FACTUAL INFORMATION

The aircraft was involved in aerial spraying operations. The pilot was preparing to do a clean-up run along the edge of a paddock on a heading of approximately 135 degrees. He initially flew due west alongside a powerline. He then turned right to fly under the powerline and return to begin the clean-up run. While approaching the start of the clean-up run, the pilot's attention was focussed on the east-west powerline which he was to again fly under. Before reaching that powerline, the pilot suddenly saw another wire immediately in front of him. He pushed the yoke hard forward to minimise the damage to the aircraft, but the powerline hit the tail area. The aircraft deviated towards the ground before he was able to regain control. The top third of the vertical stabiliser had been removed and the rudder destroyed. Even though directional control was severely affected, the pilot was able to fly the 10 NM back to the airstrip and land without further incident.

The pilot reported that the property owner had briefed him on the location of four powerlines in the area, including the powerline he had flown under. He did not brief the pilot on the powerline that was hit. The pilot stated that the property owner appeared to assume that he knew the location of all the relevant powerlines as he had sprayed in that area a few weeks prior to the accident.

The pilot reported that the powerline was difficult to see as it was not marked and the weather conditions were overcast. It was a clear span powerline between a post located amongst some trees and a shed.

ANALYSIS

The pilot was not aware of the location of the powerline which the aircraft impacted at the commencement of a spraying clean-up run. Although the pilot had been informed of four other powerlines in the area, he had not been briefed on, or noticed, this particular powerline. The clear span wire would have been difficult to detect as it was not marked, was observed against an overcast background, and the post was located amongst trees.

A Mig-15 aircraft was being flown on a series of touch and go circuits from runway 06 at Camden, NSW, for the purposes of type endorsement training. The aircraft was being flown by a student, under the supervision of an instructor pilot. During the final landing of the sequence the aircraft overran the runway at moderate speed, resulting in damage to the left hand undercarriage actuator assembly. The owner of the MIG-15 was observing the sortie from the ground, and reported that on each approach the aircraft had appeared to be fast and high on final.

During the final landing he observed the aircraft to touch down approximately 200 m in from the beginning of the runway, bounce slightly, and begin to float in ground effect. The next touchdown was about half way along the runway, after which a skid developed. He lost sight of the aircraft as it neared the end of the runway. The instructor pilot reported that the initial touchdown had been quite smooth, and gentle braking had been applied very soon after. Because the aircraft was bouncing on the nose landing gear, the instructor told the student to correct the nose attitude and progressively apply heavier braking.

However, the student pulled the control column back, resulting in the aircraft becoming briefly airborne. An instruction to the student to relax the brake pressure was apparently not heard. When the aircraft touched down again the left mainwheel tyre burst. The subsequent loss of braking and steering effectiveness resulted in the aircraft leaving the end of the runway. During a previous training sortie flown by the student earlier in the day, both mainwheel tyres had failed during landing.

The pilot was flying a Cessna 185 aircraft on a VFR charter flight from Moorabbin to Peterborough with 2 passengers. On arrival at Peterborough he overflew the strip and estimated the wind to be from 220 degrees at 5 to 7 kts. The strip has an uphill gradient to the east, and, even though this would result in a slight tailwind from the right quarter for the landing, the pilot elected to accept this and make use of the uphill gradient.

The landing was reported to have been smooth and light and was accomplished with a trickle of power and full flap (4 stages). During the roll out the aircraft diverged slightly left and then made a rapid and increasing swing to the right. Application of rudder and brake was not able to stop the developing ground loop. The aircraft left the mown strip with the group loop tightening until the left main landing gear collapsed. The aircraft came to rest pointing back down the strip towards the touchdown point.

After shutting down the engine the pilot and passengers evacuated without assistance or injury.

The pilot considered that he should have used a different technique when landing. A powered approach with 2 stages of flap, raising the flaps as soon as possible after landing, and using power to ensure adequate rudder authority during roll out would have result in control of the aircraft being maintained.

