The flight was a dual training exercise for a type endorsement. Some upper air work had been completed in the training area before the aircraft was flown to Camden for circuits and landings.

The instructor reported that during the third touch and go sequence, after a normal landing, the student had applied take-off power but then inadvertently selected the landing gear up, instead of the flaps. The instructor immediately closed the throttles as the right main landing gear collapsed. The aircraft slewed through 180 degrees before coming to rest on the flight strip. Both occupants vacated the aircraft without injury.

A Dash 8 had departed Sydney for Port Macquarie NSW. The crew was maintaining the aircraft at flight level 170 and reported that they were ready for descent. The sector 15 C controller issued instructions for the aircraft to leave controlled airspace on descent and for the crew to contact flight service for the portion of the flight to be conducted outside controlled airspace.

The boundary of controlled airspace was 12,500 ft and the crew contacted FIS 5 prior to that level. The flight service officer received the transmission but had not had any coordination on the flight from sector 15 C. Fortunately, there were no immediate traffic conflictions, and the flight service officer had time to peruse his flight strips and pass relevant traffic information to the crew of the Dash 8.

The sector 15 C controller, who was under training, had not passed the flight details regarding the Dash 8 to FIS 5. However, a tick had been placed on the flight progress strip indicating that the coordination had been completed.

While the Dash 8 had been en-route, the military airspace under the control of Williamtown air traffic control became active and this action required coordination between sector 15 C and Williamtown control, which included information on the Dash 8. This activity resulted in a short-term, high workload situation involving several conversations with Williamtown air traffic control.

At approximately the same time, a second training officer prepared to take over the training responsibilities from the original training officer. This handover/takeover took place at the console with both officers "plugged in" to the monitor jacks. This had the effect of the second training officer being unable to hear anything through his headset until the first officer removed his headset from the jack.

The crew of the Dash 8 received their instruction to contact flight service immediately after the first training officer unplugged from the console and he did not hear this transmission. The second training officer looked at the flight progress strip as the instruction was being given and, seeing that the strip notation indicated that the coordination had been completed, believed all appropriate action had been taken.

Neither the first training officer nor the trainee could remember when or why the notation was made on the flight progress strip indicating the completion of the coordination with FIS 5 but, on reflection after the occurrence, the training officer remembered that it had not been done.

There was no breakdown in separation.

FACTUAL INFORMATION

The pilot of the Cessna 172 (C172) landed the aircraft on runway 31R and vacated the runway at the A2 taxiway intersection. However, the pilot became confused by the numerous taxiway options for his return to the parking area and entered runway 35R, using it as a taxiway in a northerly direction. Runway 35R was not in use at the time and was therefore available for taxiing. Whilst on runway 35R the pilot did not notice that his aircraft had entered runway 31R. He had not requested, nor had he received, a clearance from air traffic control to use runway 31R.

He did not see any signage that indicated that he was approaching the active runway and did not notice the gable markers that were set back from the crossing point of the two runways. A Piper PA28 had just taken off from runway 31R and passed over the C172 at a height of about 50 ft. A second PA28 on final approach to runway 31R was sent around by air traffic control.

SAFETY ACTION

During the course of the investigation the Bureau of Air Safety Investigation issued the following recommendation relating to this occurrence:

R980057

(issued 25 May 1998) "The Bureau of Air Safety Investigation recommends that the Civil Aviation Safety Authority review the adequacy of movement area guidance signs and markings, particularly at runway-to-runway intersections. The review should focus initially on Moorabbin Aerodrome and other aerodromes with multiple runways and complex taxiway systems."

The pilot had completed a charter flight at Blackwater and was returning the aircraft to the company base at Emerald. Another company pilot, not endorsed on type, was the sole passenger.

Enroute to Emerald the pilot decided to do some low flying over a wheat crop. The aircraft struck a 3-phase power line about halfway across the paddock. The aircraft was arrested by the wires and came to rest upright in a fallowed part of the paddock. No one was injured.

