The pilot of the Bushby Mustang aircraft reported that he was conducting a landing on a private airstrip at the conclusion of a travel flight. During the flare, the aircraft contacted the ground heavier than normal on a soft patch on the runway. The nose wheel broke off and the aircraft overturned. The pilot egressed the aircraft without injury and, with the assistance of onlookers, extricated the passenger.

The pilot reported that when the landing gear was extended, prior to landing at Maitland, the gear down light failed to illuminate. The main landing gears appeared to have extended, but the nose gear could not be checked. Remedial action was unsuccessful so the aircraft was landed in the 23 direction. During the landing roll the nose landing gear collapsed, damaging the propeller and engine cowling undersurfaces.

It was later reported that an engineering examination found that the nose gear had failed to fully extend, due to the failure of the downlock hooks to travel to the locked position. This had resulted from the seizure of a pivot bolt due to corrosion. As the weight of the aircraft was applied to the nose gear the downlock hooks slipped, allowing the nose gear to collapse.

The Piper Arrow was being flown by a pilot undergoing a Commercial pre-licence check, under the supervision of a Grade 1 instructor. At a height of 3450 ft, some 2 NM west of the Wedderburn ALA, the instructor closed the throttle to simulate an engine failure. The weather was fine, with a light wind of about 10-15 kts from the west-south-west. 

The instructor reported that the pilot elected to conduct a glide approach to the ALA, joining the circuit on early downwind for a landing on runway 17. All required checks were correctly carried out, including exercising the throttle to prevent excessive engine cooling. An initial aiming point of about 1/3 of the strip length in from the landing threshold was used. The landing gear was lowered on base leg. Drag was progressively increased by extending flap and moving the propeller pitch to fine, during base and final legs, in order to bring the aiming point back to about 100 m beyond the threshold.

At about treetop level, on short final, an area of sink was encountered which resulted in the aircraft developing a high rate of descent. Although both the pilot and instructor selected full throttle, they were unable to prevent the aircraft from touching down heavily on the runway threshold.

The aircraft came to rest after a 30-40 m landing roll. The nose landing gear had been dislodged, the main landing gears had been bent rearwards, and substantial buckling of the wing was evident. Both occupants were uninjured and were able to vacate the aircraft normally.

The aircraft was landing towards the south-east on a sealed runway, with a 10-knot southerly wind blowing. Toward the end of the landing roll the pilot experienced difficulty in keeping the aircraft centred on the runway, with the result that it veered off the runway and nosed down in the soft ground off the sealed area. The propeller and engine area were damaged. The pilot reported that the left main tyre had deflated, probably because of the tyre not rotating during the landing. He considered that he had held his heels too high on the rudder controls, inadvertently applying brake to the left wheel during the landing flare and initial roll.

At 0252 EST, the pilot of VH-UZQ informed the tower that he had aborted the take-off and that he was returning the aircraft to the hangar. He then requested cancellation of his flight plan. Approximately one hour later, the pilot telephoned the tower and indicated that a runway light may have been damaged. The safety officer inspected the runway and reported no apparent damage. At about 11 am EST that morning, personnel from the company which operate the aircraft telephoned the tower and reported damage to the aircraft indicative of it having run off the runway and impacted with ground equipment. A second inspection of the runway revealed significant impact damage to two sets of T- Vasis boxes.

The pilot later reported that soon after he had advanced the power levers for take-off, he realised that one propeller was probably still on the start locks. He immediately brought the power levers back and while the aircraft was still rolling, he pulled the left power lever into reverse in an attempt to remove that propeller off the locks. The aircraft then departed the runway to the left. The aircraft sustained minor damage to one engine and propeller.

The on-site investigation confirmed that the aircraft departed the runway to the left approximately 150 metres into the take-off roll. The wheel tracks indicate the right propeller struck the first T- Vasis box soon after the aircraft entered the flight strip. The aircraft then passed over a taxiway before re-entering the main runway. The second T- Vasis was struck either by the main landing gear or right propeller as the aircraft was turning right to re-enter the runway. The pilot who was the sole occupant, was not injured and the aircraft was taxied to the company facilities without further incident.