The pilot of the PA28 had departed Wallan for a flight to Coolangatta. At approximately 37 km southwest of Mudgee, the aircraft engine began to run rough following a sudden loss of engine oil pressure. A burning smell and an increase in indicated engine temperature was also evident. Due to the inhospitable terrain ahead to Mudgee, the pilot decided to conduct a forced landing in a nearby field.

The pilot broadcast a distress call to Sydney Flight Service (FS) and a Distress Phase was declared. Due to the field length and surface conditions, the pilot chose to carry out a 'wheels up' landing. This was successfully carried out and the pilot and passenger vacated the aircraft without injury. The ELT was automatically activated. Upon telephone confirmation of the situation of the pilot and passenger and deactivation of the ELT, FS cancelled the Distress Phase.

The aircraft had been tasked by police to provide assistance to two people in difficulty in Lake Munmorah. With the aircraft in the hover, the crewman stepped into the water with the intention of assisting the swimmers. As the water was shallow, the crewman's foot hit the bottom of the lake hard, breaking his ankle. People from the shore rescued the swimmers and the crewman in the water. The crewman was later flown to hospital for medical treatment.

The crew's actions were in accordance with their training and the company's operations manual. However, these procedures contain a latent failure in that they are not safe in shallow water or where there may be submerged objects. Since this occurrence, procedures have been changed so that crewman can only jump from the aircraft when it is out to sea. A crewman who needs to enter the water in a bay, lake or river has to be winched into the water. The operations manual has been amended to avoid a repeat of this occurrence. No further safety action is required.

Occurrence Summary

On four occasions in three months, pilots from the same local company have reported difficulties communicating on the Whyalla MBZ frequency with the flight crews of one particular RPT operator. Following these incidents, the local company raised the following concerns:

(1) crews of the RPT aircraft do not always provide an initial taxy call on the MBZ frequency when preparing for departure from Whyalla;

(2) crews of the RPT aircraft appear to change to the Whyalla MBZ frequency at approximately 10 NM rather than the required 15 NM; and,

(3) crews of the RPT aircraft are often not contactable on the MBZ frequency following an initial inbound broadcast at 25 NM from Whyalla.

The RPT operator's standard operating procedure required crews to monitor the MBZ frequency within 25 NM of Whyalla. Any company calls were to be completed during cruise and not during the approach and arrival phases. The aircraft were equipped with dual VHF radios so that a continuous listening watch was maintained on both the MBZ and flight service frequencies. The report to flight service that the crew were switching to the MBZ frequency was a formality and indicated that this was the prime frequency for communication during the arrival and departure.

The pilot of the RPT aircraft recalled that, on 19 December 1997, all the standard reports and broadcasts were given. He also recalled that a pilot of one aircraft in the area was referring to the company name and not the aircraft's specific identification. This did not immediately attract the pilot's attention because the flight number was not specifically mentioned and several aircraft of the same company were operating in the area at the time.

The airspace around Whyalla can be congested at certain times with the arrival and departure of several aircraft as well as local aircraft operating in the area. It is not uncommon for radio communications to be overtransmitted as appeared to have occurred in one of the reported incidents. There were also a number of nearby CTAFs which utilise the same frequency as the Whyalla MBZ, which adds to the communication congestion.

Safety Action 

Representatives from both the companies, as well as from CASA, met in order to clarify the circumstances of the incidents and to resolve any outstanding concerns about operations in the MBZ at Whyalla. The trial of flight numbers for aircraft callsigns was discussed. It was agreed that flight numbers did not provide any information as to the aircraft type, and therefore its performance and flight profile. It was later clarified that the RPT operator, as with all operators who participated in the trial, was no longer bound to continue to use flight numbers as callsigns.

It was proposed to change the Whyalla MBZ to a discrete frequency as many aerodromes in the local area used the same frequency (126.7 MHZ). The Adelaide office of CASA supported the proposal.

Both companies expressed a willingness to be flexible with aircraft tracking and aircraft operation during climb and descent to facilitate operations within the MBZ.

A Boeing 747 (B747), en route from Sydney to Hong Kong, was maintaining flight level 350 (FL350) and had been radar identified by Manila Air Traffic Control. The flight crew observed another aircraft maintaining the same level approximately 20 NM to the east displayed on their aircraft's traffic alert and collision avoidance system (TCAS). The B747 crew sighted the other aircraft as it crossed their track from east to west. The crossing aircraft was en route from Manila to Kuala Lumpur and had initially been assigned FL280.

