Incorrect configuration involving a Beech Aircraft Corp E55, VH-TTL, Thevenard Island (ALA), Western Australia, on 19 November 1997

Summary

The pilot reported that she inadvertently selected the landing gear up, instead of the flap, during the landing roll. Aircraft speed was about 70 kt when the mainwheels began to retract. The landing gear warning horn sounded as the gear retracted. The right wing settled onto the ground and the aircraft slewed to a stop. Both propellers suffered ground strikes. The pilot indicated that she was not distracted by anything in particular during the selection process.

Occurrence summary

Investigation number 199703797
Occurrence date 19/11/1997
Location Thevenard Island (ALA)
State Western Australia
Report release date 19/11/1997
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Incorrect configuration
Occurrence class Accident

Aircraft details

Manufacturer Beech Aircraft Corp
Model E55
Registration VH-TTL
Sector Piston
Operation type Charter
Departure point Onslow WA
Destination Thevenard island WA
Damage Substantial

Ground strike involving a Beech Aircraft Corp 58, VH-AFK, Brewarrina Aerodrome, New South Wales, on 17 November 1997

Summary

The pilot reported that during the turn around at Brewarrina, he had not stopped the engines and the freight was placed in the aircraft through the rear cabin door. The cockpit door was not opened during the turn around. The pilot said he carried out the pre-takeoff checks and backtracked on runway 21 to use the full length of the runway for takeoff. After becoming airborne and establishing a positive climb rate he selected the gear up. Seconds later the pilot heard an explosion-like sound and noticed the cockpit door had opened. The pilot said his initial reaction was to grab the door and attempt to close it, but due to the aircraft being in a critical stage of flight he concentrated on flying the aircraft. Judging that he had sufficient runway ahead of him to land the aircraft he closed the throttles. The pilot said that after losing considerable height he realised the gear was not down, so he immediately applied full power. The pilot flew the aircraft away from the runway surface and carried out a 500 ft circuit. He subsequently carried out a normal landing, and taxied clear of the runway.

An inspection of the aircraft revealed that both propellers had contacted the runway, the step behind the right-wing root had been bent up, and the ADF sensor antenna had also been bent. The pilot said that he was certain that the cockpit door had been positively locked before the previous departure from Bourke, and that the locking handle had not been moved since that time.

Occurrence summary

Investigation number 199703846
Occurrence date 17/11/1997
Location Brewarrina Aerodrome
State New South Wales
Report release date 11/12/1997
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 Beech Aircraft Corp
Model 58
Registration VH-AFK
Sector Piston
Operation type Charter
Departure point Brewarrina NSW
Destination Walgett NSW
Damage Substantial

Fuel starvation involving a Cessna 150M, VH-RZW, 125 km east-north-east of Geraldton Aerodrome, Western Australia, on 17 November 1997

Summary

The aircraft was being used to muster cattle at Tallering Station. The pilot reported that the aircraft's fuel tanks had been filled the night before the accident. On the morning of the accident, the pilot again checked that the fuel tanks were full.

Having been airborne for approximately 4.75 hours, the pilot flew the aircraft towards the station homestead to refuel. The pilot estimated that there was sufficient fuel to remain airborne for at least a further 45 minutes. However, almost immediately, the aircraft's engine began surging and misfiring. The pilot reported that he completed the appropriate checks and when he pumped the throttle, the engine gave some response for approximately 5 to 10 seconds before it finally stopped.

The pilot reported that he attempted to find a suitable forced landing area but the aircraft impacted trees at approximately 40 kts late on final approach. The pilot was uninjured. Later, approximately 22 L of fuel was drained from the aircraft's left fuel tank but none was found in the right tank.

The aircraft's left and right fuel tanks were vented through a vent line connected to the left fuel tank. The vent line is fitted with a vent valve. However, the right fuel tank also had a vented cap. The subsequent engineering inspection found that the vent line valve had deteriorated and was sticking closed. It is likely that the vent valve had stuck closed at some point during the flight. The right tank probably fed quicker than the left tank due to it venting correctly through the vented cap. When the right tank contents had been exhausted, the low air pressure in the left tank probably created an insufficient head of fuel to feed the engine.

A defect report has been submitted to CASA by the operator's engineering organisation, recommending that both fuel tanks be fitted with vented fuel caps.