The pilot reported that he arrived at Daly River Police Station at 0745 CST and picked up his passenger who was a NT police officer. The passenger's equipment was loaded on board and the helicopter departed the police station at 0810.

The pilot flew approximately 1.5 NM northwest and landed on the pinnacle of an 800 ft high ridge. He said he frictioned all the controls down and secured the helicopter, before assisting the passenger to unload his equipment. The pilot said he and the passenger were about 10 m from the helicopter, and he had just turned to head back towards it when the left skid lifted off the ground about 2.5 to 3 ft. This subsequently caused the main rotor blades to strike the ground. The helicopter rolled over to the right and caught fire. The passenger was struck by flying debris resulting in cracked ribs.

Wind at the time of the accident was gusting from 25 to 35 kts from the south-east. The helicopter was facing a southerly direction on the edge of the mountain range.

The pilot reported that the aircraft floated about half the length of the 1130 m strip before he decided to take the aircraft around for another circuit. When he retracted the third stage of flap, the left wing dropped, and the aircraft veered off runway heading. The pilot then lowered the nose of the aircraft in an attempt to increase air speed, but when he saw that a collision with trees was imminent, he closed the throttle. The aircraft ran through a boundary fence and came to rest among saplings about 100 m further. None of the three occupants were injured.

The emergency locator transmitted, installed in the rear fuselage, did not activate.

The pilot was spraying crops adjacent to the Leigh River. The river meanders through a steep sided valley oriented approximately north-south, with the crop being sprayed located above the west ridge of the valley. The pilot advised that he had refuelled the aircraft and refilled the hopper.

The wind was gusting from the south-west and he was on a spray run, tracking to the south, at 5 ft above the ground, when a gust of wind caused the left wing to drop. The pilot advised that he was unable to stop the wing hitting an embankment and the aircraft rolled into the valley, coming to rest upright, substantially damaged and burning.

The pilot suffered a broken ankle and burns but was able to extricate himself. The aircraft was destroyed.

The student pilot was returning after a solo flight to the training area. The runway in use had a seven knot crosswind from the left. The pilot used 20 degrees of flap and approached at 65 kts. His initial flare was too high, so he reduced power and lowered the nose. A high sink rate developed, and the pilot pulled back on the control wheel before the aircraft bounced into the air. The nose was again lowered and a high sink rate followed by a bounce was experienced. This sequence was repeated on another two occasions before the aircraft nose struck the ground and the aircraft flipped on to its back.

No emergency locator transmitter was fitted to the aircraft.

During a flight involving stock spotting at 700 ft above ground level, the engine began to vibrate and then lost power. The pilot was able to restore power for about a minute but then was unable to maintain level flight. He landed the aircraft in a small clearing in the scrub. Shortly after touchdown, the nosewheel struck a log and the aircraft nosed over. The pilot reported that he crawled quickly away from the aircraft as fuel was leaking from the tanks.

A licenced aircraft maintenance engineer later reported that he had investigated the power loss and could not find any defects. He started and operated the engine for at least 30 minutes without fault. He ventured that carburettor icing may have been the cause of the power loss.

The Bureau of meteorology analysis of the temperatures indicate that the dewpoint was 6 degrees C and the estimate for the dry bulb temperature was 15 degrees C. These conditions with 20% relative humidity are well outside the range where carburettor icing could be considered a factor.

The reason for the power loss has not been determined.

There were four aircraft operating in the circuit for runway 31R when the pilot of an inbound Grumman AA5 aircraft, VH-IFN, contacted Moorabbin tower at the ACADAMY reporting point. The first aircraft in the sequence was Cessna 172 VH-APF, followed by two similarly coloured Piper PA28 Cherokee aircraft VH-HQK and VH-AFH, and a Cessna 152, VH-NAK.

The controller decided to slot IFN behind the second Cherokee, AFH.