On first contact with radar control that crew had been instructed to climb to FL350. The controller noted the proximity of the two aircraft and instructed the crew of the B747 to climb immediately to FL370. At the same time the B747 TCAS announced a "Climb" resolution advisory (RA) instruction. The B747 crew complied with the climb instruction. The crew of the crossing aircraft advised the B747 crew that they had received a TCAS RA instruction to descend which they had followed. There was a breakdown of separation. Following an investigation of the occurrence the Republic of the Philippines, Department of Transport and Communications air traffic services investigator reported that all area control centre controllers would undergo radar simulator training to enhance their proficiency. The training was to commence in January 1998.

The aircraft was returning from the training area when the pilot reported that he was experiencing engine problems. He then reported conducting a forced landing. Aircraft were dispatched by the controller to observe its progress. The pilot had elected to land in the grounds of a school. As he approached the area he found that it was too short for a normal landing and steepened his approach. The landing gear was torn off on touchdown and the aircraft stopped within the confines of the playground.

Examination of the engine disclosed failures of a number of connecting rods, which were protruding from the top of the engine block. The failure is being investigated by CASA, as part of its engine certification process.

A Boeing 767 (B767) was conducting an instrument landing system (ILS) approach to RWY 16R in instrument meteorological conditions (IMC). The aircraft had left 3,000 ft and the crew were in contact with the aerodrome controller (ADC). When some 11 NM from the airport the crew saw a target appear on their traffic collision and avoidance system (TCAS), 3.5 NM ahead, some 1,500 ft below, and climbing at 500 ft/min on a conflicting course. The crew of the B767 stopped their descent at 2,200 ft, and diverted slightly to the right of the ILS centreline to avoid the target. At about the same time the ADC observed a secondary surveillance radar (SSR) symbol from an unidentified aircraft in the Ryde bridge area. The SSR code was 2000, which was the appropriate code for civil aircraft flights in non-controlled airspace. The aircraft was west of the extended centreline of RWY16R, 8 NM north-west of the airport, and tracking north-east at an unconfirmed altitude of 1,500 ft. The crew of the B767 queried the ADC regarding the other aircraft and were advised that radar indicated the aircraft was ahead and below the B767. The two aircraft passed and the crew of the B767 subsequently encountered visual conditions and resumed their approach. The crew of the B767 did not see the other aircraft, which was later identified as a Cessna 172 (C172) that had departed Bankstown for Archerfield, tracking via the northern VFR route at 1,500 ft. Recorded data showed that the C172 had entered controlled airspace without a clearance and had subsequently passed below the B767 with 700 ft vertical separation and 0.75 NM lateral separation.

The required separation standard was 1,000 ft vertical, or 3 NM lateral. The pilot of the C172 had not previously flown in the Sydney area, and had only become aware he was off track when he realised he was too close to the city centre. At that point he had turned left to track north in order to leave controlled airspace. The progress of the B767 was the responsibility of the Director West (DIRW) controller until the aircraft landed. The DIRW had been engaged in a discussion with another controller when the C172 entered controlled airspace and consequently did not see the C172 conflict with the B767.

The ADC was provided with a radar display to assist him to appreciate the disposition of aircraft in the vicinity of the runway. However, the ADC was not responsible for separating traffic on the final approach path. Aircraft departing Bankstown to the north, outside controlled airspace, are required to track via the standard VFR route as depicted on the Visual Terminal Chart. This entails tracking 007 degrees from Bankstown, not above 2,000 ft, until reaching Pennant Hills, where climb can be continued to 2,500 ft. The VFR route passes below the approach/departure paths for aircraft using runways 16/34 at Sydney. The Manual of Air Traffic Services (MATS) states that; 'In providing radar services within controlled airspace, restricted areas, or designated restricted airspace, ATC has no responsibility to initiate avoiding action in respect of unknown aircraft which can reasonably be assumed to be outside controlled airspace. Nevertheless, if in the judgement of the radar controller, the action of an observed radar return or information received from other sources gives good reason to believe that the observed radar return of an unknown aircraft is likely to be a hazard to an aircraft under control, the controller has complete discretion to take such action as considered necessary to maintain the safety of the aircraft under radar control.