Occurrence summary

Investigation number 199703792
Occurrence date 17/11/1997
Location 125 km east-north-east of Geraldton Aerodrome
State Western Australia
Report release date 13/02/1998
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Fuel starvation
Occurrence class Accident

Aircraft details

Manufacturer Cessna Aircraft Company
Model 150M
Registration VH-RZW
Sector Piston
Operation type Aerial Work
Departure point Tallering Station WA
Destination Tallering Station WA
Damage Substantial

Loss of separation involving a Boeing 767-338ER, VH-OGO and Boeing 747-200F, 19 km north-north-west of Elbis (IFR), on 11 October 1997

Summary

Report not released due to no IP comment from the Indonesian agency on this joint investigation report. ASOR hard copy held on occurrence file. Report not to be released without the approval of the Director or a DD Signed Alan L Stray Deputy Director Investigations 6 July 1998

Occurrence summary

Investigation number 199703774
Occurrence date 11/10/1997
Location 19 km north-north-west of Elbis (IFR)
State International
Report release date 06/07/1998
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 767-338ER
Registration VH-OGO
Sector Jet
Operation type Air Transport High Capacity
Departure point Brisbane Qld
Destination Bangkok Thailand
Damage Nil

Aircraft details

Manufacturer The Boeing Company
Model 747-200F
Registration Unknown
Sector Other
Operation type Air Transport High Capacity
Departure point Sydney NSW
Destination Bangkok Thailand
Damage Nil

Loss of separation involving a Cessna 441, VH-LBY and British Aerospace PLC BAe 146-100, VH-NJZ, 37 km south of Meekatharra VOR, Western Australia, on 16 November 1997

Summary

A Cessna Conquest, VH-LBY was flying at FL240 from Plutonic to Perth via the Meekatharra and Mount Magnet radio navigation aids. A BAE 146, VH-NJZ was flying at FL250 from Perth to Paraburdoo via the Rusty reporting point and the Meekatharra aid. A second Conquest, VH-NFD was tracking to Mount Magnet, also via Rusty and the Meekatharra aid at FL250. At 0931, the pilot of LBY requested a climb to FL260 but the sector air traffic controller advised that the level was unavailable due to opposite direction traffic, (a second BAe 146, VH-NJN). VH-NJN was behind NJZ at the non-standard level of FL260. The Sector controller then cleared NJN to climb to the standard FL270. At 0935, the controller cleared LBY to climb to FL260 with a requirement for the aircraft to achieve the level by 0940. Approximately 1 minute later, the controller apparently recognised that a breakdown in separation may be possible between LBY and NJZ. He requested a level check from the pilot of LBY that indicated that the aircraft were vertically separated by 300 ft. He did not issue traffic information to either aircraft. Soon after, the pilot of NJZ requested the position of LBY and the aircraft were 17 NM apart and closing. The controller then instructed LBY to expedite the climb. Three seconds later, the pilot of LBY reported maintaining FL260.

The pilot of NJZ subsequently reported that he had calculated a time of passing with LBY of 0940 and when he heard LBY was cleared to climb, he began an immediate visual scan of the area ahead and turned the aircraft's landing lights on. The pilot of NJZ reported that approximately 1 minute after the pilot of LBY reported maintaining FL260, he sighted LBY. The pilot of LBY reported that approximately 2 minutes after establishing FL260, he sighted NJZ passing below. A breakdown of separation had occurred because the required 10 minutes separation, based on the time the aircraft expected to pass each other, had not been achieved. The aircraft had not been issued with the required traffic information when the controller became aware that the aircraft were in unsafe proximity to each other.

Whilst the controller had 3 sectors combined at the time of the incident, the workload was reported as being light to moderate and not considered excessive. Personnel were available to provide assistance if requested and evidence indicated that the controller was not under pressure at the time of the incident. The controller had not calculated a time of passing between LBY and NJZ because the aircraft were to be separated by 1,000 ft and were not in conflict. The controller's requirement for LBY to reach FL260 by 0940 was 10 minutes before the calculated time of LBY passing NFD, therefore, it is likely that the calculated separation requirement was based on LBY's passing of NFD, not NJZ.

The controller appears to have been preoccupied with ensuring separation between LBY and NFD. Therefore, he overlooked separation requirements with NJZ. This oversight subsequently led to a breakdown in separation between NJZ and LBY.

