufacturer Cessna Aircraft Company
Model A185E
Registration VH-FLU
Sector Piston
Operation type Charter
Departure point Moorabbin Vic.
Destination Peterborough Vic.
Damage Substantial

Oil system event involving a Piper PA-28R-200, VH-TRZ, 37 km south-west of Mudgee Aerodrome, New South Wales, on 26 December 1997

Summary

The pilot of the PA28 had departed Wallan for a flight to Coolangatta. At approximately 37 km southwest of Mudgee, the aircraft engine began to run rough following a sudden loss of engine oil pressure. A burning smell and an increase in indicated engine temperature was also evident. Due to the inhospitable terrain ahead to Mudgee, the pilot decided to conduct a forced landing in a nearby field.

The pilot broadcast a distress call to Sydney Flight Service (FS) and a Distress Phase was declared. Due to the field length and surface conditions, the pilot chose to carry out a 'wheels up' landing. This was successfully carried out and the pilot and passenger vacated the aircraft without injury. The ELT was automatically activated. Upon telephone confirmation of the situation of the pilot and passenger and deactivation of the ELT, FS cancelled the Distress Phase.

Occurrence summary

Investigation number 199704255
Occurrence date 26/12/1997
Location 37 km south-west of Mudgee Aerodrome
State New South Wales
Report release date 21/04/1998
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Accident

Aircraft details

Manufacturer Piper Aircraft Corp
Model PA-28R-200
Registration VH-TRZ
Sector Piston
Operation type Private
Departure point Wallan Vic.
Destination Coolangatta Qld
Damage Substantial

Flight crew incapacitation involving a Bell 412, VH-HRS, Lake Munmorah, New South Wales, on 13 December 1997

Summary

The aircraft had been tasked by police to provide assistance to two people in difficulty in Lake Munmorah. With the aircraft in the hover, the crewman stepped into the water with the intention of assisting the swimmers. As the water was shallow, the crewman's foot hit the bottom of the lake hard, breaking his ankle. People from the shore rescued the swimmers and the crewman in the water. The crewman was later flown to hospital for medical treatment.

The crew's actions were in accordance with their training and the company's operations manual. However, these procedures contain a latent failure in that they are not safe in shallow water or where there may be submerged objects. Since this occurrence, procedures have been changed so that crewman can only jump from the aircraft when it is out to sea. A crewman who needs to enter the water in a bay, lake or river has to be winched into the water. The operations manual has been amended to avoid a repeat of this occurrence. No further safety action is required.

Occurrence summary

Investigation number 199704244
Occurrence date 13/12/1997
Location Lake Munmorah
State New South Wales
Report release date 03/04/1998
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Flight crew incapacitation
Occurrence class Accident
Highest injury level Serious

Aircraft details

Manufacturer Bell Helicopter Co
Model 412
Registration VH-HRS
Sector Helicopter
Operation type Aerial Work
Departure point Newcastle NSW
Destination Lake Munmorah NSW
Damage Nil

Air-ground-air involving a Cessna 210L, VH-ROH and Saab SF-340A, Whyalla Aerodrome, South Australia, on 19 December 1997

Summary

Occurrence Summary

On four occasions in three months, pilots from the same local company have reported difficulties communicating on the Whyalla MBZ frequency with the flight crews of one particular RPT operator. Following these incidents, the local company raised the following concerns:

(1) crews of the RPT aircraft do not always provide an initial taxy call on the MBZ frequency when preparing for departure from Whyalla;

(2) crews of the RPT aircraft appear to change to the Whyalla MBZ frequency at approximately 10 NM rather than the required 15 NM; and,

(3) crews of the RPT aircraft are often not contactable on the MBZ frequency following an initial inbound broadcast at 25 NM from Whyalla.

The RPT operator's standard operating procedure required crews to monitor the MBZ frequency within 25 NM of Whyalla. Any company calls were to be completed during cruise and not during the approach and arrival phases. The aircraft were equipped with dual VHF radios so that a continuous listening watch was maintained on both the MBZ and flight service frequencies. The report to flight service that the crew were switching to the MBZ frequency was a formality and indicated that this was the prime frequency for communication during the arrival and departure.

