Collision on ground involving a Lake A/C Div. Of Consolidated Aeronautics Inc. LA-4-200, VH-FTB, King Fisher Bay, Queensland, on 9 January 1998

Summary

During the take-off run, the aircraft struck an unseen, submerged object. The impact launched the aircraft out of the water prematurely. The pilot placed the aircraft back on the surface of the water and continued the take-off run. The pilot then noticed that water was entering the cabin behind the front seats and that the aircraft began to vibrate. He rejected the take-off and stopped the engine before evacuating his passengers and himself. The aircraft sank approximately 15 minutes later.

Occurrence summary

Investigation number 199800069
Occurrence date 09/01/1998
Location King Fisher Bay
State Queensland
Report release date 15/01/1998
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Accident

Aircraft details

Manufacturer Lake A/C Div. Of Consolidated Aeronautics Inc.
Model LA-4-200
Registration VH-FTB
Sector Piston
Operation type Charter
Departure point King Fisher Bay Qld
Destination King Fisher Bay Qld
Damage Substantial

Forced/precautionary landing involving a Hughes Helicopters 369D, VH-HWD, Ulan State Mines, New South Wales, on 7 January 1998

Summary

The MD500 helicopter was engaged in a sling operation to lift a powerline to the top of a transmission tower. The pilot was hovering the helicopter about 60 ft above the 30-ft tower, and had just passed the powerline to the linesman when the engine began to "spool down", resulting in a total loss of power.

The pilot immediately banked the helicopter to the right to avoid personnel on and below the tower, and attempted a landing in light scrub. However, the helicopter came to rest on its right side, incurring substantial damage, and slightly injuring the pilot. The maintenance investigation found that the engine fuel system was contaminated with water, discoloured fuel, and particle debris. After the engine fuel system was cleaned, the engine was successfully ground-run.

The helicopter had spent 45 hours on firefighting duties in the 60 hours since the last maintenance inspection. During the firefighting operations, refuelling was routinely undertaken from an assortment of drum and mobile bowser fuel sources. "Hot" refuelling also accounted for a significant proportion of these refuelling operations. It is probable that the fuel system was contaminated during those refuelling operations.

SAFETY ACTION STATEMENT

As a result of this occurrence, the Bureau of Air Safety Investigation is currently analysing a possible safety deficiency. The deficiency identified involves the manufacturer-instigated modification of the fuel filtration system which removed the ability to do water/contamination tests at the engine driven fuel pump and filter assembly. Any recommendation issued as a result of this analysis will be published in the Bureau's Quarterly Safety Deficiency Report.

Occurrence summary

Investigation number 199800067
Occurrence date 07/01/1998
Location Ulan State Mines
State New South Wales
Report release date 14/07/1998
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Forced/precautionary landing
Occurrence class Accident
Highest injury level Minor

Aircraft details

Manufacturer Hughes Helicopters
Model 369D
Registration VH-HWD
Sector Helicopter
Departure point Charm Haven NSW
Destination Ulan State Mine NSW
Damage Substantial

Collision with terrain involving a Cessna A188B/A1, VH-HWE, 7 km south-south-east of St George, Queensland, on 3 January 1998

Summary

The day before the accident, the pilot had made some modifications to the aircraft's spray equipment. Approximately 180 lts of water was then loaded to test the equipment.

Early the next morning, the pilot decided to test spray over a paddock. After checking the paddock for hazards, he commenced a spray run from west to east with the sun still below the horizon. The pilot noticed a loss of spray pressure and as he looked down inside the cockpit to adjust the pressure, the main landing gear struck the ground. The aircraft nosed over and slid upside down for approximately 40 m before coming to rest. The pilot was not injured and was able to extricate himself without outside assistance.

An emergency locator transmitter (ELT) was not fitted to the aircraft.

Occurrence summary

Investigation number 199800065
Occurrence date 03/01/1998
Location 7 km south-south-east of St George
State Queensland
Report release date 15/01/1998
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Collision with terrain
Occurrence class Accident

Aircraft details

Manufacturer Cessna Aircraft Company
Model A188B/A1
Registration VH-HWE
Sector Piston
Operation type Aerial Work
Departure point St George Qld
Destination Aspen ALA Qld
Damage Substantial

Loss of separation involving a Israel Aircraft Industries Ltd 1124, VH-AJJ and The Boeing Company 747, 9M-MPG, 4 km south-south-east of Sydney Aerodrome, New South Wales, on 6 January 1998

Summary

VH-AJJ, a Westwind, departed Sydney runway 16L on a COOKS ONE standard instrument departure (SID) for a maintenance test flight. The SID required the aircraft to turn left on reaching 500 ft. Radar observation, however, indicated that the aircraft remained on runway heading and did not comply with the SID. The departures controller instructed the pilot to turn left immediately as there was an international B747 departing from runway 16R on a GUEST TWO SID. The tower had both aircraft in sight at all times but there was a breakdown in separation.

