The pilot reported that the number three engine was shut down after the oil pressure indicator showed erratic movement and then dropped to zero. The low oil pressure light did not illuminate. The flight continued for an uneventful landing at the planned destination. Post flight examination confirmed erroneous oil pressure indication. The oil pressure transducer for the number three engine oil pressure gauge was replaced and the aircraft returned to service without further incident.

The aircraft was on descent towards Brisbane via Jacobs Well. The crew reported seeing glare from what they believed was a laset light east of the Brisbane - Gold Coast highway near the Gold Coast.

The light was not known to CASA. Consequently, there was no NOTAM concerning the light. CASA advised that it had also received a report concerning the light from a helicopter operator and intends to conduct a night flight to determine the position of the light and then proceed with NOTAM or other action as appropriate.

The aircraft had been radar vectored for a pilot intercept of the outbound track. The controller had monitored the aircraft's track, which indicated compliance with the planned track. Later the aircraft was observed diverging from track and potentially in conflict with an overflying aircraft. The controller instructed the pilot of the diverging aircraft to adopt a new heading to avoid a loss of separation. A subsequent report from the pilot indicated that he had been using the course deviation indicator bar to maintain track. The bar had later moved to one side, and he had turned to centre the bar. He later found that the bar was giving erroneous indications compared with the RMI needle.

The pilot reported that the flaps became asymmetric when full flap was selected at about 300 ft on final for landing at Palm Island. The pilot immediately returned the flap selector to the previous position and carried out a "go around". The flight returned for an uneventful landing at Townsville. Post flight examination found the right flap extend cable had failed in the radius of a pulley. The cable was due for special inspection in approximately 20 hours flight time.

The maintenance organisation, Operator and CASA Airworthiness in Townsville were all contacted concerning this incident. The maintenance organisation is currently submitting a Major Defect Report detailing the failure. The maintenance organisation will be recommending to CASA that the affected cables be placed on a shorter special inspection period or be replaced at short time intervals.

The aircraft was being radar vectored to short final approach runway 01. ATC had advised that a Cessna 210 aircraft was conducting aerial work near the runway. The B737 crew could clearly see the Cessna, and it did not threaten safety. Just before turning on to final approach, a TCAS resolution advisory was triggered by the Cessna. The approach and landing continued uneventfully.

The pilot in command and aircraft owner was restricted to flying with a co-pilot because of his age (79). The pilots were carrying out practice for a spot-landing competition to take place later that day.

The pilot reported that his first approach was lower than normal, and he had to apply power in an attempt to reach the runway threshold. Although the wind was blowing directly down the runway, at about 5 kt, there was some turbulence, and he believed there was a downdraft on late, final approach.

The pilot was concentrating his attention on touching down on the threshold markers, as practice for landing on his selected spot, when the co-pilot called "up, up". Immediately after the call, the aircraft collided with the top rail of a cattle holding yard, crashed to the ground, slid across a road and through the airfield boundary fence and onto the runway, where it came to a stop.

The major factor in the accident was that the pilot was concentrating all his attention on achieving his selected touchdown point (tunnel vision) and was not situationally aware in that he was not observing the other required parameters, height above the ground, glide-path angle and obstacle clearance, as he allowed the aircraft to descend well below a safe glidepath. It is possible that a downdraft may have increases the rate of descent in the last seconds of flight.

An aircraft was flight planned to track from Alice Springs direct to Ayers Rock. When the plan was being processed by flight data staff, the routing was checked with a supervisor. The staff were instructed to generate flight progress strips to indicate that the aircraft would track via ANGAS. (Preferred routes for the area are via ANGAS to Ayers Rock and direct to Alice Springs from Ayers Rock). Approaching Alice Springs, the crew became aware that an aircraft was tracking from Ayers Rock to Alice Springs and would present a confliction for their descent. After passing Alice Springs, in order to give the controller adequate time to make arrangements, they informed the controller that their descent point would be 75 NM from Ayers Rock, whereupon the controller issued a descent clearance. The crew questioned whether the other aircraft would be a confliction. They indicated that their flight plan had been to track direct from Alice Springs to Ayers Rock. The aircraft was then issued with a clearance to track via ANGAS.