The aircraft had experienced APU problems during the turn-around in Sydney. This had resulted in the crew turning the APU off and isolating the system. The flight then continued, requesting ground power to be available at the ports at which the aircraft was scheduled to land.

The aircraft departed Sydney and had two very short intermittent APU fire warnings during the climb from Sydney. The fire warning light and bell did not remain on during this time. The flight continued normally until the top of descent when the APU fire warning and fire light illuminated. The crew completed the checklist actions for a fire warning and when the light remained illuminated they discharged one fire extinguisher bottle. After these actions the light still remained illuminated and the crew advised Canberra Air Traffic Control (ATC) of the problem and asked for the local fire services to be placed on stand-by. ATC declared a distress phase shortly after this notification.

The aircraft tracked for a right base for runway 35 and during the approach the warning light became intermittent. The crew advised the purser that they had a fire warning and would be landing at Canberra in 5 minutes. She was also told that the landing would be normal and the fire service vehicles would be waiting for the aircraft.

The aircraft landed normally on runway 35 and was followed by the fire tenders. The fire services advised that no fire or smoke was evident and the crew elected to taxy the aircraft to the terminal. The fire tenders again advised that there was no fire or smoke present as the aircraft approached the terminal and the crew advised that the fire services would no longer be required. The aircraft parked at the gate and the passengers disembarked normally. An inspection of the APU by engineers revealed a fault in the fire indication system.

The pilot performed a daily inspection of the aircraft with the intention of flying to Dysart. During this time, he filled the aircraft fuel tanks with Avgas and carried out a fuel contamination check. A small amount of water was drained from the left fuel system. During the engine run-up checks, all pressures and temperatures were within normal operating tolerances.

The pilot reported that following a normal take-off, at about 100 ft, and after landing gear retraction, the right engine lost power. He transmitted a MAYDAY broadcast which was received by Brisbane Flight Service. While carrying out the engine failure vital actions, he thought that the engine may have regained power. However, when the engine did not respond to throttle movements, he completed the vital actions, which included feathering the right propeller. The pilot observed that the indicated airspeed was below the best single-engine climb speed and that the aircraft was not climbing. He was aware of rising terrain ahead and decided to land the aircraft in a flat field beyond the aerodrome boundary. He selected the landing gear down, but the aircraft touched down heavily before the gear had extended. The left tip tank ruptured and caught fire on impact. The aircraft slid for 120 m. and when it stopped, the pilot and passenger exited the aircraft, and the pilot extinguished the fire with the fire extinguisher from the aircraft.

A witness reported that the aircraft took off normally but then suddenly diverged left of the extended runway centreline. A short time later, he lost site of the aircraft behind buildings. The investigation did not determine why the aircraft diverged left after the right engine failed.

Examination of the right propeller indicated that it had been feathered prior to the impact, while damage to the left propeller was indicative of a low-power setting at impact.

Extensive examination of the engines and their systems failed to identify any deficiencies which might have contributed to the reported engine failure. The examination included operating the engines at various power settings.

The controller involved was undergoing a check. MAS135 and VH-HYJ were third and fourth in a six aircraft sequence. Both aircraft were inbound to Brisbane from the north-west with VH-HYJ behind MAS135 and operating at a higher speed. As the sequence progressed, the controller was late in detecting the reducing separation between the two aircraft. VH-HYJ was turned away from MAS135 but not sufficiently early to prevent lateral separation reducing to 4NM. At this time, vertical separation was 500 feet.

The pilot was conducting his first commercial agricultural spraying operation and had been operating on the task for several hours in the afternoon. He was asked by the farmer who owned the property being sprayed, to avoid spraying in the dam on the paddock. Whilst the pilot was attempting to identify the dam, the aircraft's left wing clipped the top of a tree, and the aircraft descended steeply into the ground. The pilot was able to escape from the wreckage, having sustain soft tissue damage, fractures to lower vertebra and both ankles dislocated.

