During the initial climb after take-off, the pilot of the Cessna 402 observed that the nose landing gear had failed to retract. While orbiting clear of the airfield, the pilot commenced troubleshooting and found that the hydraulic system circuit breaker had tripped. After resetting the circuit breaker, several further retraction attempts failed to resolve the problem. The pilot then attempted to lower the landing gear using the emergency function. These attempts were also unsuccessful. After briefing the passengers on emergency procedures and with RFFS in position, the pilot commenced the landing with an unlocked nose gear. During the approach, the pilot shut down both engines and turned off the fuel. He then realised that the aircraft would land short of the runway.

The aircraft came to rest 10 metres outside of the airport boundary fence. The pilot and passengers were uninjured. Engineering inspection of the aircraft revealed a wire in the electrical loom to the left main landing gear which had shorted to structure. When a selection was made with the landing gear selector lever, power applied to move the electro-hydraulic shuttle valve from the idle position to either up port or down port would pop the circuit breaker. This prevented the nose gear from completing the cycle to the fully down position and also prevented the return of all the gears to the up and locked position. The emergency blow down bottle was removed and examined. It was found to require a force well in excess of the maintenance manual requirement to operate the mechanism. These two defects prevented the landing gear from being locked down.

The pilot of VH-MGZ was instructed to taxi for runway 30 and to hold short of runway 35. The aircraft was later observed approaching the holding point and taxiing at a considerable speed. The pilot was instructed to stop immediately. The aircraft came to a halt just within the flight strip of runway 35. VH-CSN was sent around from short final approach. The pilot reported that he had been distracted by his preparation for a navigation exercise and by the two passengers on board his aircraft.

During the pre-flight inspection, the pilot of the Cessna 402 noticed an unusual amount of free play in the elevator trim tab system. A maintenance inspection did not detect any abnormality. During the subsequent flight, while in the cruise, the aircraft suddenly pitched nose down without any input from the pilot. He disconnected the autopilot but this did not remedy the pitch problem. Re-trimming the aircraft also made no difference to the pitch down tendency. After an uneventful landing at the destination, an inspection by a licenced aircraft maintenance engineer revealed that the bolt attaching the trim tab actuator rod to the trim jack could not be located.

The pilot reported that he had started the right engine and was about to select the generator ON when he inadvertently touched the left engine start switch momentarily. The pilot was aware that the left door was open, and loaders were completing last-minute loading. Shortly afterwards, the pilot was advised by the senior base pilot who was in attendance that the left propeller had rotated briefly and struck a loader who was walking towards the front of the aircraft. The loader was uninjured, and the flight proceeded as planned.

As the result of an inquiry by the freight company, the following recommendations were made and have been accepted by the aircraft operator:

1. Development of a documented training program on tarmac operations and procedures.

2. Implementation of a recurrent training program for tarmac personnel.

3. Loading personnel to be certified or "signed up" for single-engine turn-around and loading procedures with engines running.

The operator has included training on "error types" and prevention strategies as part of the company's in-house human factors management on initial and recurrent training courses. During the regular monthly safety meetings pilots have been alerted to the need for propeller and personnel awareness.

While conducting a regular public transport operation between Williamtown and Sydney, the pilot of a British Aerospace J31 secured the right engine of the aircraft after it auto shut down. He informed the air traffic controller who then issued a clearance to proceed direct to Sydney. The investigation revealed that a support bearing in a gear shaft had failed within the engine gearbox, disconnecting the gear shaft. This deprived the oil pump, fuel control unit, and fuel pump of drive, thereby shutting down the engine. The bearing failure is the subject of a major defect report to the Civil Aviation Safety Authority.

The pilot advised that during the engine run prior to take-off the windscreen fogged up both internally and externally. She shut down the engine and wiped both surfaces free of moisture. There was light fog present in the area. During the subsequent take-off run the windscreen again fogged over and she lost visual reference. The pilot closed the throttle and rejected the take-off. However, the aircraft diverged off the runway and impacted trees before coming to rest substantially damaged. The four occupants were able to evacuate unaided and were not injured.

About 45 minutes after departure, the crew of the Airbus A320 noticed a burning smell in the cockpit and cabin. This was followed by the activation of the `AIR ENG2 BLEED FAULT', `NUMBER 2 PACK FAULT', `LAVATORY SMOKE' and `AVIONICS SMOKE' warnings. At the same time, the Number 1 air conditioning pack began to cycle uncontrollably to an overtemperature of 250 degrees Celsius. The crew commenced an immediate descent to flight level 210 and notified air traffic control. The crew observed that, after selecting the `BLOWER' and `EXTRACT' fans, the avionics smoke warning cleared.

The `AIR BLEED 2' fault procedures were then carried out, but the crew was unable to stabilise the No. 1 air conditioning pack. After selecting the `CROSSBLEED' valve to `OFF', the No. 1 air conditioning pack stabilised and the outlet temperature reduced to acceptable values. The flight then proceeded using the No. 1 air conditioning pack. The investigation revealed severe cracking in the air bleed duct assembly aft of the pre-cooler at the Temperature Limitation Thermostat (TLT) sensor-mounting boss for the No. 2 engine. The TLT duct and sensor were replaced. The failure was the subject of a major defect report (MDR) submission to the Civil Aviation Safety Authority.

