VH-NFD departed Jandakot WA at 1822 WST for Busselton WA as a medical priority flight. The pilot reported that at 1851 he made a straight in approach to runway 21 at Busselton Airport. After establishing the aircraft on final approach and lowering the undercarriage, approach flap was selected at approximately 700 ft. The pilot selected full flap with the speed at 120 knots.

Passing 500 feet, the pilot experienced yaw towards the left and a complete loss of engine power from the left engine, followed by a loud backfire. The pilot shut the engine down and continued to land on runway 21. After landing the pilot managed to clear the runway by using a series of large circles to work his way to the taxiway and to the tarmac area where he cancelled the SAR, and advised Perth FSE what had happened.

The military Lockheed C-130 aircraft was tracking to Pearce from Edinburgh via reporting points BADJA and PEPPA, whilst an Avro RJ-70 was tracking from Perth to Telfa via CLIFY and PEPPA.

The pilot of the C-130 had been cleared to descend to 8,000 ft by Perth ATC and the RJ-70 was on climb to FL290. However, the C-130 was observed on radar to drift south of track and then turn left prior to PEPPA. As a result of the early turn, the C-130 passed approximately 3 NM south of PEPPA. The C-130 crew could not recall why the aircraft had drifted south or turned early. However, it was reported that it was possible that the C-130's inertial navigation system (INS) may have experienced some drift. It was also reported that because the INS calculates an intercept to the next leg based on the aircraft's expected turn radius, it may have commanded a turn earlier than ATC expected.

Perth ATC directed the pilot of the RJ-70 to turn the aircraft right to pass behind the crossing C-130. Just after the RJ-70 pilot gave his read-back to the instruction, he advised Perth ATC that he had received a TCAS alert. Perth ATC passed traffic and the two aircraft passed abeam each other at 4 NM with no vertical separation. There was a breakdown in separation as the required standard was 5 NM.

Perth ATC reported that just prior to the incident, Pearce Control had experienced a radar failure. As a result, the Perth "Inner" air traffic controller, who was under training and being supervised at the time, experienced a substantial workload increase requiring him to scan a larger area than normal, thus changing his radar scan parameters. He also had 12 aircraft on frequency. The trainee air traffic controller's workload, whilst heavy, was not considered excessive because he had completed 4 weeks of the 6 week training course and was already an experienced procedural controller.

Perth ATC reported that at 15 NM inbound to PEPPA, the C-130 had a groundspeed of 330 kts and the trainee controller assessed that the separation between the aircraft would be adequate. However, abeam PEPPA, the C-130's groundspeed unexpectedly reduced to 220 kts before increasing again to 255 kts. The speed changes may have been associated with the aircraft accelerating in the descent and then slowing following the level off. The C-130's unexpected speed changes and early turn near PEPPA adversely affected the trainee controller's planned separation between the two aircraft.

The trainee had issued frequency transfer instructions to the pilot of the C-130 just before the impending breakdown in separation was noticed. Although the training officer assumed control of the position as the separation breakdown developed, he could only issue instructions to the pilot of the RJ-70. This limited the options available to the training officer when he was attempting to correct and avoid the separation breakdown.

It is probable that the workload increase caused by the non-operative Pearce radar associated with the C-130's unexpected deviation from the air route and groundspeed changes, were factors in allowing the breakdown in separation to develop. When the training officer noticed the developing separation breakdown, his options in ensuring the required separation were limited by the C-130 being on another frequency.

The helicopter was refuelled from a drum positioned approximately one metre from the left hand side of the aircraft. The helicopter was parked facing north with an approximate 15 knot wind from the east. Pilot and passenger then boarded the helicopter and commenced normal start procedures before lifting into the hover. The helicopter was close to maximum all up weight. After coming into the hover the helicopter was weather cocking and difficult to stabilise.

Due to the proximity of the fuel drum, out of sight on the left side of the aircraft, and the aircraft weather cocking in the cross wind, the pilot decided to do a hovering left hand circuit of the fuel drum to enter into wind. As the pilot looked to his right to check the area was clear the aircraft yawed to the right. The pilot pushed full left pedal and applied left cyclic to stop the yaw at the same time pushing forward cyclic to clear the drum. The rear of the left hand skid came into contact with the fuel drum and the helicopter rolled onto its left-hand side.

FACTUAL INFORMATION

The pilot of the Beech 55 Baron advised that he made a transmission to Avalon Tower while taxiing at Ceres. This transmission was neither heard nor recorded by Avalon, and no acknowledgment was received by the pilot.

Avalon Tower was staffed by a trainee air traffic controller under the supervision of a rated aerodrome controller. The trainee was performing the aerodrome control tasks at the time.

The Baron subsequently departed Ceres. The pilot remained clear of the Avalon control zone until radio communication was established with Avalon Tower, when he requested an airways clearance to Bairnsdale on climb to 9,000 ft. The reply from the Avalon controller was spoken in a soft voice and was intended only to confirm the details of the request but used the words "...cross the zone, confirming on climb to 9,000 to Bairnsdale ...". The pilot advised that he did not hear the full transmission. He interpreted the communication as an airways clearance and initiated a climb to 9,000 ft. The pilot only acknowledged this perceived clearance with the word "affirmative" and did not read back the full clearance.

This situation resulted in the pilot believing that he had a clearance to enter controlled airspace on track to Bairnsdale and on climb to 9,000 ft, whereas the controllers believed that no clearance had been issued.