The pilot of a Brasilia aircraft had an estimated time of arrival (ETA) over Bundaberg non-directional beacon (NDB) of 0920 UTC. On descent, he was notified by Brisbane Centre of a Shorts 3-60 inbound to Bundaberg from Gladstone, ETA 0917 and a Beech A36 inbound to Bundaberg from Hervey Bay, ETA 0927.

When the Shorts pilot changed to the Bundaberg mandatory broadcast zone (MBZ) frequency 126.9 MHz, he advised that he was on the inbound leg of the runway 14 NDB approach. As the Beech 36 was several minutes behind the Brasilia, it was not in conflict at that time.

When the Brasilia was approaching the NDB, the Shorts pilot advised he was at the minima, not visual, and was executing a missed approach. The Brasilia pilot maintained 3,600 ft and tracked over the aid.

When the Shorts pilot advised that he was 5 NM by GPS south of the NDB and maintaining 2,600 ft, the Brasilia pilot commenced an NDB approach. When the Brasilia was turning inbound, the Shorts pilot advised he was over the aid and would commence an approach and follow the Brasilia in the procedure.

At the minima for the NDB approach procedure, the Brasilia crew were not visual with the runway, and commenced a missed approach in heavy rain at 0927. The Brasilia pilot was aware that the Beech 36 was now in conflict (ETA 0927), and tried to contact the pilot on both the mandatory broadcast zone (MBZ) and area frequencies without any response. Brisbane Centre was then contacted to ascertain the whereabouts of the Beech 36. Brisbane Centre said that the pilot had last reported when he changed to the MBZ frequency. Brisbane Centre then passed traffic on a DHC8 inbound from Brisbane to Bundaberg ETA 0935. Communications were established between the Brasilia and the DHC8 on the MBZ frequency.

The Brasilia pilot then executed a sector entry for a further attempt at the NDB approach. As the Brasilia approached the aid, the Shorts pilot advised that he was going around at the minima, and he also tried to contact the pilot of the Beech 36. As the Brasilia pilot commenced the second approach, the Shorts pilot advised that he was diverting to Brisbane. When the Brasilia pilot was turning inbound, the DHC8 pilot advised that he was over the aid and would follow the Brasilia in the procedure.

The Brasilia pilot said that approaching 800 ft they noticed the weather was improving, and they became visual at approximately 700 ft. After landing on runway 14, the Brasilia pilot executed a 180-degree turn to backtrack and saw the landing lights of an aircraft on short final for runway 14. The Brasilia pilots turned on all landing lights to illuminate themselves to the oncoming aircraft, then expedited to the taxiway as the other aircraft executed a low-level go-around and joined left downwind. The Brasilia pilot said he assumed the aircraft they had seen was the Beech 36, and he made a broadcast to the pilot of the inbound DHC-8 to alert him of the circuit traffic. The pilot of the Beech 36 was still unable to be contacted on the radio, and he landed in front of the approaching DHC-8, taxied off the runway, and parked. Prior to shutdown, the Brasilia pilot heard Brisbane Centre ask the DHC-8 pilot to attempt to contact the pilot of the Beech 36 on the superseded MBZ frequency 119.1 MHz. The pilot of the Beech 36 was located on this frequency and the pilot of the DHC-8 advised him of the correct frequency.

The investigation revealed that the pilot of the Beech 36 had been referring to an out-of-date Bundaberg runway 14 NDB instrument approach procedure. The page showed the superseded MBZ frequency. The pilot had written the correct frequency, which he had obtained from the en-route supplement, on his flight plan. However, he had not referred to the flight plan again. Due to the adverse weather conditions and high workload, he had only referred to the out-of-date approach chart, and this had led him to select the incorrect frequency. During his arrival, because he had not heard any radio transmissions from the other aircraft that were inbound, he assumed that they had landed. He had then conducted a holding pattern, a sector entry, and the NDB approach procedure with the crews of the other aircraft being unaware of his presence.

