The pilot reports that he intended to conduct a practice flight to rehearse for an upcoming air display. His intention was to activate the aircraft's display smoke system on the runway threshold and complete a tight turn through 360 degrees, prior to commencing the take-off roll. This would be followed by a steep climb out to position the aircraft for commencement of the airborne display routine. A gusting crosswind was blowing across the runway being used for departure.

The pilot indicates that after turning left through approximately 90 degrees, the aircraft accelerated sideways across the grass and the right main wheel began to skip. The pilot was unable to maintain control of the aircraft and the right wheel appeared to dig into the grass runway surface. The aircraft was observed to nose over, before toppling onto its back. The pilot was not injured. The pilot states that the loss of control was most likely a combination of the gusting crosswind conditions and the right main wheel digging into the soft runway surface.

During the take-off run, the aircraft's nose landing gear collided with a pig that had strayed onto the runway. The nose landing gear collapsed, causing both propellers to strike the ground. The aerodrome was surrounded by an electric fence designed to prevent the entry of animals. This had been breached once before, and the fence had been repaired. An inspection by the council aerodrome inspector did not reveal where the pig had gained entry. The inspector now conducts daily inspections of the aerodrome area before the arrival of the regular public transport flight, and the electric fence power unit has been upgraded.

The pilot of VH-KST, a Cessna 210M aircraft, was instructed to extend the first crosswind leg of his circuit for Runway 36 to allow the departure of VH-JSH, a DHC-8 aircraft from Runway 29. As JSH rotated for take-off, KST turned downwind and crossed in front of JSH. The crew of JSH saw KST but did not take evasive action. JSH passed approximately 1,000 m behind KST at the same altitude, about 1,000 ft AMSL. The pilot of JSH confirmed the miss-distance estimation.

The investigation revealed that the pilot of KST did not recall any ATC instructions to maintain first crosswind. The transcript of communications of the automatic voice recording (AVR) tape showed that the pilot acknowledged the crosswind instruction but did not respond to three subsequent transmission directed to his aircraft by the tower controller. The chief pilot of the company which operated KST was on the aircraft supervising the pilot in command. He said that the communications system in the aircraft had an unserviceability which resulted in the pilot operating the VHF radio with a headset and a hand microphone. The supervising pilot was not able to monitor air to air communications due to the unserviceability.

The amphibious aircraft was being flown by an instructor who was training another pilot on the aircraft type. His initial intention was to evaluate surface conditions on Brisbane Waters before conducting training in water operations. The prevailing weather conditions were fine with a reasonably strong north-easterly air flow. The instructor said that the effect of the north-easterly wind was evident from some whitecaps and windlanes in the open water areas. There was a large area in the lee of some high ground which had relatively calm surface conditions. The instructor spent some time discussing the conditions with the student before selecting a suitable circuit pattern and touchdown area.

An into-wind approach was flown by the instructor at a speed of 60 kts. The touchdown was normal at about 45 kts, however, when power was reduced at 35-40 kts, after travelling about 40-50 m, the aircraft suddenly rolled left and pitched nose-down. The nose of the aircraft dug into the water causing the aircraft to overturn before coming to rest. Both occupants were able to escape with minor injuries.

The aircraft was salvaged and transported to Bankstown where it was examined for any evidence of structural failure. The damage found was consistent with water impact. Although there was substantial structural damage, the hull had remained intact. The instructor concluded that the aircraft had been subjected to a sudden wind gust associated with "down wash" from nearby high ground. This had resulted in the left wing-tip striking the water with an associated nose-down pitch.

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While on final approach to runway 36 at Darwin, the pilot observed a crane operating slightly east of the extended runway centreline. The pilot avoided the crane but its location and height concerned him. The pilot reported that he had not received notification about the crane from air traffic control.

When the Civil Aviation Safety Authority (CASA) in Darwin was made aware of the crane's existence by Darwin ATC, the CASA District Aerodrome Inspector checked the information and found that the crane protruded 4.6 m through the Obstacle Limitation Surface (OLS) for the approach to runway 36. The crane operator had informed the aerodrome operator about the crane but the aerodrome safety officer who received the call had miscalculated the location and height of the crane, believing it to be just under the OLS. When the safety officer realised his mistake, he informed air traffic control. The crane has since been removed.