No operating limitation for the route from Alice Springs was evident on the enroute chart, so the pilot had planned via the direct track. After the incident he found that the preferred route was via ANGAS.

FACTUAL INFORMATION

A Dash 8 had departed Melbourne on a flight to Wynyard, Tasmania and was climbing to flight level (FL) 170 via Cowes, a reporting point and navigational aid south-east of Melbourne en-route to Wynyard. A SAAB 340 had departed Wynyard for Melbourne and was also tracking via Cowes, maintaining FL160. The crew had been instructed to descend to FL130 "when ready". The Melbourne Inner South controller had recognised that there was a potential conflict and coordinated, with the departures controller, for the Dash 8 to be radar vectored to the left of track. This action would provide radar separation between the aircraft to allow both crews to change level without infringing the separation standards.

The crew of the Dash 8 requested, and were given, permission to climb to and maintain FL150. When the controller issued the left turn instruction, the crew of the Dash 8 asked if a right turn was available. The controller checked the route on a longer range radar scale and decided that the direct track to Wynyard would be adequate for radar separation purposes and would be a shorter track for the aircraft. A new instruction was then issued for the crew to track from their present position direct to Wynyard. The controller had, in fact, looked at the wrong track and destination when changing radar range scales and had mistaken a geographical point on the Tasmanian coast as Wynyard, when it was actually Smithton.

Wynyard was not displayed on the map. When the Dash 8 commenced the turn, the controller realised the mistake but thought that there would be sufficient distance between the crossing flight paths to provide the required radar separation. Meanwhile the crew of the SAAB 340 had commenced descent and, as vertical separation was reducing, the controller realised that the aircraft would pass with less than the required standard. The crew of the SAAB 340 were instructed to turn right 20 degrees in an attempt to maintain the standard but the turn proved to be insufficient and a breakdown of separation occurred. Radar analysis indicated that the aircraft passed with 4.7 NM horizontal separation and a vertical separation of 900 ft.

The required standard was either 5 NM horizontally or 1,000 ft vertically. A second SAAB 340 had departed Devonport, Tas. on a flight to Melbourne and was on a similar track to the first SAAB 340. This SAAB was approximately 15NM behind the leading SAAB and the crew had just commenced descent from FL160 in accordance with the controllers instructions. Approximately 80 seconds after the initial incident, the radar separation between the Dash 8 and this second SAAB 340 reduced to 3.5NM with the radar indicating that the aircraft had passed each other with 900 ft vertical difference.

The controller had issued descent instructions to the crew of the SAAB 340 which negated the existing vertical separation standard of 1,000 ft. However, the crews had reported sighting and passing each other's aircraft. The controller had established this visual contact by obtaining a report from the crew of the Dash 8 that "we have the SAAB passing on our left hand side".

ANALYSIS

The radar map showed a track and destination for Smithton but no information at all for Wynyard. Whereas Wynyard was a regular destination, traffic to Smithton was infrequent in controlled airspace. Although the controller promptly detected the initial error, track shortening was allowed to proceed. Although actively monitoring the developing situation, the decision to allow unrestricted climb and descent did not provide separation assurance. When the track of the Dash 8 also conflicted with the second SAAB 340, there was a vertical separation standard in existence.

However, the controller authorised descent for the SAAB 340 with only minimal radar separation. The controller had based separation on pilot reports of mutual sighting. Whereas the SAAB crew could have been safely expected not to miss-identify the Dash 8 aircraft, the Dash 8 crew may have been referring to the first of the two SAAB aircraft.

SIGNIFICANT FACTORS

1. The Inner South controller mistakenly identified the location of Smithton on the radar display map as that of Wynyard.

