A domestic Boeing 767 was inbound to the holding pattern at Cullerin and the crew had been issued a requirement to reach their assigned level of FL 290 before entering the pattern. The crew of a Boeing 747 already established in the Cullerin pattern observed the inbound aircraft descending through its assigned level and alerted ATC. The descending aircraft was visually sighted and was displayed as traffic on the TCAS.

The pilot of the descending B 767 indicated that the autopilot had not captured the assigned level as programmed. The pilot indicated that this was possibly complicated by late amendments to the holding instruction. The crew intervened when it became apparent that the autopilot had not captured the assigned level, but not before the aircraft had descended approximately 400 ft through the assigned level.

The controller indicated that 1,000 ft vertical separation between the two aircraft was quickly re-established, and the aircraft were horizontally separated by 3 - 4 NM.

The pilot reported that while cruising at about 600 ft AGL, he heard a loud noise and the helicopter shook violently. He initiated autorotation and helicopter landed heavily a short time later. Both occupants escaped with minor injuries.

Subsequent investigation revealed that the transmission torsion coupling had broken, and two steel back up pins had sheared. The transmission failure had caused complete loss of torque to the main rotor. The tail rotor and gear box showed no evidence of pre -impact damage.

FACTUAL INFORMATION

The Airbus A340 (A340) was on air route A587 and the Boeing 737 (B737) was on air route G462. The routes intersected at waypoint KETUT, which is 200 NM bearing 103 degrees magnetic from Bali. Both aircraft had been cleared to enter the Bali flight information region (FIR) at flight level (FL) 350. The waypoint KETUT is a reporting point for aircraft on A587 but not for aircraft on G462. All communications prior to this point were made on high frequency (HF) radio SELCAL, which does not alert pilots that there may be conflicting traffic.

The conflicting traffic was under the jurisdiction of the Bali East controller. There was radar coverage to approximately 150 NM, and a combination of procedural and radar control was being used by the controller. Flight plans for both aircraft had been received at the Bali Control Centre. However, the flight plans did not indicate an estimate for the KETUT position.

At the time of the incident, the controller had three aircraft on his frequency - the B737, the A340, and a Boeing 747 (B747) en route Singapore to Sydney. The B747 was tracking via Bali at FL330 and the B737 would have had to descend through that level for arrival at Bali. The B747 was identified on radar and was estimating overhead at Bali at 1436 UTC. The other two aircraft were not identified on radar.

At 1410, the A340 pilot reported to Bali East at ONOXA, a reporting point on the FIR southern boundary. ONOXA is 197 NM from KETUT on the designated route A587. The Bali East controller then requested an estimated time of arrival (ETA) for IKAPI, a reporting point on the northern FIR boundary where the aircraft would exit the FIR. The pilot advised an estimate of 1530 and the controller coordinated this information to Ujung Pandang, which was the next control agency.

KETUT was a compulsory reporting point for aircraft on A587. The reason the A340 crew did not advise an estimate for KETUT when reporting at ONOXA was not established. The reason the controller did not request A340's ONOXA estimate was also not established.

At 1428, the crew of the B737 reported at SOTRA at FL350. The Bali East controller requested an ETA for GABIT, a reporting point 150 NM east of Bali, and the crew advised that their ETA was 1447. At 1439 the crew of the A340 requested advice of any traffic at FL350. The controller asked the crew to repeat the request. The A340 crew then stated that they were descending to FL310 to avoid conflicting traffic. The crew of the B737 asked the crew of the A340 to report their position. There was no reply to this request. The A340 crew then reported to the Bali East controller that there was traffic 2 NM to their north, passing from right to left at FL350. The controller questioned this report. The A340 crew repeated the information and reported that they were maintaining FL310. The controller then advised the A340 to "maintain FL310 for a while". At 1443, the A340 was cleared to climb to FL350 by the Bali East controller.

At the time of the occurrence, the control centre was staffed by four controllers and a supervisor. The Bali East controller had left the control room on a break and another controller had taken over control duties of the Bali East sector. The controller taking over had not been aware of the potential conflict between the aircraft on air routes A587 and G462.

Although the occurrence location was within normal radar coverage, the radar data was not being recorded during the period of the incident due to a technical problem.

Each control position had a single flight progress strip bay. The bay was used to store pending flight progress strips. Active flight progress strips were placed on the flat console surface in front of the radar screen. There was a checklist for the compilation of flight progress strips, but this had not been compiled with.

