Forced/precautionary landing involving a Schweizer Aircraft Corp 269C-1, VH-CBZ, 4 km south of Kingscliffe (ALA), New South Wales, on 8 May 1997

Summary

The pilot reported that he was in the Coolangatta training area practising forced landing procedures with a student pilot. An autorotation was entered by lowering collective initially, then the throttle was wound off. Carburettor heat was selected fully on, carburettor air temperature was indicating approximately 12 degrees Celsius, and the engine was idling. The pilot said he turned towards the forced landing area and was briefing the student on the wind direction. The rotor RPM was in the green range and indicated airspeed was 55 knots, the correct autorotation airspeed. The pilot said that at this stage he was downwind (5-10 knots approx) and was ready to turn into wind at approximately 300 ft AGL. The collective was raised and the throttle was opened fully, but the manifold pressure increased only to 14-15 inches, there was a definite lack of power and the rotor RPM decayed. He maintained heading and airspeed and re-entered autorotation heading for the forced landing area when he noticed the engine had stopped. He said he attempted a restart but at this stage he was too low to risk a turn and accepted his present direction. The landing was made onto a tree lined track. The main rotor contacted trees and the aircraft rolled over to the right on the sandy surface. The pilot suspected that carburettor icing may have been the problem.

The weather conditions at the time were light drizzle or rain with a temperature of 18 -20 deg C. These conditions were conducive to carburettor icing. The pilot said that he had experienced power loss with this type of helicopter in similar situations, but usually on the initial entry into the autorotation. The aircraft manufacturer carried a technical investigation and found no evidence of any failure or malfunction that may have led to the accident. The manufacturer stated that the carburettor heat fully applied in autorotation produces an indication on the carb air temp gauge of full scale deflection. However, this has not been the operators experience. The operator advised that with full carb heat the temperature remains in the mid (caution) range and pilots have been advised to terminate autorotations and apply power if the carb air temp falls below this value. The operator now requires pilots to practice autorotations over a clear landing site, so that a landing may be terminated should the situation recurr.

Occurrence summary

Investigation number 199701493
Occurrence date 08/05/1997
Location 4 km south of Kingscliffe (ALA)
State New South Wales
Report release date 22/07/1997
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 Schweizer Aircraft Corp
Model 269C-1
Registration VH-CBZ
Sector Helicopter
Operation type Flying Training
Departure point Coolangatta QLD
Destination Coolangatta QLD
Damage Substantial

Near collision involving a de Havilland Canada DHC-6 SERIES 320, VH-KZQ and Piper PA-31-350, VH-HVA, 20 km south-west of Aeropelican (ALA), New South Wales, on 7 May 1997

Summary

FACTUAL INFORMATION

A Piper Chieftain departed Sydney for Maitland via Kamba, a position located 30 NM north-east of Sydney, on climb to 5,000 ft. The Chieftain was on an Instrument Flight Rules (IFR) flight and the pilot-in-command's (PIC) estimate for Kamba was 1756 EST. Kamba was the position where the Chieftain would leave controlled airspace (CTA) and the PIC would transfer from the air traffic control (ATC) frequency to the flight service (FS) frequency.

At 1753 a DeHavilland Twin Otter taxied at Aeropelican for a IFR flight to Sydney via the Calga Non-Directional Beacon (NDB) navigation aid at a planned altitude of 6,000 ft. Calga NDB was located approximately 32 NM north of Sydney and 12 NM to the west of Kamba. The Twin Otter's intended track crossed the Chieftain's planned track north of Kamba. The Twin Otter departed at 1756 and was transferred to ATC at 45 NM from Sydney. While the aircraft was in non-controlled airspace the PIC continued to monitor the FS frequency on a second radio.

The weather in the area north of Sydney was such that conditions were Instrument Meteorological Conditions (IMC). The Chieftain was approximately three minutes ahead of the PIC's estimate for Kamba due to a strong tailwind. The PIC transferred to the FS frequency at 30 NM from Sydney and reported that the aircraft was maintaining 5,000 ft. The FS operator did not acknowledge the report and the PIC of the Chieftain did not confirm that FS had received this report.

At 1759 the PIC of the Chieftain reported to the FS operator that the aircraft was leaving 5,000 ft on descent into Maitland. The FS operator acknowledged the report. Shortly after, the FS operator gave the crews of both aircraft the relevant traffic information on their flights. The PIC of the Twin Otter called the PIC of the Chieftain and reported passing 5,300 ft on climb. The PIC of the Chieftain sighted the Twin Otter off to his right and about 400 ft above the level of his aircraft but was unable to assess the distance between the aircraft. The crew of the Twin Otter did not sight the Chieftain. The investigation did not ascertain the actual vertical and lateral distance between the aircraft.