This may comprise the provision of:

a. traffic information; or

b. controller initiated traffic avoidance advice; or

c. a safety alert' Local safety action taken as a result of this occurrence included;

1. Providing a video recording of the occurrence to highlight to controllers the implications of not maintaining an adequate scan of the radar display.

2. Amending radar controller refresher training to include situations in which aircraft infringed controlled airspace, and

3. Reminding aerodrome controllers that while they are not responsible for the separation of aircraft on the final approach path they are, in conjunction with the Directors, responsible for monitoring the approach and departure areas for infringing aircraft.

The Piper Cherokee Lance (PA32R-300) was prepared for departure from runway 35 at Essendon for a flight to Moorabbin, Phillip Island and return. The outside air temperature was 29 degrees C and the wind was from 320 degrees, gusting between 15 and 25 kt. This resulted in a crosswind of 12 kt and a density altitude of approximately 2,000 ft.

The pilot decided to conduct a flapless take-off. He had used this take-off configuration successfully on previous departures from Essendon. The pilot reported that during the take-off roll the aircraft accelerated normally and the engine reached its maximum power indications of 2,700 rpm and 27 in of manifold pressure. As the aircraft lifted off at an airspeed of approximately 65 kt the right wing dropped suddenly, and the aircraft yawed to the right. The pilot corrected the wing drop and the yaw but then realised that the aircraft was not climbing normally. With maximum power still being applied, the airspeed was still indicating 65 kt.

The pilot retracted the landing gear when he had insufficient runway remaining on which to land and advised ATC that he had a problem. When the tower controller observed the aircraft at a very low altitude and flying towards a series of high-tension powerlines, he activated the 'common-crash' alarm.

The pilot was able to fly the aircraft over the high-tension powerlines at the lowest point of the span, which meant that the aircraft was below the height of the pylons. He stated that he felt the aircraft seemed to be having difficulty remaining airborne and that it only felt normal when he lowered the nose attitude. However, he then had to raise to nose attitude to climb over obstacles. He carried out relevant checks but was not able to identify any problems that may have affected the aircraft's performance.

The pilot was able to keep the aircraft flying until he reached a large paddock suitable for a forced landing. He applied two stages of flap and extended the landing gear for the landing. The surface of the paddock was very rough and sloped downhill from the touchdown point. The pilot was not able to stop the aircraft before it continued across a low embankment and through a fence. The aircraft was substantially damaged. The pilot and his two passengers were not injured and were able to evacuate the aircraft without assistance.

The investigation did not find any evidence of a malfunction with the aircraft, the engine, or associated systems. However, it was found that the elevator trim was in the full nose down position and that the rudder trim was full nose left. This flight was the first after a periodic maintenance check had been carried out. It is likely that the trims were not returned to neutral following the maintenance, and this was not noticed by the pilot during his pre-take-off checks.

At the take-off weight of approximately 1500kg the PA32R-300 flight manual charts indicate that the take-off safety speed (TOSS) for the aircraft is 72 knots. The nose attitude is required to be raised smoothly for a flapless take-off, and the aircraft accelerated to a minimum of 72 knots, before the pilot adopts the appropriate attitude to attain a climb speed of 92 knots.

It is likely that the aircraft was adversely affected by a gust of wind as it lifted off. In addition, the incorrect trim tab settings would have resulted in the aircraft flying in an unbalanced condition. This imbalance would have produced extra drag with a resulting reduction in airspeed. To correct the wing drop and yaw the pilot would have had to promptly apply coarse control inputs. Drag would have further increased, with a corresponding reduction in airspeed. It is probable that the aircraft did not have sufficient power to overcome the drag resulting from the low speed and high nose attitude - a condition commonly known as 'flying on the back of the drag curve'. The density altitude and high temperature on the day would have also adversely affected the aircraft's performance.