ANALYSIS

The controller had taken over the Bali East sector duties only a short time before the incident and he had not been properly briefed on the traffic that was within his jurisdiction. His attention appeared to have been focussed on the potential conflict between the southbound B747 at FL330, and the B737 inbound to Bali at FL350. He was aware that the B737 would require descent through the B747's level but had not been briefed that there was a requirement to establish vertical separation between the A340 and the B737. The situation was compounded because the flight progress strips were not prepared in accordance with the checklist and the flight progress bays were not being utilised in the most appropriate manner to provide situational awareness of the traffic in the sector.

Although, in this instance, an estimate for the KETUT position was omitted by the crew of one aircraft, the provision of an estimate by the crew of the other aircraft may have assisted the controller to better appreciate the traffic disposition, and alerted him to the confliction. In this context, the promulgation of KETUT as a compulsory reporting point for the two intersecting routes (A587 and G462) would have provided a higher level of safety.

Controllers normally combined flight progress strips for aircraft being controlled on the radar display console. However, this action ensured that aircraft being controlled by different procedures (radar and procedural control) were not easily differentiated. It also provide limited cues to controllers to assist them in maintaining an awareness of traffic disposition in their area of responsibility. Use of the available flight progress board with a number of key position designators would assist controllers in the management of aircraft under procedural control. Positioning the flight progress strips for radar-identified aircraft at the radar display console, adjacent to the procedural flight progress board, would have provided a better overall representation of traffic disposition.

SIGNIFICANT FACTORS

1. KETUT was not a compulsory reporting point for both routes.

2. The controller who compiled the flight progress strip for the A340 did not notate KETUT on that aircraft's strip.

3. The controller handing over responsibility for Bali East control did not conduct an adequate handover.

4. The Bali East controller did not adequately review the active flight progress strips after taking over responsibility for the position.

5. A procedural flight progress board was not used to manage aircraft operating in the Bali East area of responsibility.

6. The crew of the A340 did not advise an estimate for KETUT, a compulsory reporting point.

7. The Bali East controller did not appreciate the conflict between the A340 and the B737.

SAFETY ACTION

As a result of this occurrence the B737 operator:

1. issued a safety notice to all aircrew advising them of the details of the occurrence; and

2. recommended that the priority be given for the fitment of a traffic alert and collision avoidance system (TCAS) to company aircraft operating international flights.

In addition, the Bureau of Air Safety Investigation suggests that the Indonesian Directorate of Aviation Safety, in conjunction with Angkasa Pura I:

1. review flight progress strip display practices and procedures, including strategies to ensure their correct compilation;

2. review published handover/takeover procedures, including strategies to improve controller compliance; and

3. 3. Include KETUT as a compulsory reporting point for aircraft operating on route G462.

The pilot of a Grob 115 aircraft was conducting solo circuits from runway 21L at Parafield. The pilot reported difficulty in maintaining directional control of the aircraft during the first landing flare and attempted to go around. However, the aircraft crash landed to the left of the runway and was substantially damaged. The pilot, who was uninjured, vacated the aircraft without assistance.

A Fletcher aircraft was being operated from an agricultural strip located on undulating terrain. During take-off, the pilot was unable to prevent the aircraft colliding with two sheep as it came over the blind crest of a hill. The pilot reported feeling the elevator move during the impact and the aircraft briefly became airborne, in a nose-up trimmed condition due to elevator damage.

The pilot closed the throttle and attempted to land in a paddock straight ahead. However, during the landing, the nose wheel separated from the aircraft, resulting in substantial damage being incurred during the ensuing ground roll.

A Bell 206 helicopter was returning from a fire mapping operation along the Colo River at low altitude. Both the pilot and passenger were reported to be looking for wires when the helicopter main rotor struck a single wire that was strung steeply between two poles. The helicopter was operating approximately 300 ft above ground level.

The helicopter immediately landed to conduct an inspection for damage, before returning to the operating base. A detailed examination by a LAME was conducted at the base before the helicopter was returned to operational service.

A SAAB 340 aircraft was conducting a right circuit for a landing on runway 34 right at Sydney, NSW. The aircraft subsequently positioned itself behind a Boeing 767 on final approach to runway 34 left, infringing wake turbulence separation standards.

The crew report that the controller had inquired while the aircraft was downwind if they would like a radar vector to slot them between to heavy aircraft inbound for runway 34 left. The subsequent vector for base leg was assumed by the crew to be a right base, for runway 34 left. The crew did not recall hearing the controller refer to the assigned runway at any stage of their approach. On being cleared for a visual approach at approximately 10 miles the crew dialled up the runway 34 left ILS.

The controller observed the SAAB flying through the centreline of runway 34 right at approximately 7 miles. The crew was cautioned about wake turbulence, taken out of the landing sequence and processed for a right-hand circuit for runway 34 right. The aircraft landed safely without further incident.

