The aircraft was maintaining 10,000 ft enroute from Canberra, ACT to Albury, NSW. The weather was a south-westerly airstream, resulting in cloud and rain along the flight path. Consequently, the aircraft was being flown in accordance with the Instrument Flight Rules (IFR). At a position approximately 113km north east of Albury, the pilot reported that she had experienced problems with the right engine and had shut the engine down.

A PAN was declared. Due to a steady 50 kt headwind to Albury, and maintaining flight on only one engine, the pilot chose to divert the aircraft for a landing at Wagga. After holding south of Wagga, due to low cloud and inclement weather over the aerodrome, the pilot carried out an uneventful single engine landing.

The maintenance assessment carried out by the aircraft owner, determined that the right engine problem had occurred due to a failure of the impeller shaft bearing in the right turbocharger unit. This had resulted in a failure of the compressor impeller. The aircraft owner then sent the turbocharger to the manufacturer for examination. This examination found that the impeller and bearing damage had occurred as a result of the ingestion of soft foreign material from an unknown source. Such soft material was stated to include, shop towels, water, paper, filter media or some plastics. The owner reported that no soft material was found following the engine failure. Due to the conflicting examination reports, the reason for the turbocharger failure could not be determined.

During the investigation the passengers reported that some icing had been present on the aircraft wings. The investigation determined that some light icing had been present during the flight, however, the extent noted was insufficient to have had any significant effect on the aircraft's performance.

The pilot reported that the alternator failed while the aircraft was between Birdsville and Broken Hill. The pilot reduced the aircraft's electrical load to preserve battery power. On arrival at Broken Hill the battery was flat, and the pilot was unable to lower the landing gear either by normal or emergency methods. After emergency services were in position the aircraft was landed with the landing gear retracted.

When the aircraft was raised by engineers the landing gear was able to be extended normally. The investigation disclosed that the alternator body securing bolts had loosened thereby allowing the rotor to contact the windings, shorting out the electrical supply. The battery had depleted prior to arrival at Broken Hill; therefore, the electrically powered hydraulic pump that normally retracts and extends the landing gear was rendered inoperative. No fault was found with the landing gear system.

Upon reflection the pilot advised that he most probably did not hold the emergency gear extend lever down long enough to bleed off the hydraulic pressure and allow the landing gear to extend. The pilots operating handbook advises that under normal conditions the lever should be held down for approximately 10 seconds. However, industry experience is that it can take up to 20 seconds. The pilot advised that during his endorsement training on this aircraft he was taken through the emergency extend procedures but did not activate the system. He therefore did not have an appreciation of either the effort or the length of time the handle was required to be held down.

During climb, the crew noticed an odour in the cabin which was suspected to have resulted from bleed air system cleaning during earlier maintenance. Further checks carried out by the crew identified a strong smell of petrol, increasing in intensity towards the rear of the cabin. As the aircraft was carrying dangerous goods, detailed as a petrol engine in the forward hold, an immediate return to Los Angeles was initiated. During the return the smoke/fumes removal drill was carried out and fuel was jettisoned. The cabin crew were instructed to switch off any non-essential electrical equipment and the aircraft was descended to 20,000 ft. Oxygen masks were not deployed and the return to Los Angeles was completed without further incident.

A subsequent ground inspection of the forward hold revealed that a motorcycle had fallen onto its side and petrol had leaked from its fuel tank. The petrol spill had been contained within the hold. The motorcycle was offloaded, the petrol spill was cleaned up and the service continued. The operator carried out an investigation into the incident and determined that the motorcycle fuel tank had been drained to the reserve level for shipment. This complied with the dangerous goods regulations for transportation of the motorcycle in an upright position. However, the motorcycle had been inadequately restrained on its transport stand. Only two securing straps had been used instead of five, and no timber had been used between the motorcycle and the pallet floor. This had resulted in the motorcycle falling over, probably during take-off, and the remaining fuel leaking out.