2. The Inner South controller did not use adequate separation assurance techniques.

3. The Inner South controller misjudged the radar separation between the Dash 8 and SAAB 340 aircraft.

SAFETY ACTION

As a result of the investigation, Airservices Australia Southern District management put in place amendments to the radar display map that indicate the location of Wynyard for controller reference.

FACTUAL INFORMATION

A Beech 1900 (B1900), callsign SMH, had departed Sydney on a flight to Port Macquarie, NSW. The crew were maintaining the aircraft at flight level (FL) 210 in controlled airspace. The airspace was controlled by Brisbane Sector 15C.

A Swearingen SW4 (Metro) had departed Port Macquarie on a flight to Williamtown, NSW. The crew were maintaining the aircraft at FL140. The base of controlled airspace was 12,500 ft.

At 1433 EST, the crew of the B1900 commenced descent into Port Macquarie but were restricted to FL150 by sector control due to the opposite direction conflict with the Metro.

A second B1900, callsign IMH, was also on the control frequency and had commenced descent into Williamtown. This aircraft was well south of the conflicting aircraft and there were no restrictions for its descent.

At 1436, the sector controller instructed the crew of IMH to contact Sydney flight service (FIS5) on frequency 121.6 Mhz. The reply was broken but included the words "? Mike Hotel". Almost immediately the crew of IMH asked the controller to confirm that the previous transmission was for them. This was confirmed by the controller and the crew transferred to FIS5 as instructed.

The controller then noticed on radar that SMH had descended below its assigned level and attempted to contact the crew to instruct them to return their aircraft to FL150 for separation with the Metro. There was no answer.

The crew of SMH had acknowledged the frequency transfer instruction issued to IMH and had contacted FIS5. The flight service officer had received the correct coordination on SMH and had informed the crew that there was no instrument flight rules traffic conflicting with their intended flight path in his area of responsibility. FIS 5 provided a traffic information service for aircraft travelling outside controlled airspace; that is, at and below 12,500 ft.

The crew of SMH decided that, as control had transferred them to FIS5, the controller was approving their descent from controlled airspace. Consequently, they elected to continue descent from FL150. However, they had not received a specific clearance to descend below FL150.

As soon as the controller realised that the crew of SMH was not on the control frequency, he coordinated with the flight service officer to broadcast on 121.6 Mhz an instruction to the crew to maintain FL150. On receiving this instruction, the crew maintained FL140 because that was the level they were passing at the time. They reported to FIS5 that they were maintaining FL140 and this information reached the controller at approximately 1438, by which time the two aircraft had passed each other. The controller then issued a clearance for the crew of SMH to leave controlled airspace on descent.

Neither crew saw the other aircraft and radar analysis indicates that they passed at 1437 with approximately 2.6 NM horizontal separation and 200 ft vertical separation. The appropriate standard was 5 NM or 1,000 ft.

There was a breakdown of separation standards.

ANALYSIS

The crew of SMH were expecting further descent as they approached FL150 and, hearing such an instruction issued to IMH, misheard the callsign and acted as if the instruction was issued to them. The controller only heard the last two letters of the response and, therefore, did not instantly recognise that the wrong crew had responded. As soon as the crew of IMH questioned the callsign for whom the instruction was intended, the controller commenced action to contact the crew of SMH to re-introduce positive separation that he had observed to have been contravened.

Because they believed that they had been transferred from control frequency, the crew of SMH incorrectly assumed that sector control had no further restrictions for them and descended. They did not receive, nor did they seek, a clearance to descend from FL150.

SIGNIFICANT FACTORS

1. The crew of SMH misheard the callsign "IMH" when an instruction for descent was issued to the crew of IMH.

2. The crew of SMH descended below their assigned level.

Circumstances

The crew advised that the number one engine experienced an uncommanded excelleration to about 84% NI, as the thrust levers were advanced on final approach to land. The engine was shut down in accordance with the requirements of the non-normal check list. The approach was continued for a normal landing. Post flight examination traced the problem to a fault in the fuel flow regulator. The regulator was replaced and after carrying out the appropriate ground runs, the aircraft returned to service without further incident.