Occurrence summary

Investigation number 199703781
Occurrence date 16/11/1997
Location 37 km south of Meekatharra VOR
State Western Australia
Report release date 13/02/1998
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 British Aerospace
Model BAe 146-100
Registration VH-NJZ
Sector Jet
Operation type Air Transport High Capacity
Departure point Perth WA
Destination Paraburdoo WA
Damage Nil

Aircraft details

Manufacturer Cessna Aircraft Company
Model 441
Registration VH-LBY
Sector Turboprop
Operation type Charter
Departure point Plutonic WA
Destination Perth WA
Damage Nil

Collision on ground involving a Beech Aircraft Corp A36, VH-EUM, Moorabbin Aerodrome, Victoria, on 7 November 1997

Summary

The instructor was conducting a dual check on a licensed pilot in a Bonanza which did not have dual brakes. The pilot under check started the engine and was about to taxy when he inadvertently applied a large amount of power which made the aircraft lurch forward. The instructor immediately told him to apply brakes, but the pilot was startled and expected the instructor to apply brakes. The instructor then tried to shut down the engine by closing the throttle and selecting mixture to idle cut off, but he was momentarily hampered by the student's hand still on the throttle. The instructor simultaneously tried to steer the Bonanza to the left between parked aircraft but was unsuccessful. The Bonanza struck the front of a Cessna 172 parked almost opposite about 15 m away. The Bonanza's propeller was almost stopped when it slashed the leading edge of the Cessna's right wing. The Bonanza's right wing also struck the Cessna's lower left engine cowl below its propeller.

The pilot being checked on the Bonanza advised that he had never been in a Bonanza before and that the instructor's pre-flight briefing was mostly concerned with the performance of the Bonanza. He found that the Bonanza layout was very different to the Cessna 172 and the Piper PA28s which he had been flying recently. At the time of the accident the student was unaware that the instructor did not have brakes, and he was not expecting the large power response from the throttle setting selected.

Occurrence summary

Investigation number 199703748
Occurrence date 07/11/1997
Location Moorabbin Aerodrome
State Victoria
Report release date 26/11/1997
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Accident

Aircraft details

Manufacturer Beech Aircraft Corp
Model A36
Registration VH-EUM
Sector Piston
Operation type Flying Training
Departure point Moorabbin Vic.
Damage Substantial

Involving an Airbus A320-211, VH-HYF, Adelaide Aerodrome, South Australia, on 8 November 1997

Summary

An A320 had been cleared to line up for departure on runway 23 at Adelaide. Traffic in the vicinity at that time was a VFR aircraft transiting the control zone on the coastal route to Parafield. The aerodrome controller (ADC) had decided to orbit this aircraft clear of runway 23 to facilitate the departure of the A320. Additional traffic was a Metroliner which was being sequenced to land on runway 30 at Adelaide. The ADC instructed the VFR traffic to make a right orbit, but the pilot seemed to experience difficulty in understanding the instruction and performed a left orbit. After ensuring that the take-off direction was clear the ADC cleared the A320 for take-off. At this time the Metroliner was turning onto final approach for runway 30.

The investigation revealed that after being cleared for take-off, the ADC's perception was that the A320 had not moved in the expected time frame when the Metroliner reported on short finals. The ADC then cancelled the take-off clearance. The ADC's attention was divided between the orbiting aircraft, the A320 and the Metroliner. Following the landing of the Metroliner, the A320 was cleared to depart.

The ADC's primary focus had been to ensure that the take-off path of the A320 was clear. His attention had been diverted by two issues, the VFR aircraft which had not followed his instruction to make a right orbit and the A320's seemingly slow reaction to the take-off clearance. Furthermore, the ADC may have misjudged the speed and distance of the Metroliner from the runway 30 threshold. However, the investigation indicated that the ADC acted quickly and in the correct sequence, cancelling the A320 take-off clearance then clearing the Metroliner to land.

Occurrence summary

Investigation number 199703723
Occurrence date 08/11/1997
Location Adelaide Aerodrome
State South Australia
Report release date 08/01/1998
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Incident

Aircraft details

Manufacturer Airbus
Model A320-211
Registration VH-HYF
Sector Jet
Operation type Air Transport High Capacity
Departure point Adelaide SA
Destination Melbourne Vic.
Damage Nil

Forced/precautionary landing involving a Piper PA-31, VH-WAL, 6 km north-north-east of Maitland (ALA), New South Wales, on 12 November 1997

Summary

The pilot was conducting a scheduled freight run and earlier that day had refuelled the aircraft and departed Bankstown with full main tanks (401 litres) and 160 litres in the auxiliary tanks. The accident flight was on the Scone to Maitland sector, and the pilot reported that when departing Scone, the aircraft had about 108 kilograms of freight and 430 litres of fuel.