The controller instructed IFN to join base and report at 3 miles. The pilot of IFN acknowledged the instruction. Shortly afterwards the second Cherokee, AFH, called "downwind touch and go" and was instructed to "follow the Cessna (APF) late downwind" The pilot of IFN reported at 3 miles and was advised that he was number 3 for landing, and to follow the Cherokee on mid downwind.

The pilot of IFN advised that he had "traffic sighted and I'll slow down to follow". IFN has a circuit speed some 20 knots higher than the PA28 that he was following. The weather was hazy, and visibility was approximately 3NM, but visibility was reported to be slightly less in the sector from ACADEMY to runway 31R.

Shortly after IFN had made the 3 miles call, HQK, the first Cherokee, called "downwind".

The controller now realised that the pilots of the two PA28's had reported their positions in such a way that the controller thought they were in the reverse order to that in which they actually were. This took a little time to identify and rectify but did not change the order of the sequence in relation to the pilot of IFN, who was still following two PA28s.

When the controller gave the pilot of IFN his landing sequence number, he referred to him being number 3 to land when there was actually 3 aircraft between him and the runway threshold. There was also the C152, NAK as number five in the sequence.

As the sequence progressed, the first of the five aircraft involved, APF, commenced a touch and go. The pilot temporarily lost control of the aircraft and departed the sealed runway onto the grass strip. The controller concentrated on this event in order to closely monitor proceedings. The pilot of APF finally regained control of the aircraft and successfully became airborne. The controller had been unsure if the pilot of APF was going to avoid an accident and had sent round HQK, the first of the PA28 aircraft. He then needed to closely monitor the flight paths of APF and HQK to ensure no conflict occurred. He instructed HQK to turn early to avoid APF and to rejoin the sequence behind the last aircraft, the C152, NAK.

While the controller's attention was occupied with the runway separation problems, IFN overtook AFH, reportedly passing about 2m directly over the top of AFH. The pilot of AFH took avoiding action and advised the controller of the near miss. The controller observed the closeness of the aircraft and sent IFN around. The pilot of IFN reported that he did not at any stage see AFH.

Analysis

The pilot of IFN did not sight AFH at any time, most probably because AFH was below and ahead of him, and because the pilot of IFN was only expecting to see two aircraft ahead of him. He therefore was maintaining clearance from, and following, the first of the two Cherokee's rather than the second.

When the controller gave initial traffic instructions to the pilot of IFN, he decided to only include the two PA28s in the sequence ahead of IFN. This decision may have confused the pilot who, after initially turning to follow the second PA28, may have seen the C172 and the first PA28 as the two aircraft ahead when subsequently checking the preceding traffic. The fact that the two PA28s were of similar colour schemes would have contributed to any misidentification by the pilot and the reduced visibility further restricted his ability to observe all aircraft in the sequence.

When the C172 was cleared to commence a touch and go, the first PA28 was on base leg and had passed mid-base position. The second PA28 was on downwind about to turn base. Therefore, although being told that he was number three in the sequence, the pilot of IFN had three aircraft between late downwind and the threshold of runway 31R.

As a result of the confusing position reports given by the pilots of both PA28s, the controller's attention had been concentrated on establishing the actual sequence of these two aircraft until the near accident occurred on the runway. This action did not affect the sequence from the point of view of the pilot of IFN, or from the air traffic controller's traffic plan, other than the order of the two PA28s.

Because of the near accident involving the touch and go landing of the C172, the controller's attention was focussed on his primary functions of runway separation and safety when the track of IFN started to conflict with that of the second PA28, AFH.

Significant factors

1. The controller indicated to the pilot of IFN that there were two aircraft ahead of him in the sequence, when there were, in fact, three.

2. The visibility was such that spotting and recognising aircraft was difficult.

3. The controller's attention was occupied with his primary function of runway separation at the time that the tracks of IFN and AFH came into conflict.