During an IFR pre-licence test the pilot of a Beech 76 aircraft, enroute from Maitland to Bankstown, made a MAYDAY call advising that both engines had failed. No location was given and the pilot did not respond to calls from Flight Service. A distress phase was declared and the appropriate authorities notified. A short time later a telephone call was received from the operator, advising that the aircraft had made a forced landing on the Galston sports oval. Both occupants were uninjured, although the aircraft was substantially damaged. Emergency services were in attendance. The distress phase was then cancelled.

The aircraft had touched down on a small sporting oval, but the pilot was unable to stop within the confines of the field. The aircraft struck the top of an embankment, where the left wingtip collided with a power pole, and the right main landing gear was torn off. The aircraft then collided with a chain mesh fence, coming to rest in a right wing low attitude.

The pilot subsequently reported that about ten minutes prior the event, whilst at 6,000 ft, the left engine had surged and stopped. The propeller was feathered and the fuel crossfeed was selected to the right tank. The engine was restarted and developed normal power. The aircraft was then descended to 1,500 ft, but shortly after, both engines began to surge, causing the aircraft to yaw violently. A MAYDAY call was transmitted but there was insufficient time to report position before the forced landing.

The investigation determined that only an unusable quantity of fuel remained on board the aircraft after the accident. Although both left and right fuel tanks had been holed during the accident sequence, testing determined that both tanks were capable of retaining substantial quantities of fuel whilst the aircraft remained in the right wing low attitude at the accident site. An examination of fuel records determined that the aircraft had not been refueled on the day of the accident. Calculations using the previous recorded flying times, and fuel uplifts on the day prior to the accident, determined there had been insufficient fuel on board, prior to takeoff, to complete the flight.

Two hot air balloons had departed from Archerfield in company at approximately 0615 EST and the pilots had been cleared to operate not above 2,500 ft by the terminal area controller. One of the balloons was operating a transponder but the transponder was not equipped with a mode C (height readout) function. The other balloon was not equipped with a transponder. The ATC radar display of the transponder return from the balloon was intermittent.

After initial identification of the balloon, radar contact was lost for a period of some minutes. At the same time, a Boeing 767 (B767) was inbound to Brisbane from the north and was being radar vectored for a left circuit for a runway 01 ILS approach. At about the same time, a light aircraft departed Archerfield for Brisbane, and the pilot requested airways clearance. The pilot was instructed to proceed outside controlled airspace towards the TV towers, and to expect clearance at that position. The pilot was advised of the presence of the balloons. The radar return of the balloons was not visible to the controller at this time. The B767 had by this time reached a position 5 NM south-west of Archerfield, was cleared to 3,000 ft and vectored onto a heading of 090 for the base leg. At about 1 NM west of Archerfield the B767 pilot requested a heading of 040 "due to balloon" and the aircraft was observed to climb by the controller. The heading requested was approved with a further clearance to descend to 2,500 ft and to commence the ILS approach. As the B767 intercepted the localiser, the radar return for one of the balloons reappeared on the radar, just south of the return for the B767. The controller then realised that there had been a breakdown of separation standards between the balloon(s) and the B767.

The balloon pilots had seen the approaching B767 and said that it had appeared from the west out of cloud. The aircraft was heading towards them but climbed and turned left. One of the balloon pilots estimated that the B767 passed 500 metres to the north and about 600 ft above.

During the time that the B767 was being radar vectored, the balloon transponder return had not been visible on the controller's radar screen, and the controller had temporarily forgotten their presence.

The balloon operator said it was not uncommon for radar contact with balloons to be lost, because the transponder antenna was sometimes masked by the gas installation in the basket. The operator has undertaken to improve the antenna installation to overcome this problem. The balloon operator was operating under a Civil Aviation Safety Authority (CASA) Permit. One of the conditions of the permit required the balloon to be fitted with a transponder capable of mode C operation, to be operated as directed, unless exempted by ATC. At the time of the occurrence, the balloon was operating under an exemption. As a result of the occurrence, Airservices Australia removed the exemption was removed and stated that, in future, no such exemptions for operations of this nature would be made.

A recommendation was made to the Archerfield District Flying Operations Manager that the words "unless exempted by ATC" be removed from the permit.

The left wing of the aircraft struck a powerline from below during a pull up from a clean-up run. The aircraft rolled along its longitudinal axis and struck the ground inverted in an adjacent paddock. The cabin of the aircraft remained intact, consequently the pilot was not injured.

The clean-up spray run was flown at about 90 degrees to the previous spray runs and parallel to a high-tension power line running north-south. Immediately south of the paddock the power line converged at about 20 degrees and joined a power line at approximately 80 degrees to the high-tension line. The pilot said that the converging wire had not been an obstruction for his spray runs as the convergence started outside the field. He said that he saw the converging power line too late to avoid it.