LOCAL SAFETY ACTION

CASA Darwin has advised that the District Aerodrome Inspector is reviewing the processes used by the aerodrome operator, from initial notification to the final output, to reduce the likelihood of a similar occurrence.

The pilot in command reported that during cruise on a flight from Singapore to London, he began to suffer the increasing effects of food poisoning. Four technical crew members are carried on the Singapore London sector, and when he became ill, the pilot in command transferred control of the flight to a co-pilot. After consultation with a crew member who was a qualified nurse, the pilot in command commenced a period of bed rest. About three hours later, his condition improved, and he resumed formal control of the aircraft. The pilot in command believed that the source of his illness was food consumed during the stopover in Singapore and was not the result of a crew sandwich snack, the only food he had eaten in-flight prior to falling ill.

The DC9 freighter crew performed a missed approach to Melbourne runway 27 when they did not get a landing gear safe indication after gear extension. The crew carried out a manual extension of the gear and obtained the safe indication, then proceeded to a safe landing. Because the landing gear doors remain open after manual extension the crew stopped the aircraft on the runway to allow engineers to secure the doors. This was the second of three similar events (refer BASI occurrences 9805884 and 9805886).

After two failed attempts to re-rig the landing gear system it was found that normal extension could only be achieved if the system was rigged outside of maintenance manual tolerances. The mis-rig problem has been referred to the aircraft manufacturer and the aircraft was cleared for flight. The aircraft has subsequently operated satisfactorily

FACTUAL INFORMATION

VH-TJN, a Boeing 737 (B737), was en route from Melbourne to Brisbane and tracking via air route H29 at flight level (FL) 290 and was estimating overhead Mudgee at 1938 ESuT.

VH-CZK, another B737, had departed Sydney at 1914, tracking via Richmond and Nyngan to Darwin on air route T74. The crew had planned to cruise at FL310 and was instructed by Sydney Air Traffic Control (ATC) to maintain FL280 due to airspace requirements in the Sydney area. Air routes H29 and T74 intersected 113 NM north-west of Sydney.

The crew of CZK was transferred from Sydney ATC to the Melbourne Sector 16 controller (SEC16) approximately 45 NM west of Sydney. The controller asked the crew of CZK if they could meet a requirement to climb to FL310 by 100 NM from Sydney. The crew of CZK responded with "... we are showing it 90 miles to run 310". The controller instructed the crew to climb to FL310, as he understood from their reply that the aircraft would reach that level by 90 NM from Sydney. Shortly after, the crew advised the controller that they would reach FL310 about 140 NM from Sydney. The controller then instructed the crew to maintain FL290. The controller advised the crew that they could expect further climb in approximately 25 NM once they were clear of crossing traffic in their 10 o'clock position at 18 NM.

The controller then observed CZK climbing above FL280 as it was passing TJN. The controller asked the crew of CZK to confirm that they were cleared to maintain FL280. The crew advised the controller that they had been cleared to maintain FL290. As CZK had already passed TJN, the crew of CZK was instructed to climb to FL310. Subsequent investigation of the radar recording found that CZK had passed within 2 NM laterally and 500 ft vertically below TJN. The prescribed vertical separation standard was 1,000 ft, and the lateral standard was 5 NM. There had been an infringement of separation standards.

The flight progress strip for CZK had been annotated with "280" to indicate that the crew was initially instructed to maintain FL280. This annotation had two adjacent ticks. The first tick was placed on the flight progress strip after the crew had made the initial call to SEC16, advising that they were climbing to FL280. The controller wrote "310" on the flight progress strip to record the instruction to climb to FL310, and this was ticked following the correct read-back by the crew. After the crew was instructed to maintain FL290 and they had read the instruction back correctly, the controller placed a second tick next to the existing "280" on the flight progress strip. The controller did not annotate the flight progress strip with "290" following the instruction to the crew to maintain FL290.