The foreign registered Boeing 747 was arriving at Melbourne in weather conditions of low cloud that required an instrument landing system (ILS) approach. Air traffic control had issued radar vectors to the crew that required a pilot interpreted intercept of the runway 16 localiser.

As the aircraft approached the localiser, the crew received "off " flag indications on both ILS receivers. Air traffic control reported to the crew that the aircraft had flown through the localiser and issued further instructions for them to re-intercept the localiser from the right.

The crew was then instructed to transfer to the aerodrome controller but did not acknowledge the transfer. They left the approach control frequency but did not initially transmit on the tower frequency due to the workload in the cockpit. The aircraft was again observed to pass through the localiser and the approach controller decided to issue go-around instructions. However, there was no response from the crew to his transmissions. He informed the aerodrome controller that the crew were not on his frequency and asked that the instruction be repeated on the tower frequency. The aerodrome controller replied that the crew had not reported on his frequency, but he did not initially broadcast any instructions. A few seconds later, after further coordination with the approach controller, the aerodrome controller issued the go-around instructions but the crew had already commenced a missed approach.

The crew had received a traffic alert and collision avoidance system (TCAS) ground proximity warning of 1,000 ft above ground level and, as they were not established on the localiser and not visual with the runway, they commenced the missed approach. They broadcast on the tower frequency that they were in the go-around and radar vectors were given for a second ILS approach to runway 16.

While being radar vectored, the crew re-tuned the ILS receivers and had no repetition of the intermittent signals during the second approach.

After commencing the missed approach, the crew used the term "radio problems" to describe the intermittent localiser signal. This was interpreted by air traffic control to mean radio communication problems; an interpretation supported by the lack of two-way radio communications at the time that the approach controller wanted to commence go-around procedures. Although not directly contributing to the occurrence, this difference in interpretation between Australian and American terminology did cause confusion as to the reasons for the track diversions.

An Airtrainer departed Moruya for Tamworth, climbing to 6,000 ft, and estimating Bindook at 1842. The flight was being conducted in accordance with the instrument flight rules (IFR). An IFR Aerostar departed Young for Bankstown on climb to 7,000 ft. The Aerostar pilot planned to track to the north of Bindook and had been provided with traffic information on two aircraft, but not the Airtrainer. The Flight Service (FS) officer for that sector (FS17) estimated that the Aerostar would pass abeam Bindook at 1845. The FS officer contacted the crew of the Airtrainer to advise of a Duchess tracking from Katoomba to Camden via Bindook at 6,000 ft. The crew of the Airtrainer requested traffic information for climb to 7,000 ft in order to remain clear of that aircraft. Although the proposed climb would place the Airtrainer at the same level as the Aerostar, the FS officer advised no additional IFR traffic. Because it was very busy at the time, the FS officer did not fully analyse the traffic situation. Consequently, mutual traffic information was not passed to the crews of the Airtrainer and the Aerostar, and the potential conflict was not annotated on their flight progress strips. The crew of the Airtrainer subsequently reported having passed Bindook at 1843, leaving 6,000 ft for 7,000 ft. The pilot of the Aerostar reported passing abeam Bindook at 1845 maintaining 7,000 ft. Although the FS officer responded with additional traffic information, no advice was provided about the Airtrainer.

At about that time, the crew of the Airtrainer received an alert from their traffic collision and avoidance device (TCAD). The TCAD indicated an impending conflict with another aircraft at 7,000 ft, about 10 NM north of Bindook. At that time the aircraft was in instrument meteorological conditions. The pilot in command (PIC) of the Airtrainer initiated a rapid descent to 5,500 ft and turned away from the unknown traffic. Not aware that FS did not have access to radar information, the PIC of the Airtrainer asked the FS officer whether there were any radar paints in the area. The FS officer instructed the PIC of the Airtrainer to stand by while traffic information was passed to other aircraft, and while various other aircraft transmitted on the frequency to establish separation between each other. Subsequent radar analysis determined that at the time of the TCAD alert, the aircraft were within 3 NM of each other and closing, with only 100 ft vertical displacement. At 1 NM range, vertical displacement increased to 400 ft and, when the aircraft passed each other, vertical separation had increased to approximately 900 ft. When clear of the Aerostar the pilot of the Airtrainer re-commenced a climb to 7,000 ft and advised FS of the conflict. The FS officer confirmed that there was no additional IFR traffic for the climb other than the Duchess and another aircraft. Shortly after that information was passed to the crew, the Airtrainer climbed in cloud through the level of the Duchess. Radar analysis indicated that when the Duchess and the Airtrainer passed each other in cloud there was a lateral displacement of approximately 1.5 NM and 900 ft vertical separation. Neither crew reported being aware of the close proximity of the other aircraft. To assist FS officers with the maintenance of a mental model of aircraft traffic, a flight progress board utilising a geographic display layout was used. Local instructions required FS officers to place active flight progress strips above the geographic designator until all initial actions, including checking for traffic information, were completed. When all actions were completed, the strips were to be placed below the designator in the appropriate bay. Flight progress strips were to traverse the geographic display as the flight progressed across the displayed tracks or fixes of the FS officer's area of responsibility. Initially, the flight progress strip for the Airtrainer was in the Goulburn/Shelleys bay to the south of Bindook, and was later moved to the Bindook bay. The strip for the Duchess was in the Wyatt/Katoomba/Watle bay, directly to the north of the Bindook bay. Because the Aerostar was tracking from Young direct to Bankstown, and would pass to the north of Bindook, the strip for that aircraft was placed in the Riley Bay, to the north-west of the Bindook bay. The FS officer was managing 12 aircraft on frequency within the area of responsibility, and had processed 16 aircraft in the 10-minute period prior to the first occurrence. There were numerous aircraft en route to Bankstown, operating IFR due to weather. Moreover, there were additional aircraft crossing that traffic from both the north and south, making traffic management complex for the FS officer. It was normal practice in such high workload situations for the team leader, or another FS officer, to assist in identifying potential conflicts by acting as a 'traffic spotter'. Although the workload was high due to a busy and complex traffic situation, the officer did not ask for assistance because other officers were taking a break, after a pilot had earlier been on frequency attempting to commit suicide in an aircraft. That experience had unsettled many of the staff.