The pilot reported that while on descent and at about five miles from Maitland, the right engine RPM began to fluctuate with an accompanied increase in vibration. The pilot, thinking that it was a malfunction of the propeller governor, reported that he shut down the right engine and selected the right propeller to feather.

The pilot observed that the right propeller was still windmilling, the indicated airspeed was decreasing and that the aircraft was unable to maintain height, so he elected to land in a nearby field. He closed the left throttle and selected the landing gear down. The landing gear collapsed on touchdown as there had been insufficient time for it to extend and lock. The aircraft slid for about 120 metres.

Investigation of the fuel system indicated that the auxiliary tanks were empty while the main tanks each contained about 140 litres. The cockpit fuel selectors indicated that the main fuel tanks were selected.

Investigation of the engines and their systems, including the propellers and governors, could not determine the reason for the reported propeller malfunction or the inability of the aircraft to maintain height.

Occurrence summary

Investigation number 199703704
Occurrence date 12/11/1997
Location 6 km north-north-east of Maitland (ALA)
State New South Wales
Report release date 06/07/1998
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-31
Registration VH-WAL
Sector Piston
Operation type Charter
Departure point Scone NSW
Destination Maitland ALA NSW
Damage Substantial

Operational non-compliance involving a Fairchild SA227-DC, VH-KDT, Adelaide Aerodrome, South Australia, on 5 November 1997

Summary

The pilot in command of a Metro 23 had requested an intersection departure on runway 23 at Adelaide airport. At the time of the incident, weather conditions were VFR and radio traffic on the tower frequency was increasing. The pilot in command of the Metro 23 had been instructed to line up and be ready for an immediate departure (visual) with a maintain runway heading restriction. However, the pilot recalled that there had been considerable radio traffic on frequency and the ADC had spoken to at least one other aircraft between the times when he had passed the departure instructions and the take-off clearance.

The co-pilot had received the departure instructions because the pilot in command had had his attention diverted to another pre-take-off task when the clearance was issued. The pilot stated that he was concerned that a B737 was awaiting departure instructions at the threshold of the same runway and he wanted to minimise any inconvenience to that aircraft. He stated that perhaps as a result of the traffic on the tower frequency and that the departure instructions and take-off clearance had been passed in two distinct transmissions, he had overlooked the requirement to confirm the maintain runway heading instruction with the ADC. The pilot in command stated that at the time of take-off he was sure that the only instruction which had been passed was "118.2 airborne, clear for take-off".

When airborne and at a safe height he had queried the co-pilot whether or not they should make a left turn as they had made a visual departure. The pilot then elected to make the left turn, and they sighted another aircraft which was tracking to intercept final for rwy 30. It then became apparent to the crew of the Metro 23 that a mistake had been made. The error was later confirmed when they transferred to the approach frequency and the controller asked whether or not the ADC had stipulated maintain runway heading in the departure instructions.

Although it remains the responsibility of the pilot in command to abide by ATC instructions, this incident has highlighted the dangers associated with ATS personnel "splitting" an instruction. If ATS had repeated the requirement to maintain runway heading as part of the take-off clearance, the crew would have been reminded of the instruction at the point of departure.

Occurrence summary

Investigation number 199703721
Occurrence date 05/11/1997
Location Adelaide Aerodrome
State South Australia
Report release date 15/04/1998
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Operational non-compliance
Occurrence class Incident

Aircraft details

Manufacturer Fairchild Industries Inc
Model SA227-DC
Registration VH-KDT
Sector Turboprop
Operation type Air Transport Low Capacity
Departure point Adelaide SA
Destination Mt Gambier SA
Damage Nil

Loss of control involving an Amateur Built IIIM, VH-MXA, Camden Aerodrome, New South Wales, on 10 November 1997

Summary

A Cassuit Racer had completed a short flight in the Camden area. The pilot reported losing directional control on touch down, following a normal approach and flare. The aircraft nosed over during the accident sequence, causing damage to the lower engine cowl and propeller.

The pilot had recently purchased the aircraft, and this was his first flight on type. As it is a single seat aircraft, he was completing a self-endorsement under the supervision of another pilot.

Occurrence summary

Investigation number 199703693
Occurrence date 10/11/1997
Location Camden Aerodrome
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 Loss of control
Occurrence class Incident

Aircraft details

Manufacturer Amateur Built Aircraft
Model IIIM
Registration VH-MXA
Serial number N77
Sector Piston
Operation type Private
Departure point Camden NSW
Destination Camden NSW
Damage Minor