The operator of VH-AJJ reported that the flight test was to observe the operation of the aircraft's pressurisation system. The pilot was aware of the departing B747 from the parallel runway but was intent on cabin and engine instruments during the initial climb. He realised he had failed to comply with the SID when he was instructed to turn left.

Occurrence summary

Investigation number 199800051
Occurrence date 06/01/1998
Location 4 km south-south-east of Sydney Aerodrome
State New South Wales
Report release date 25/03/1998
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 Israel Aircraft Industries Ltd
Model 1124
Registration VH-AJJ
Sector Jet
Departure point Sydney NSW
Destination Sydney NSW
Damage Nil

Aircraft details

Manufacturer The Boeing Company
Model 747
Registration 9M-MPG
Sector Jet
Operation type Air Transport High Capacity
Departure point Sydney NSW
Destination Melbourne Vic.
Damage Nil

Collision with terrain involving a Cessna 172M, VH-WTG, Dubbo Aerodrome, New South Wales, on 8 January 1998

Summary

The aircraft was on final approach to Dubbo aerodrome when it suddenly descended, collided with power lines and cartwheeled to the ground. The aircraft was destroyed in the accident but the solo student pilot managed to escape with minor injuries.

The pilot subsequently reported that he had the aircraft configured for a short field landing with full flap and 60 kts approach speed. At about 400 ft on mid final, a sudden wind gust lifted the nose and right wing to a high attitude. The pilot applied full power and opposite aileron but the aircraft failed to recover before colliding with the power lines.

It is likely that the high nose attitude resulted in the aircraft stalling at a height which was insufficient to effect a recovery.

Occurrence summary

Investigation number 199800049
Occurrence date 08/01/1998
Location Dubbo Aerodrome
State New South Wales
Report release date 23/02/1998
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Collision with terrain
Occurrence class Accident
Highest injury level Minor

Aircraft details

Manufacturer Cessna Aircraft Company
Model 172M
Registration VH-WTG
Sector Piston
Operation type Flying Training
Departure point Dubbo NSW
Destination Dubbo NSW
Damage Destroyed

Oil system event involving a Short Bros Pty Ltd SD360, VH-MVW, 46 km south of Bundaberg Aerodrome, Queensland, on 1 January 1998

Summary

A passenger alerted the crew to fluid leaking from the left engine cowling. Several minutes later, the oil pressure began fluctuating. The crew reduced power on the affected engine as stipulated in the Abnormal Procedures checklist. They declared an emergency and advised the sector controller of their intention to divert to Bundaberg. Emergency services were alerted and in place for an uneventful landing.

Company maintenance staff found an engine oil leak. The leak was traced to the failure of an oil seal at the gas generator tachometer gear.

Occurrence summary

Investigation number 199800011
Occurrence date 01/01/1998
Location 46 km south of Bundaberg Aerodrome
State Queensland
Report release date 07/01/1998
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Incident

Aircraft details

Manufacturer Short Bros Pty Ltd
Model SD360
Registration VH-MVW
Sector Turboprop
Operation type Air Transport Low Capacity
Departure point Brisbane Qld
Destination Rockhampton Qld
Damage Nil

Collision with terrain involving a Maule Aircraft Corp M-7-235, VH-JLU, Lady Musgrave Island, Queensland, on 5 January 1998

Summary

The pilot reported that while taking off from Lady Musgrave lagoon, just after the aircraft became airborne, a gust of wind caused the right wing to drop. The wing contacted the water surface, and the aircraft cartwheeled to the right. The windscreen was shattered and the cockpit filled with water immediately. The aircraft came to rest inverted under the floats in approximately 8 metres of water.

The rear seat passengers egressed safely from the right side of the aircraft with cuts and bruises. The pilot's door was jammed but the pilot kicked out the side window and egressed with the front seat passenger from the left side of the aircraft. The aircraft was eventually washed onto the reef and destroyed by wave and tide action. An attempt to salvage the aircraft was unsuccessful.

The pilot reported that the wind at the time was a 20-25 knot south-easterly, the general weather was squally conditions with wind gusts to 30 knots, and the sea state was choppy with waves to one metre.

Occurrence summary

Investigation number 199800002
Occurrence date 05/01/1998
Location Lady Musgrave Island
State Queensland
Report release date 28/01/1998
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Collision with terrain
Occurrence class Accident

Aircraft details

Manufacturer Maule Aircraft Corp
Model M-7-235
Registration VH-JLU
Sector Piston
Operation type Charter
Departure point Lady Musgrave Lagoon Qld
Destination Bundaberg Qld
Damage Substantial

Forced/precautionary landing involving a Bell 206B (III), VH-LAL, Innamincka (ALA), South Australia, on 9 October 1997

Summary

Soon after the helicopter had left Moomba on a charter flight to Whanto, the pilot reported hearing a loud bang and noticed that the rear left door of the aircraft, and associated pillar, were missing. The pilot reduced power, confirmed that his passengers were safe, and checked that the flight controls and systems were performing normally before turning to land at Innamincka Station homestead.