The Avalon controllers then coordinated the details of the Baron's intended flight with Melbourne radar control which resulted in an agreed altitude limit of 2,000 ft for the Baron. The coordination included an assessment of the relative position of the Baron with a Boeing 767 conducting training in the Avalon airspace. The radar controller was unable to provide any radar separation between the two aircraft.

During the ensuing radio exchange between the Avalon controller and the pilot of the Baron, the controller did not mention the word "clearance" when instructing the pilot to maintain 2,000 ft and track to Portarlington. He did, however, specifically instruct the pilot to maintain his own separation with the Boeing 767. The pilot accepted both instructions and proceeded to Portarlington.

The pilot of the Baron now believed that the original (perceived) clearance was still current but that he had a temporary restriction to maintain 2,000 ft until reaching Portarlington. This belief was further validated in his mind when he was instructed to Squawk Code 3000, a code used to radar identify aircraft.

During the transit of the Avalon control zone, the pilot of the Baron made radio contact with Melbourne Flight Service and passed his position and departure time.

The Melbourne radar controller had expected the Baron to remain outside controlled airspace but observed the aircraft passing through 4,500 ft after passing Portarlington. He issued a different squawk code via Flight Service and made a positive identification. A violation of controlled airspace had occurred but there was no breakdown of separation standards.

The use of non-standard phraseology had resulted in confusion between the pilot of the Baron and Avalon Tower. Air traffic control had not specifically mentioned the word "clearance" at any time, leaving the pilot to misinterpret the transmissions as an airways clearance.

Had the pilot read back the perceived clearance in full, the controllers may have realised that the misinterpretation had occurred.

The student was briefed by his instructor for a solo flight as part of the CPL training Block. The published route is Merredin - Wagin - Hyden - Merredin. The planned landing point for this exercise is Wagin, which has an adequate runway for the purpose. To meet the operational requirement of a 2.5 hour flight, students are permitted to divert en route Wagin to Hyden, direct to Merreden, after considering such factors as ground speed and fuel remaining.

This student elected to divert in the Merredin to Wagin leg, and proceeded to Hyden where he then conducted an unauthroised landing at a private airfield to the North of the town, not the Shire strip as published in the WA Country Airfield Guide. The student later reported that on his final approach for a landing to the South he was distracted by something close to the threshold, possibly a fence, which prompted him to change his original aiming point.

This action lead to a bounce on touch down followed by an attempted go around, during which the aircraft departed the runway centreline to the left towards some trees. He then tried to manoeuvre the aircraft back to the runway and then could not remember hearing the stall warning prior to the impact of the nose and right wing into the ground. The aircraft came to rest 10m from the runway edge sustaining considerable damage to the propellor, engine, nose and right undercarriage plus sundry damage to the airframe including the tailplane.

The pilot reported that he discontinued take-off on runway 27 due to severe nosewheel aquaplaning. The departure was changed to runway 34 and during this time the inertial reference systems lost alignment. Re-alignment was not possible, and the aircraft was returned to the terminal.

As the aircraft commenced descent, the crew heard and felt a loud thump. On final approach, the crew heard and felt a second thump and concluded that a container in the forward hold was incorrectly restrained.

When the hold was opened at the ramp, an engineer confirmed that the aft restraint on one pallet was not engaged, permitting the pallet to move approximately 15 cm forward and rearward.

No text.

The Boeing B767 aircraft was operating an RPT passenger service from Sydney direct to Perth. As the aircraft was rotated for lift-off the co-pilot, who was the handling pilot for the flight, found that the aircraft was very nose heavy. The crew contacted load control and requested a loading check. The check disclosed that 400 kg of cargo had been loaded into position 11, the most forward bay, and this load had not been entered into the loading data. The crew received revised stabiliser trim settings which were confirmed during the arrival into Perth.

The investigation found that the load controller had established what load had to be loaded onto the aircraft and had made the relevant weight and balance computations. However, the load controller had not locked out the computer field related to freight as is required by the relevant procedures. This allowed the aircraft loaders to load the additional cargo and make an entry into the computer.

This entry did not become obvious to the load controller and, because the load controller thought there was no changes to the original computations, the crew were not advised to reconfigure the aircraft. The operator has instituted training procedures designed to improve discipline in the loading system.

The pilot of VH-PHO was not familiar with procedures in the Tamworth Control Zone (CTR). He had obtained a clearance from the tower controller to enter the CTR at 3,000 ft and had been instructed to report at 5 NM. After reporting at this position, the pilot was instructed to maintain 3,000 ft and to join the circuit upwind for runway 12 Right. At this time, there were four aircraft in the circuit. The pilot of PHO was then asked by to report sighting an aircraft on the upwind leg one mile ahead. He reported that he had the traffic sighted and was instructed to follow that aircraft. A short time later, the controller observed PHO descending and tracking for a mid-downwind position. This action conflicted with VH-YTQ which was on the downwind leg.

The pilot of YTQ reported manoeuvring to avoid PHO. In response to a query from the controller, the pilot of PHO reported that he was below 2,500 ft. The pilot of PHO did not fully understand the procedure for upwind circuit entry. Further, he believed that the instruction to follow YTQ meant that he was cleared to descend from 3,000 ft. The pilot indicated that he operated inside controlled airspace infrequently. Investigation revealed that the relevant publications do not include a definition for the term 'follow'. SAFETY ACTION As a result of this occurrence, the Bureau of Air Safety Investigation is investigating a perceived safety deficiency relating to the use of "sight and follow" procedures by air traffic controllers. Any safety output issued as a result of this analysis will be published in the Bureau's Quarterly Safety Deficiency Report.