The aircraft landed with the landing gear retracted. The pilot said that he had forgotten to extend the gear.

The Cessna 210 aircraft had completed a local flight in the Bankstown area and was returning to land on runway 29 right. On final approach the pilot noticed that the windsock was indicating a crosswind from the left and elected to complete the landing using flap 20. The pilot reported crossing the runway threshold at an airspeed of approximately 80 knots, although the aircraft seemed to have a higher ground speed than would be normally associated with this approach speed.

The aircraft was flared and touched down briefly, before becoming airborne again. The pilot attempted an unsuccessful recovery from the initial bounce, but the aircraft continued to porpoise down the runway. As the nose wheel contacted the runway for the fourth or fifth time, a loud bang was heard and the nose of the aircraft settled onto the runway.

The aircraft slid to a stop and the occupants vacated the aircraft without assistance. The Aerodrome Safety Officer extinguished a small fire that had broken out in the wheel well.

The pilot reported that had commenced the take-off run with no flap selected but felt that the aircraft was slow to accelerate to take-off speed. He then selected flap and the aircraft became airborne. There were trees and high ground beyond the end of the strip and the pilot turned the aircraft right to avoid this area.

As the aircraft turned, it struck a powerline and then impacted the ground in a nose down attitude. The pilot and passenger were uninjured. The pilot stated that the aircraft was about 100 lb under maximum weight with the centre of gravity within the envelope. He believed that the aircraft encountered wind shear and a downdraft leading to loss of performance. The ambient air temperature was 34 degrees C, with less than 5 kts wind at the time of the accident.

The pilot was conducting topdressing operations from a property airstrip located in undulating terrain. He reported that he had refuelled the aircraft after 11 flights, and that the accident occurred on the seventh take-off after refuelling. The aircraft appeared to be operating normally but failed to gain flying speed before reaching the end of the strip.

During the subsequent collision with the terrain, both wings, both elevators, the engine, and the main landing gear were torn from the aircraft. The aircraft came to rest facing back towards the airstrip, about 200 m beyond and 100 ft below the level of the airstrip. The pilot stated that he had observed indications of localised whirlwinds and considered it likely that as he attempted to lift the aircraft from the strip, the aircraft's performance had been adversely affected by one. Weather conditions at the time were fine with a north-westerly wind of 6 to 10 kts.

Port Moresby ATC passed coordination to Brisbane Centre on ANA923 and QFA 114 but the flight levels coordinated were incorrect. ANA 923 was coordinated at flight level 390 and QFA114 at flight level 370. At 1700, the pilot of ANA923 reported at VIPAM at flight level 370. When this was passed to Brisbane sector 11, confirmation of the flight level was requested, and this was confirmed by the pilot. Sector 11 contacted Port Moresby by telephone, and Port Moresby confirmed flight level 390.

At approximately 1710, Port Moresby called back to apologise and advise that the level coordinated should have been flight level 370, and QFA 114 should have been flight level 390.

The helicopter was being used for flight training. The student had been experiencing some problems in stabilising the hover so the instructor placed the helicopter light on the skids to allow the student to practice use of the cyclic control. Because the student had a tendency to allow the helicopter to drift right as the helicopter came light on the skids, the instructor gave the student control of the cyclic and yaw pedals whilst he retained control of the collective.

After several attempts, the student's cyclic control had apparently improved sufficiently that the instructor was confident to bring the helicopter into the hover. However, during the following three attempts the student found hover control difficult and after several seconds in the hover, the instructor had to take control. During the fourth attempt, the student allowed the helicopter to drift right slightly. With the helicopter approximately 1 ft off the ground, the student unexpectedly made a large right cyclic input and allowed the helicopter to yaw left. The instructor did not respond quickly enough to prevent the helicopter sinking and the right rear skid struck the ground. As the ground contact was firmer than normal, the instructor decided to air taxi the helicopter to the parking area. The helicopter's airframe, right skid and tailboom were found damaged.

The pilot reported that during a flight from Sydney to Lismore the right engine suffered two "rollbacks". Rollback is a phenomenon in which aircraft engines lose power. On the subsequent flight to from Lismore to Sydney the right engine suffered one "rollback". The problem is a known fault and can be caused by icing at the inlet cowl area.

A domestic Boeing 767 was inbound to the holding pattern at Cullerin and the crew had been issued a requirement to reach their assigned level of FL 290 before entering the pattern. The crew of a Boeing 747 already established in the Cullerin pattern observed the inbound aircraft descending through its assigned level and alerted ATC. The descending aircraft was visually sighted and was displayed as traffic on the TCAS.

The pilot of the descending B 767 indicated that the autopilot had not captured the assigned level as programmed. The pilot indicated that this was possibly complicated by late amendments to the holding instruction. The crew intervened when it became apparent that the autopilot had not captured the assigned level, but not before the aircraft had descended approximately 400 ft through the assigned level.

The controller indicated that 1,000 ft vertical separation between the two aircraft was quickly re-established, and the aircraft were horizontally separated by 3 - 4 NM.

The pilot reported that while cruising at about 600 ft AGL, he heard a loud noise and the helicopter shook violently. He initiated autorotation and helicopter landed heavily a short time later. Both occupants escaped with minor injuries.

Subsequent investigation revealed that the transmission torsion coupling had broken, and two steel back up pins had sheared. The transmission failure had caused complete loss of torque to the main rotor. The tail rotor and gear box showed no evidence of pre -impact damage.