The pilot of the RPT aircraft recalled that, on 19 December 1997, all the standard reports and broadcasts were given. He also recalled that a pilot of one aircraft in the area was referring to the company name and not the aircraft's specific identification. This did not immediately attract the pilot's attention because the flight number was not specifically mentioned and several aircraft of the same company were operating in the area at the time.

The airspace around Whyalla can be congested at certain times with the arrival and departure of several aircraft as well as local aircraft operating in the area. It is not uncommon for radio communications to be overtransmitted as appeared to have occurred in one of the reported incidents. There were also a number of nearby CTAFs which utilise the same frequency as the Whyalla MBZ, which adds to the communication congestion.

Safety Action 

Representatives from both the companies, as well as from CASA, met in order to clarify the circumstances of the incidents and to resolve any outstanding concerns about operations in the MBZ at Whyalla. The trial of flight numbers for aircraft callsigns was discussed. It was agreed that flight numbers did not provide any information as to the aircraft type, and therefore its performance and flight profile. It was later clarified that the RPT operator, as with all operators who participated in the trial, was no longer bound to continue to use flight numbers as callsigns.

It was proposed to change the Whyalla MBZ to a discrete frequency as many aerodromes in the local area used the same frequency (126.7 MHZ). The Adelaide office of CASA supported the proposal.

Both companies expressed a willingness to be flexible with aircraft tracking and aircraft operation during climb and descent to facilitate operations within the MBZ.

Occurrence summary

Investigation number 199704234
Occurrence date 19/12/1997
Location Whyalla Aerodrome
State South Australia
Report release date 04/03/1998
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 Cessna Aircraft Company
Model 210L
Registration VH-ROH
Sector Piston
Operation type Air Transport Low Capacity
Departure point Port Pirie, SA
Destination Whyalla, SA
Damage Nil

Aircraft details

Manufacturer Saab Aircraft Co.
Model SF-340A
Sector Turboprop
Operation type Air Transport Low Capacity
Destination Whyalla, SA
Damage Nil

Loss of separation involving a Boeing 747-438, VH-OJO and Unknown Aeroplane, 370 km south-east of Mipap (IFR), on 28 December 1997

Summary

A Boeing 747 (B747), en route from Sydney to Hong Kong, was maintaining flight level 350 (FL350) and had been radar identified by Manila Air Traffic Control. The flight crew observed another aircraft maintaining the same level approximately 20 NM to the east displayed on their aircraft's traffic alert and collision avoidance system (TCAS). The B747 crew sighted the other aircraft as it crossed their track from east to west. The crossing aircraft was en route from Manila to Kuala Lumpur and had initially been assigned FL280.

On first contact with radar control that crew had been instructed to climb to FL350. The controller noted the proximity of the two aircraft and instructed the crew of the B747 to climb immediately to FL370. At the same time the B747 TCAS announced a "Climb" resolution advisory (RA) instruction. The B747 crew complied with the climb instruction. The crew of the crossing aircraft advised the B747 crew that they had received a TCAS RA instruction to descend which they had followed. There was a breakdown of separation. Following an investigation of the occurrence the Republic of the Philippines, Department of Transport and Communications air traffic services investigator reported that all area control centre controllers would undergo radar simulator training to enhance their proficiency. The training was to commence in January 1998.

Occurrence summary

Investigation number 199704226
Occurrence date 28/12/1997
Location 370 km south-east of Mipap (IFR)
State International
Report release date 10/07/1998
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 The Boeing Company
Model 747-438
Registration VH-OJO
Sector Jet
Operation type Air Transport High Capacity
Departure point Sydney NSW
Destination Hong Kong China
Damage Nil

Aircraft details

Manufacturer Unknown
Model Aeroplane
Registration UNKNOWN
Departure point Manila Philipinnes
Destination Kuala Lumpur Malaysia
Damage Nil

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