The helicopter landed without further incident. After shutdown, the missing door was found impaled upon the horizontal stabiliser. The helicopter was configured to carry a stretcher by incorporating an approved kit, in accordance with Bell Service Instruction No. 206-68. With the kit correctly fitted, the co-pilot door could not be closed unless the pillar-locking handle was in the locked position. An additional safeguard of the system was that when the co-pilot door was closed and locked, the pillar-locking handle could not be moved to the unlocked position.

Following the accident, the operator found that the stretcher pillar had unlatched in flight. An inspection revealed that the locking handle was in the unlocked position. However, the locking handle had been installed 180 degrees from the correct position, circumventing defences designed to prevent the helicopter departing with the pillar unlatched or being unlatched during flight.

LOCAL SAFETY ACTION

The operator has advised the Civil Aviation Safety Authority of possible shortcomings in the flight manual supplement, with regard to the correct operation of the litter kit. The operator has also incorporated a modification that includes a safety latch, preventing the pillar-locking handle from being incorrectly installed.

Occurrence summary

Investigation number 199704323
Occurrence date 09/10/1997
Location Innamincka (ALA)
State South Australia
Report release date 03/08/1998
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 Bell Helicopter Co
Model 206B (III)
Registration VH-LAL
Sector Helicopter
Departure point Moomba SA
Destination Whanto SA
Damage Substantial

Loss of separation involving a de Havilland Canada DHC-8-102, VH-TQP and de Havilland Canada DHC-8-201, VH-TQG, 19 km south of Williamtown Aerodrome, New South Wales, on 30 December 1997

Summary

A Dash 8 aircraft, VH-TQP departed Sydney for Coffs Harbour on climb to FL190. Shortly after this aircraft departed, a second Dash 8, VH-TQG departed Sydney for Port Macquarie on climb to FL170. The second aircraft in the departure sequence was a later model Dash 8, capable of maintaining a high-speed cruise climb. To maintain separation between the two aircraft, both were restricted to 160 KIAS on climb.

As TQG approached top of climb (FL170), the controller observed TQP, the slower Dash 8 ahead, still well below FL170. To expedite the departure of the faster aircraft and achieve coordination with a southbound aircraft, the controller decided to restrict the climb of TQP to FL160. The crew understood their instruction was to FL170, selected this level with their assigned altitude indicator and read this altitude back to the controller. The controller did not detect the discrepancy between the assigned altitude and the crew's read back of the instruction.

The controller was then distracted for a short period of time with other sector controllers involved with an aircraft experiencing communication difficulties. During this period the mode C readout from TQP was noticed at FL168, in close proximity to TQG maintaining FL170.

TQP was instructed to immediately descend to FL160 and TQG initiated a turn to increase the separation between the two aircraft. The aircraft proceeded safely to their destinations following this occurrence.

Occurrence summary

Investigation number 199704320
Occurrence date 30/12/1997
Location 19 km south of Williamtown Aerodrome
State New South Wales
Report release date 15/04/1998
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 De Havilland Canada/De Havilland Aircraft of Canada
Model DHC-8-102
Registration VH-TQP
Sector Turboprop
Operation type Air Transport Low Capacity
Departure point Sydney NSW
Destination Coffs Harbour NSW
Damage Nil

Aircraft details

Manufacturer De Havilland Canada/De Havilland Aircraft of Canada
Model DHC-8-201
Registration VH-TQG
Sector Turboprop
Operation type Air Transport Low Capacity
Departure point Sydney NSW
Destination Port Macquarie NSW
Damage Nil

Flight control systems involving a Bell 206B (III), VH-JSM, 11 km south of Jacobs Well VOR, Queensland, on 24 December 1997

Summary

The pilot reported that he was ferrying the helicopter back to the company base after maintenance via a helicopter landing site near Jacobs Well. At approximately 200 ft AGL during the approach, the cyclic control became restricted in that the pilot was unable to introduce any left cyclic control. The pilot said there was insufficient control available to conduct a safe landing. Eventually, he was able to force the cyclic control free and land safely.

After landing, the pilot consulted the maintenance organisation and confirmed that work had been carried out under the front seats. The pilot then removed the front seats and discovered that the cyclic control had been jammed by a radio control box. The box had not been re-installed correctly after maintenance. The matter has been referred to CASA airworthiness at Brisbane for further investigation.

Occurrence summary

Investigation number 199704314
Occurrence date 24/12/1997
Location 11 km south of Jacobs Well VOR
State Queensland
Report release date 10/02/1998
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Flight control systems
Occurrence class Incident

Aircraft details

Manufacturer Bell Helicopter Co
Model 206B (III)
Registration VH-JSM
Sector Helicopter
Operation type Charter
Departure point Brisbane Qld
Destination Jacobs Well
Damage Nil