The FS operator was required to give traffic information to the crews of IFR flights about other IFR flights. The Manual of Air Traffic Services detailed criteria to be used in assessing whether traffic information was required to be advised. The FS operator had correctly assessed that traffic information would need to be issued to the crews of both aircraft because of their respective tracks. A local instruction required FS operators to give traffic information to the appropriate ATC sector for relay to crews of aircraft before leaving CTA. In this instance the FS operator believed he would have sufficient time to give the traffic information to both crews once they were on his frequency. He also thought that the PIC of the Chieftain may request a climb to 7,000 ft or an amended track direct to the destination, which would amend the traffic information.

ANALYSIS

The FS operator advised the crew of the Twin Otter to contact ATC at 45 NM Sydney which was prior to the crossing point of the tracks of the two aircraft. Traffic information on the Chieftain should have been given to the crew prior to their being instructed to change to the ATC frequency.

The FS operator believed that the level or route of the Chieftain might change and this aspect probably caused him to delay giving the traffic information to the crew of the Twin Otter. Subsequently, the FS operator either forgot or became distracted with other actions such that the information was not advised until the aircraft were in close proximity.

The reason for the FS operator not hearing the initial report from the PIC of the Chieftain could not be ascertained. The PIC of the Chieftain should have continued to report to the FS operator until an acknowledgement was obtained. A lack of acknowledgement may mean that either the aircraft's or the ground operator's radio was unserviceable. The PIC may have been distracted by the weather or some aspect of the aircraft's operation and consequently did not appreciate that his report had not been acknowledged.

SIGNIFICANT FACTORS

1. The FS operator did not request ATC to give traffic information to the PIC of the Chieftain prior to the aircraft leaving CTA.

2. The FS operator did not give traffic information to the Twin Otter crew prior to the aircraft entering an area of conflict. 

3. The FS operator did not hear the initial report by the PIC of the Chieftain.

4. The PIC of the Chieftain did not ensure that his report was acknowledged by the FS operator.

Occurrence summary

Investigation number 199701495
Occurrence date 07/05/1997
Location 20 km south-west of Aeropelican (ALA)
State New South Wales
Report release date 09/06/1998
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Near collision
Occurrence class Incident

Aircraft details

Manufacturer De Havilland Canada/De Havilland Aircraft of Canada
Model DHC-6 SERIES 320
Registration VH-KZQ
Sector Turboprop
Operation type Air Transport Low Capacity
Departure point Aeropelican NSW
Destination Sydney NSW
Damage Nil

Aircraft details

Manufacturer Piper Aircraft Corp
Model PA-31-350
Registration VH-HVA
Sector Piston
Operation type Air Transport Low Capacity
Departure point Sydney NSW
Destination Maitland NSW
Damage Nil

Forced/precautionary landing involving a Howard Hughes Engineering P/L GA-55 LIGHTWING I, 25-0434, Tartrus (ALA), Queensland, on 2 May 1997

Summary

HISTORY OF THE FLIGHT

The pilot and the passenger, who was also the owner of the aircraft, performed a pre-flight check of the aircraft. Seated at the right control position, the pilot then taxied the aircraft for departure with the intention of conducting cross wind circuits. The airstrip was aligned approximately 020 degrees magnetic.

Shortly after take-off, when the aircraft was about tree top height, the passenger became aware that the aircraft did not appear to be performing normally. At about the same time the pilot assessed that the nose attitude was too steep. He lowered the nose and felt the aircraft descend. He confirmed that the throttle was set at full power and, assuming that the aircraft was stalling, lowered the nose further. When the aircraft continued to descend, the pilot attempted to land in an area about 100 m beyond the end of the airstrip.

The aircraft collided with a stack of several large posts and concrete pipes and came to rest inverted 120 m from the northern end of the airstrip but displaced about 50 m to the west of the airstrip alignment.

Both the pilot and the passenger sustained serious injuries.

At the time of the take-off the pilot had estimated that there was an easterly crosswind of about five knots, with a headwind component of about three knots. The windsock was located to the north-west of, and close to the hangar and farm buildings. A worker employed on Tartrus reported that the wind had been a light south-easterly.

The pilot normally flew and instructed in Cessna C172 or Piper PA28 type aircraft. He held an Australian Ultralight Federation pilot's certificate, but had limited experience flying ultralight aircraft. He had previously flown the aircraft at Tartrus Station four or five times.

Both the pilot and the passenger indicated that although the engine seemed to operate normally the aircraft had lacked performance. The passenger noticed that when the nose of the aircraft was aligned approximately with the horizon, the aircraft was descending. She was aware that there was a large performance degradation with two people on board and would normally fly the aircraft alone. When flying with a passenger she preferred the cooler hours of the day and would make as much use of ground effect as possible after lift-off.

AIRCRAFT EXAMINATION

The Hughes Lightwing GA-55 was manufactured in Ballina, NSW, and was powered by an Aeropower (modified Volkswagen) four cylinder, four stroke, air cooled engine driving a two bladed wooden propeller. The airframe was of high wing monoplane design. An Artex E03 emergency locator beacon was mounted behind the pilot's seat and was activated by the impact.

The aircraft forward fuselage area below and in front of the rudder pedals had sustained substantial damage.