Safety action

The operator, in conjunction with the overseas freight handling agent, instigated an immediate retraining program for all staff involved in export handling procedures. In addition, new instructions have been issued for the handling of dangerous goods.

The pilot advised the Bureau that while flying his Quickie Q2 aircraft in the circuit at Shepparton Vic. he felt that the aircraft was not responding as usual to control inputs. The pilot said that during the roll out after a smooth landing the right canard failed. The propeller was damaged when it contacted the runway after the canard failed.

Arrangements were made for examination of the failed components by the Civil Aviation Safety Authority's structures specialists. It was determined that the upper surface of the canard had failed under a single application of a compression load parallel with the plane of the skin. The inner structure of the section showed damage that was consistent with the upper surface being under compression. Examination of the composite materials indicated that there was no apparent degradation of the matrix. Given these features it was considered that the wing had failed as a result of a large sudden upward force on the wing.

There were many witnesses to the events on the day. It was determined that when the pilot arrived at the airfield and declared his intention to fly the Q2, a highly experienced local pilot advised the Q2 pilot to take some instructional flying in a Pitts Special aircraft that was available. The Q2 pilot declined the offer even though he had only very limited recent flying experience, non of which was in an aircraft comparable to the Q2. Witnesses advised that during the take-off the aircraft had been lifted off too early at a very low airspeed. Immediately after lift off the pilot encountered control difficulties, however these were overcome and the aircraft was flown out of the circuit towards the training area.

Ten minutes later the aircraft was observed overhead the airfield and was manoeuvred to join crosswind for runway 18. The aircraft was observed to be flying very slowly on the final approach and after touch-down commenced porpoising. The aircraft veered to the left, continued to porpoise, and then veered right, back across the runway. The pilot applied considerable power and lifted the aircraft off the runway at very low speed with a high nose attitude. At approximately 3 metres above the runway the aircraft stalled, dropped to the right and impacted on the right canard which fractured. The aircraft slewed and came to rest. The pilot evacuated without assistance.

The investigation determined that this was most probably the pilot's first flight in the aircraft. He had purchased it 28 months before the accident, and, while he informed the Bureau that he had flown the aircraft for 5 hours, changes and deletions in his pilot's log book precluded verification. The investigation was told that the pilot had been observed taxiing the aircraft but this was the first time the pilot had been observed to fly the aircraft. Witnesses stated that on one occasion while taxiing fast the pilot lost control and the aircraft was damaged.

This accident was not reported and the repairs were not reflected in the aircraft's logbooks. It is probable that the accident occurred because the pilot had no experience on the type, had very limited recent flying experience, and lost control of the aircraft on landing.

A military Hercules aircraft, operating under visual flight rules, was conducting an airdrop exercise at low level onto Tumbarumba airfield. Due to a delay in the airdrop, the aircraft was holding in a right orbit east of the airfield at an altitude of 1,000ft above ground level. A Piper Chieftain aircraft, on an instrument flight rules charter flight, was on descent to Tumbarumba.

The pilot of the Chieftain made transmissions on the area frequency at the top of descent and on arrival in the circuit area but heard no replies from other aircraft. While flying on downwind for a left circuit to runway 19, the Chieftain pilot, and his passengers, observed the Hercules aircraft on their right side on a parallel track and at about the same altitude. When the Chieftain pilot specifically addressed a radio transmission to the Hercules aircraft in the Tumbarumba area, the Hercules crew replied that they had visual contact with the Chieftain and would remain clear.

The Chieftain completed its landing on runway 19 and the Hercules departed the Tumbarumba area at low level. The operator of the Hercules reported that the crew had received the broadcasts from the Chieftain pilot but had replied on the wrong frequency due to the incorrect positioning of the copilot's radio transmit selector. After receiving the call directed at their aircraft type, the crew discovered their error and transmitted on the correct frequency.