SAFETY ACTION

As a result of this occurrence, representatives of the Bureau of Air Safety Investigation held a meeting with officers from Airservices Australia and the Civil Aviation Safety Authority to discuss the safety deficiencies identified during the investigation. Agreement was reached that as a matter of priority, the Civil Aviation Safety Authority and Airservices Australia would:

1. amend pilot operating procedures so that when a frequency change is made, notification will be provided to other traffic of the location and frequency of the MBZ/CTAF to which the pilot is changing; and

2. institute radio checks for pilots in IMC entering a MBZ/CTAF who have been previously advised of traffic information and are subsequently unable to make radio contact with the other pilot(s).

The meeting considered a number of other issues in relation to MBZ/CTAF operations and the consequent effect on safety. In this context, the Bureau representatives agreed to review these issues with a view to framing appropriate recommendations. Subsequently, the Bureau issued Interim Recommendation IR970110 to Airservices Australia and the Civil Aviation Safety Authority on 4 July 1997. The interim recommendation stated the following:

"The Bureau of Air Safety Investigation recommends that Airservices Australia and the Civil Aviation Safety Authority:

1. implement methods for the timely dissemination of the MBZ or CTAF frequency to pilots;

2. implement methods of providing to pilots confirmation of the correct selection and operation of an MBZ or CTAF frequency;

3. examine the requirement for the establishment and operation of traffic alerting services at all aerodromes during RPT operations;

4. examine the provision of additional radar coverage in the Bundaberg area; and

5. examine the provision of surveillance for other locations serviced by RPT operations".

The following response was received from Airservices Australia on 1 September 1997:

"Reference is made to the Bureau's Air Safety Interim Recommendation No IR970110 which relate to communications procedures for MBZ and CTAF. With regard to Interim Recommendation 1, Airservices have issued a NOTAM instructing pilots to report the frequency to which they are changing as part of the "Changing To" call. The frequency quoted is, whenever practicable, recorded by ATS for the information of other pilots. Airservices do not intend providing the MBZ or CTAF frequency to pilots on an individual basis as a matter of routine. Other methods of disseminating the MBZ or CTAF frequency, e.g. via AWIB broadcast will be taken into consideration.

It should be noted however, that the longevity of this procedure is not great, given the likely directions of Airspace 2000 and introduction of the National Advisory Frequency (NAF) in Class G airspace.

Interim Recommendations 2 and 3 fall within the CASA areas of responsibility for a response.

Interim Recommendations 4 and 5 relating to the provision of additional surveillance in the Bundaberg area and for other locations serviced by RPT will be considered by Airservices."

The following response was received from the Civil Aviation Safety Authority on the 13 November 1997:

"I refer to your letter of 4 July in relation to BASI Occurrence 9701646 generating Air Safety Interim Recommendation IR 970110. The occurrence resulted from incorrect frequency usage in the Bundaberg MBZ.

The following are the CASA responses to the individual parts of the Interim Recommendation:

IR part 1

The normal AIS process is designed to ensure that pilots have the correct information pre-flight. This is supported by CAR 233(1)(h) which requires pilots, before commencing a flight, to have the latest editions of maps, charts and other aeronautical information.

IR Part 2

A NOTAM was issued requiring pilots to advise the frequency changing to; this was complemented with an instruction to ATS staff to record this frequency for advice to subsequent aircraft as required. CASA is awaiting a response from BASI as to the reduction in the number of incidents since this procedure was implemented.

[The Bureau forwarded the incident information to the Civil Aviation Safety Authority on 25 November 1997.]

The CASA Board has determined to initiate a legislative process to require the provision of third party communications at uncontrolled airports served by RPT; industry and Airservices will be advised in the near future. CASA is also seeking results of the initial trials of the "beep back" facility which, in responding to radio calls, confirms selection of the correct frequency.

IR part 3

As part of the "third party communications" legislative initiative mentioned above, CASA will examine the requirement for the operation of traffic alerting services at aerodromes during RPT operations. This would need to integrated with Airspace 2000 initiatives and policy issues such as classification of operations.

IR parts 4 and 5

CASA does not have specific standards for the provision of radar services, but has encouraged use of existing radar coverage to enhance safety. While it may prove to be a significant safety enhancement to provide additional radar coverage in the Bundeberg [sic] area, it would not seem practical or cost efficient to require radar surveillance of all terminal areas serviced by RPT operations."