The controller had been rostered for one familiarisation shift after having spent 5 weeks instructing in the simulator and a further 2 weeks on annual recreation leave. The controller had been operating under supervision for approximately 4 hours of the shift and his supervisor reported that he was performing satisfactorily. He was subsequently certified to operate solo on sector 16. The controller then had a rest period of approximately 1 hour prior to operating the sector 16 position for the last 2 hours of his shift. The separation infringement occurred approximately 20 minutes prior to the completion of his shift.

The crew of TJN which was fitted with a traffic alert and collision avoidance system (TCAS), was conducting training during that flight and was aware of the crossing traffic. However, they thought that CZK was on climb to maintain FL280. As CZK passed behind them, they realised that CZK had climbed above FL280. The crew did not hear SEC16 advise the crew of CZK of the crossing traffic at 18 NM. The crew of TJN advised that they "also had the traffic sighted and on TCAS".

After receiving the query for the FL310 requirement from SEC 16, the crew of CZK had ascertained from the flight management computer that the aircraft would reach FL310 in 90 track NM. The pilot in command stated that he wished to convert this to, and report it as, a distance from Sydney in accordance with the request. The co-pilot advised the controller that they would reach FL310 in 90 NM from their present position. The pilot in command was not satisfied with that response and manipulated the flight management computer to obtain the top-of-climb distance as 140 NM from Sydney. This was then advised to the controller. The crew sighted TJN after the controller had advised them of the crossing traffic. They thought that the crossing traffic was at FL310. As CZK approached the intersection of the air routes, the crew thought that the crossing traffic, TJN, was approximately 1,000 ft above them. The crew of CZK advised that they had sighted the crossing traffic. CZK was not fitted with TCAS.

ANALYSIS

The response from the crew of CZK, "... we are showing it 90 miles to run FL310", led the controller to believe that the aircraft would reach FL310 by 90 NM from Sydney. The controller then issued an instruction to climb to FL310 with the intention of monitoring the separation on radar. When the crew later advised that they would reach FL310 by 140 NM from Sydney, the controller intended to revert back to his original plan and maintain CZK at FL280. The investigation could not ascertain why the controller subsequently issued the instruction to CZK to climb to FL290. The controller thought that he had issued an instruction to climb to FL280. However, he incorrectly instructed the crew to climb to FL290 and did not appreciate the error when the crew correctly read back FL290.

By giving CZK an unconditional clearance to climb to the planned level of FL310, the controller did not apply positive separation assurance. From that point on, the prevention of an infringement of separation standards between CZK and TJN depended on the controller remembering that this potential confliction was still unresolved, and then taking timely and appropriate action to positively separate the aircraft. In the event, when the controller returned to resolve the potential conflict between CZK and TJN, an error was made.

The controller did not advise the crew of CZK of the level of the crossing traffic as he thought that the aircraft were vertically separated. The crew of CZK thought that TJN was 1,000 ft above them. The crew of TJN was discussing training issues and was probably not as vigilant in maintaining their situational awareness as if in a non-training situation. If the controller had mentioned the callsign of the crossing traffic, the crew of TJN may have realised that they were in fact the conflicting aircraft.

SIGNIFICANT FACTORS

1. The response from the crew of CZK to the level requirement was ambiguous and misled the controller into believing the aircraft would reach FL290 by 90 NM from Sydney.

2. The controller cleared the aircraft to the incorrect level and did not recognise the error when the crew read back the level.

The DC9 freighter crew performed a missed approach to Melbourne runway 27 when they did not get a landing gear safe indication after gear extension. The crew carried out a manual extension of the gear and obtained the safe indication, then proceeded to a safe landing. Because the landing gear doors remain open after manual extension the crew stopped the aircraft on the runway to allow engineers to secure the doors. This was the second of three similar events (refer BASI occurrences 9805884 and 9805887).

After two failed attempts to re-rig the landing gear system it was found that normal extension could only be achieved if the system was rigged outside of maintenance manual tolerances. The mis-rig problem has been referred to the aircraft manufacturer and the aircraft was cleared for flight. The aircraft has subsequently operated satisfactorily