The minimum distance between the two aircraft could not be established. The minimum separation reported by the Chieftain pilot varied from that reported by the crew of the other aircraft. Radar data was unable to reconcile the discrepancy as the Tumbarumba circuit area is shielded from all nearby radar heads by undulating terrain. However, neither pilot believed that a collision risk existed. Although the Hercules crew transmitted on the wrong frequency, they were monitoring the correct frequency and were aware of the Chieftain. They maintained visual separation with the other aircraft throughout the occurrence.

The pilot of the Piper Pawnee glider tug reported that soon after take-off, at about 200ft AGL the engine lost power. The pilot of the glider being towed realised there was a problem and released the tow line. The glider was able to return to the airfield for a normal landing. The Pawnee collided with the tops of trees as the pilot attempted to force land into a paddock. The aircraft subsequently landed heavily and suffered substantial damage. The aircraft was fitted with one 84 litre fuel tank in each wing.

The investigation found that the left tank was empty while the right tank was approximately three quarters full. The fuel selector was found selected to the empty left tank. The pilot advised that he had refuelled the aircraft the previous night with 55 litres of fuel. He was unable to recall whether he had put any of that fuel in the left tank. He said that he did not physically check the fuel quantities after the refuelling or during the daily inspection on the morning of the accident. He advised that he conducted the first flight of the day with the fuel selector to the right tank. He noticed during that flight that the aircraft appeared to fly right wing heavy.

For the next flight, the accident flight, the pilot changed the fuel selector to the left tank. He was unable to explain why he had selected the left tank when he knew that the right wing was heavy. He did not check the fuel quantity gauges when he changed the selection. It was reported that a fuel stain had been noted under the aircraft while it was in the hangar prior to the day's operation.

No investigation was carried out to determine if the stain was as a result of a fuel leak. The gliding club has required the pilot to undertake a flight review with an emphasis on fuel management and pre-flight inspection procedures. The club is also to require all tug pilots to undertake a session on tug operating procedures as a part of their biennial flight review.

The Cessna 206 floatplane was on a charter flight taking passengers from Kimberley Coastal Camp to Lake Kununurra. During descent 25 NM from Lake Kununurra, the aircraft's engine lost power. The pilot reported that he immediately switched the fuel selection from the left to the right fuel tank. He also selected full throttle, full rich fuel mixture, boost pump to low prime and full fine on the propeller pitch control. The engine did not respond so he elected to conduct an emergency landing on the Ord River. The pilot reported that the descent took about five minutes, during which he selected high prime on the boost pump for several seconds.

The engine did not recover power throughout the descent. The landing was conducted without further incident. The aircraft was undamaged, and the passengers were uninjured. The pilot reported that he filled the tanks before leaving Lake Kununurra for the Camp. Because of the amount of fuel he thought was in the left tank, the pilot had intended to select the right tank at 15 NM from Lake Kununurra. However, the engine lost power before he could do so. After the landing, the aircraft's left fuel tank was found to have about 8 L of fuel remaining, approximately 20 L less than the pilot had planned. The right tank had about 60 L. The operator reported that the only fuel system fault was three clips that secured the left fuel tank bladder to the wing were found undone. No fault could be found with the engine.

Prior to landing, the pilot confirmed that the landing gear was down (three greens) on the downwind leg and again on final for landing. Approximately 2 to 3 seconds into the landing roll, the right landing gear collapsed allowing the right propeller, landing light and flaps to contact the runway. After the aircraft came to rest on the grass, the pilot and passengers egressed without injury.