The team leader did not assign another officer, nor did he offer himself, to assist as a 'traffic spotter'. The FS officer was experienced in air-ground operations and held appropriate endorsements for the position. However, because of ongoing staff shortages in air-ground operations, the officer was on a rotating roster of one week on air-ground duties and three weeks in the briefing office during each 28-day period. On the day of the occurrence, it was the FS officer's second day in an air-ground position after a 3-week rotation through the briefing office, and it was also the officer's sixth consecutive day of duty. The FS officer had completed the FS17 proficiency assessment during the Class G airspace trial. At the time of that assessment, the area of responsibility encompassed a small portion of airspace near Young. Following termination of the trial, changes in procedures resulted in a tenfold increase in the area of FS17. Despite that change, the officer received only one shift under supervision before resuming duties in the pre-demonstration airspace. The FS officer had not previously worked the larger area of airspace since April 1997, except for one month whilst under training. Local supervisory staff had been made aware of the FS officer's concerns regarding proficiency but it was reported that those concerns were not addressed. A management decision was made that all endorsements held during the Class G airspace trial would remain valid in the new but significantly changed environment. Management reported having 29 staff available to meet a requirement for 35 positions. The shortfall was reported to be having an effect on the provision of training and recreational leave, necessitating overtime. The investigation determined that, although the FS officer may have intended to review and provide a more accurate traffic assessment for the Airtrainer and Aerostar, the officer was overwhelmed by heavy workload at the time, resulting in routine actions not being completed.

It is considered that the errors made by the FS officer were symptomatic of wider organisational factors. These factors included inadequate training; inadequate geographic display; increased area of responsibility; staff shortages; management decisions relating to airspace procedures; and a lack of adequate supervision. When the crew of the Airtrainer first proposed a climb from 6,000 ft to 7,000 ft, the FS officer did not fully analyse the traffic situation and made an incorrect traffic assessment. The Aerostar flight progress strip being in an inappropriate section of the geographic display exacerbated the potential for error. The placement of the flight progress strip into the Riley Bay for the Aerostar, and the Goulburn/Shelleys bay for the Airtrainer, together with their different cruising altitudes, did not highlight a potential traffic confliction, nor provide an effective traffic situation display to the FS officer.

SIGNIFICANT FACTORS

1. The geographic display system did not provide an effective traffic situation display to the flight service officer.

2. The flight service officer did not pass mutual traffic information to the crews of the Airtrainer and Aerostar.

3. The flight service officer had not received adequate training for the FIS 17 area of responsibility following termination of the Class G airspace trial.

4. The traffic situation at the time of the occurrence was of increased complexity and density due to instrument meteorological conditions.

5. The flight service officer was not provided with supervision or sufficient assistance during a busy and complex period of operation.

6. The rostering practices applicable to the flight service officer were not conducive to maintaining an adequate level of proficiency.

7. The flight service officer was exposed to a period of heightened anxiety immediately prior to the occurrence.

8. The situational awareness of the crew of the Airtrainer to their proximity to the Duchess may have been adversely affected by their preceding confliction with the Aerostar.

SAFETY ACTION

Local safety action

The Airservices Australia Occurrence Investigation report recommended that:

1. CATSOAM be amended to reflect the requirement for flight service officers to maintain the same recency requirements as air traffic controllers (7 hours in the preceding 14 days);

2. A review of the functionality of the FS17 flight progress board be conducted by Melbourne flight service to evaluate its functionality during periods of adverse weather conditions and high traffic loading;

3. At least two Melbourne flight service centre staff be sufficiently trained to provide an acceptable level of peer support in line with the ATC controller friend provisions; and

4. Air traffic services establish an operational performance check requirement for any staff who have not held a valid rating on airspace post a procedures change.