FACTUAL INFORMATION

The Airbus A340 (A340) was on air route A587 and the Boeing 737 (B737) was on air route G462. The routes intersected at waypoint KETUT, which is 200 NM bearing 103 degrees magnetic from Bali. Both aircraft had been cleared to enter the Bali flight information region (FIR) at flight level (FL) 350. The waypoint KETUT is a reporting point for aircraft on A587 but not for aircraft on G462. All communications prior to this point were made on high frequency (HF) radio SELCAL, which does not alert pilots that there may be conflicting traffic.

The conflicting traffic was under the jurisdiction of the Bali East controller. There was radar coverage to approximately 150 NM, and a combination of procedural and radar control was being used by the controller. Flight plans for both aircraft had been received at the Bali Control Centre. However, the flight plans did not indicate an estimate for the KETUT position.

At the time of the incident, the controller had three aircraft on his frequency - the B737, the A340, and a Boeing 747 (B747) en route Singapore to Sydney. The B747 was tracking via Bali at FL330 and the B737 would have had to descend through that level for arrival at Bali. The B747 was identified on radar and was estimating overhead at Bali at 1436 UTC. The other two aircraft were not identified on radar.

At 1410, the A340 pilot reported to Bali East at ONOXA, a reporting point on the FIR southern boundary. ONOXA is 197 NM from KETUT on the designated route A587. The Bali East controller then requested an estimated time of arrival (ETA) for IKAPI, a reporting point on the northern FIR boundary where the aircraft would exit the FIR. The pilot advised an estimate of 1530 and the controller coordinated this information to Ujung Pandang, which was the next control agency.

KETUT was a compulsory reporting point for aircraft on A587. The reason the A340 crew did not advise an estimate for KETUT when reporting at ONOXA was not established. The reason the controller did not request A340's ONOXA estimate was also not established.

At 1428, the crew of the B737 reported at SOTRA at FL350. The Bali East controller requested an ETA for GABIT, a reporting point 150 NM east of Bali, and the crew advised that their ETA was 1447. At 1439 the crew of the A340 requested advice of any traffic at FL350. The controller asked the crew to repeat the request. The A340 crew then stated that they were descending to FL310 to avoid conflicting traffic. The crew of the B737 asked the crew of the A340 to report their position. There was no reply to this request. The A340 crew then reported to the Bali East controller that there was traffic 2 NM to their north, passing from right to left at FL350. The controller questioned this report. The A340 crew repeated the information and reported that they were maintaining FL310. The controller then advised the A340 to "maintain FL310 for a while". At 1443, the A340 was cleared to climb to FL350 by the Bali East controller.

At the time of the occurrence, the control centre was staffed by four controllers and a supervisor. The Bali East controller had left the control room on a break and another controller had taken over control duties of the Bali East sector. The controller taking over had not been aware of the potential conflict between the aircraft on air routes A587 and G462.

Although the occurrence location was within normal radar coverage, the radar data was not being recorded during the period of the incident due to a technical problem.

Each control position had a single flight progress strip bay. The bay was used to store pending flight progress strips. Active flight progress strips were placed on the flat console surface in front of the radar screen. There was a checklist for the compilation of flight progress strips, but this had not been compiled with.

ANALYSIS

The controller had taken over the Bali East sector duties only a short time before the incident and he had not been properly briefed on the traffic that was within his jurisdiction. His attention appeared to have been focussed on the potential conflict between the southbound B747 at FL330, and the B737 inbound to Bali at FL350. He was aware that the B737 would require descent through the B747's level but had not been briefed that there was a requirement to establish vertical separation between the A340 and the B737. The situation was compounded because the flight progress strips were not prepared in accordance with the checklist and the flight progress bays were not being utilised in the most appropriate manner to provide situational awareness of the traffic in the sector.

Although, in this instance, an estimate for the KETUT position was omitted by the crew of one aircraft, the provision of an estimate by the crew of the other aircraft may have assisted the controller to better appreciate the traffic disposition, and alerted him to the confliction. In this context, the promulgation of KETUT as a compulsory reporting point for the two intersecting routes (A587 and G462) would have provided a higher level of safety.

Controllers normally combined flight progress strips for aircraft being controlled on the radar display console. However, this action ensured that aircraft being controlled by different procedures (radar and procedural control) were not easily differentiated. It also provide limited cues to controllers to assist them in maintaining an awareness of traffic disposition in their area of responsibility. Use of the available flight progress board with a number of key position designators would assist controllers in the management of aircraft under procedural control. Positioning the flight progress strips for radar-identified aircraft at the radar display console, adjacent to the procedural flight progress board, would have provided a better overall representation of traffic disposition.

SIGNIFICANT FACTORS

1. KETUT was not a compulsory reporting point for both routes.

2. The controller who compiled the flight progress strip for the A340 did not notate KETUT on that aircraft's strip.

3. The controller handing over responsibility for Bali East control did not conduct an adequate handover.

4. The Bali East controller did not adequately review the active flight progress strips after taking over responsibility for the position.

5. A procedural flight progress board was not used to manage aircraft operating in the Bali East area of responsibility.

6. The crew of the A340 did not advise an estimate for KETUT, a compulsory reporting point.

7. The Bali East controller did not appreciate the conflict between the A340 and the B737.

SAFETY ACTION

As a result of this occurrence the B737 operator:

1. issued a safety notice to all aircrew advising them of the details of the occurrence; and

2. recommended that the priority be given for the fitment of a traffic alert and collision avoidance system (TCAS) to company aircraft operating international flights.

In addition, the Bureau of Air Safety Investigation suggests that the Indonesian Directorate of Aviation Safety, in conjunction with Angkasa Pura I:

1. review flight progress strip display practices and procedures, including strategies to ensure their correct compilation;

2. review published handover/takeover procedures, including strategies to improve controller compliance; and

3. 3. Include KETUT as a compulsory reporting point for aircraft operating on route G462.