Maintenance organisation inspection revealed several anomalies, which were not conducive to the continued proper functioning of the landing gear retraction system. The significant factors determined from the inspection were:

1. A lack of lubrication of the landing gear system.

2. A bush missing from the right main gear outboard drive tube.

3. Main landing gear system was out of rigging.

FACTUAL INFORMATION

An Airbus Industrie A340 registered as BHXI and operating flight number Cathay 104 (CPA104) had been flight-planned to operate a flight from Melbourne to Hong Kong. The crew of the A340 had been cleared to depart Melbourne on a KEPPA TWO standard instrument departure (SID) with a requirement to maintain 5,000 ft. The KEPPA TWO departure was able to be conducted from Melbourne runways 16, 27 or 34. The Melbourne Automatic Terminal Information service (ATIS) was "Information Sierra" with a variable easterly wind at 5 kts. Downwind on runway 27 was reported as 5 kts. The duty runway at Melbourne was runway 16 for arrivals and runway 27 for departures.

The departure of CPA104 was coordinated with both the Departures North controller and the Essendon aerodrome controller (ADC) by the Melbourne ADC. The crew of CPA104 was cleared for take-off and instructed to contact Departures airborne.

A Cessna C172 registered as VH-ZWR had been flight-planned from Essendon to Kyneton at 3,500 ft, flying under the visual flight rules. The Essendon ADC had cleared the pilot in command to depart the Melbourne CTR on an amended route via Rockbank at an amended level of 1,500 ft. The aircraft had departed from Essendon's runway 17 and had made a right turn to track via Rockbank. Because the C172 would transit only controlled airspace that was the responsibility of Essendon Tower, coordination for this aircraft with other control agencies was not required.

The Departures North controller identified CPA104 airborne and cleared the crew to climb to flight level 200. The controller then observed on radar an unidentified aircraft squawking code 4000, departing Essendon westbound and crossing the departure track of the A340. The controller initiated corrective action but the A340 passed behind the unidentified aircraft with 1 NM horizontal and 900 ft vertical separation. The separation standard was infringed: the required standard between these two aircraft was either 3 NM or 1,000 ft. The unidentified aircraft was subsequently confirmed to be VH-ZWR.

Air traffic control coordination procedures required the Melbourne ADC to obtain departure instructions for CPA104 from the Departures North controller, as the aircraft was planned to depart on a northerly track. The coordination between ADC and Departures was carried out and an "unrestricted" clearance was obtained. The use of the non-duty runway for departures from Melbourne was not unusual. Runway 16 was often used for aircraft tracking to southerly destinations or for the larger international aircraft requiring the longer runway.

Because CPA104 was departing from runway 16, additional coordination was required between the Melbourne ADC and the Essendon ADC in accordance with Local Instruction LOA2976 - Coordination for Non-Duty Departures Runway 16. Coordination with the Essendon ADC was attempted; however, due to conflicting traffic, the departure was not authorised by the Essendon ADC at the time.

The workload at Essendon was considered to be high with controllers working in all operational positions. Additional airspace had been negotiated and released to Essendon by the Melbourne Centre. The airspace configuration on this day was unusual. The usual configuration was for Essendon Tower to have the south-east quadrant of the Melbourne control zone (CTR) up to and including 2,000 ft. The south-east quadrant was from south of the extended centreline to runway 26 to east of the extended centreline from runway 17. For a planned calibration of the Essendon instrument landing system (ILS), an extension to the airspace was agreed that would encompass normal airspace, plus the airspace from the extended centreline of runway 26 to the western edge of the CTR up to and including 3,000 ft. This additional airspace included all airspace south of the extended centreline of Essendon's runway 26 up to and including 3,000 ft.

The aircraft conducting the calibration testing of the ILS was operating to and overshooting from Essendon's runway 26. The aircraft was an Astra 1125 jet aircraft operating under the callsign of Auscal 01 (ADA01). This was the first time that this type of aircraft had been used for calibration tests: previously the Airservices Australia Fokker F28 had conducted the testing. When the F28 did the testing, it was able to overshoot from the approach prior to crossing the runway intersection, which obviated the need to sequence the aircraft with other traffic. The Astra aircraft needed to conduct an overshoot from all approaches, which necessitated complex sequencing with all other traffic. It was this aircraft that precluded CPA104 getting airborne when the Melbourne ADC first attempted to coordinate a departure with the Essendon ADC.

When the Melbourne ADC next attempted to coordinate with the Essendon ADC the departure of CPA104, the Essendon controller pre-empted the request as soon as the "hotline" communication line was opened by issuing a clearance using the word "approved" for the Melbourne runway 16 departure. Melbourne Tower advised that "he (CPA104) would be after the one on short final". The Essendon ADC replied with the statement "OK, behind him, approved". The Essendon ADC stated during interview that he couldn't recall issuing the approval for the departure of CPA104.

Although not a documented procedure, the practice in Essendon Tower was to place a runway-16 departure designator strip in the bay containing departure strips. The designator strip was used to remind and alert controllers of aircraft cleared to depart from runway 16 at Melbourne. Essendon Tower did not hold individual flight progress strips for Melbourne's aircraft and the runway-16 designator strip was used to indicate a pending departing aircraft. Controllers were trained to scan the strip bay to identify conflicting aircraft prior to issuing a subsequent clearance to an aircraft that could potentially conflict with aircraft departing Melbourne's runway 16. The Essendon ADC stated during interview that although the designator strip was placed in the departure bay, he did not scan the strip bay prior to clearing VH-ZWR for departure and the right turn.

ANALYSIS

Although the Essendon ADC did not recall approving the departure clearance for CPA104, the designator strip was reputedly placed in the departure bay. Analysis of the audio recording indicated that the Essendon ADC issued the take-off clearance for VH-ZWR approximately 3 seconds after approving CPA104's departure. This action indicated that the Essendon ADC did not recognise the potential for conflict between the two aircraft when the judgement was made to clear VH-ZWR for take-off and make the right turn. An alternative hypothesis is that a judgement was made that there was no conflicting traffic for the departure of VH-ZWR, prior to issue of the take-off clearance and receipt of the hotline call from Melbourne. The controller's mind-set regarding VH-ZWR did not change because the implications of CPA104's departure did not register with the controller. Importantly, the potential for conflict was not recognised when the Essendon ADC approved CPA104's departure. The latter hypothesis is supported by the controller's failure to scan the strips prior to the take-off transmission being made because his mind-set was that VH-ZWR was clear for take-off.

The traffic density and complexity on this particular day was reported to be unusually high. This additional workload may have increased the cognitive demands on the controller, unbeknown to other members of the team. The other controllers were also busy and the ADC was reputedly a very experienced controller. These two factors may have been the reason that the performance of the ADC was not monitored more closely.

Analysis of the radar data indicated that when the 3-NM radar separation standard was infringed, vertical separation indicated that CPA104 was 500 ft below VH-ZWR and climbing. When the aircraft were at the same level of 1,300 ft, radar separation had reduced to 2.2 NM. When CPA104 passed behind VH-ZWR, vertical separation had increased to 900 ft and radar separation had reduced to 1.25 NM. A vertical separation standard of 1,000 ft was re-established when the aircraft were 1.4 NM apart.

SAFETY ACTION

The Airservices Australia investigating officer made the following two recommendations:

"1. Amend LOA 2976 to:

a. Give better examples of the approval process for Melbourne runway 16 departures; and

b. Promulgate usage and the process to be followed by Essendon tower of the runway 16 designator strip.

2. Consider releasing all control zone airspace to Melbourne and Essendon towers".

Melbourne ATC management agreed to implement Recommendation 1 at the next revision of Local Instructions. Management will consider Recommendation 2 following consultation with terminal control unit staff.

The pilot reported that before landing he had obtained the appropriate cockpit indications that the landing gear was locked down. However, the nose gear collapsed during the landing roll. The main landing gear also collapsed after the aircraft had been inspected and was being moved. Subsequent examination and testing of the landing gear system failed to identify any fault.