No pre-existing defect which may have affected the controllability of the aircraft was found.

Examination of the fuel tanks found that the tanks were empty but the soil beneath the right fuel tank filler cap was found to be soaked with fuel to a depth of about eight centimetres.

The engine was fitted with a standard aircraft magneto and dual electronic modules. The electronic modules were found to be impact damaged and could not be tested. Specialist examination of the engine indicated that the magneto external timing was advanced 10 degrees beyond the recommended setting but was serviceable. No evidence was found that the magneto timing adjustment was altered during the impact sequence. No other pre-existing defect was found.

ANALYSIS

It is likely that the position of the windsock resulted in a shielding effect when the wind was south-easterly. This may have caused the pilot to incorrectly assess both the wind direction and the strength. Consequently, it is possible that the marginal performance of the aircraft was further degraded when, shortly after take-off, the aircraft encountered a crosswind with a tailwind component.

The pilot's limited experience flying this aircraft type, and ultralight aircraft generally, may have led him to apply an inappropriate handling technique in response to the low performance.

SIGNIFICANT FACTORS

1. The aircraft had marginal performance characteristics when carrying a passenger.

2. The pilot was inexperienced on the aircraft type.

3. The pilot did not maintain adequate flying speed after take-off.

Occurrence summary

Investigation number 199701420
Occurrence date 02/05/1997
Location Tartrus (ALA)
State Queensland
Report release date 30/09/1997
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 Serious

Aircraft details

Manufacturer Howard Hughes Engineering P/L
Model GA-55 LIGHTWING I
Registration 25-0434
Sector Piston
Operation type Private
Departure point Tartrus Station, QLD
Destination Tartrus Station, QLD
Damage Destroyed

Collision with terrain involving a Hughes Helicopters 269C, VH-NLK, 105 km east-south-east of Derby Aerodrome, Western Australia, on 5 May 1997

Summary

The pilot of the helicopter was conducting a familiarisation flight for the wife of the station owner who had contracted the helicopter. It was late afternoon, with the sun low on the horizon and the fine weather with no cloud or wind. End of daylight was approximately 1745. The homestead, from which the helicopter departed, was located to the west of a swamp. The swamp's water depth was approximately 1 m and the surface was reported as being mirror-flat at the time of the accident. There were two islands located in the swamp and their foliage had a maximum height of approximately 3 m.

The helicopter departed at approximately 1700 and tracked north, climbing to approximately 800 ft AGL before completing a counterclockwise circuit towards the swamp. The pilot decided to make a shallow, northerly approach to the southern island. The island's southern shore was approximately 500 m from the mainland approaching from the south. As the helicopter crossed the mainland-shore on the final approach, the pilot assessed his height as being 20 to 30 ft. 

Late in the approach the pilot decided that a landing on the island was impractical and he commenced a go-around. He stated that he placed the helicopter in an accelerative-attitude and commenced a slight right turn to avoid a bird. The passenger, sitting in the right seat, stated that she thought that the helicopter was at about 10 ft from the surface of the water as the turn commenced. She recalled a spray of water from the front right side just before the helicopter impacted the water. 

The occupants remained secured to their seats and the helicopter remained substantially intact although the canopy bubble imploded, the tail rotor gearbox was flung clear and the main rotor system and fuselage were substantially deformed. The wreckage spread and passenger report indicate that it is likely that the main rotor struck the surface of the water causing the helicopter to cartwheel before coming to rest upright.

After the impact, the occupants released themselves from the wreckage and waded ashore. They reached the shore at approximately 1725.

The pilot later reported that he was unaware of the difficulties associated with visually judging height over calm water. Lacking a radio altimeter, the final approach starting altitude and shallow angle was inappropriate in the prevailing conditions. It is likely that, when the pilot selected the accelerative-attitude and commenced the right turn, the helicopter descended slightly causing the main rotor to strike the surface of the water. The smooth water surface, failing light and low foliage height probably caused the pilot to underestimate the helicopter's height above the water and not perceive a slight descent during the go-around.

Occurrence summary

Investigation number 199701447
Occurrence date 05/05/1997
Location 105 km east-south-east of Derby Aerodrome
State Western Australia
Report release date 25/06/1997
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 Hughes Helicopters
Model 269C
Registration VH-NLK
Sector Helicopter
Operation type Charter
Departure point Blina Station WA
Destination Blina Station WA
Damage Destroyed

Loss of separation involving a Piper PA-31-325, VH-OYO and Boeing 747, 9VSFC, 15 km south-west of Sydney Aerodrome, New South Wales, on 3 May 1997

Summary

A Piper Chieftain (PA31) departed Bankstown on a flight to Moorabbin in accordance with the Instrument Flight Rules. The Sydney Departures controller issued the pilot with radar vectors to intercept the Sydney-Cordo track, together with an instruction to climb to and maintain 5,000 ft. At about that time a Boeing 747 (B747) was approaching Sydney from the west, in instrument meteorological conditions, following a RIVET Standard Terminal Arrival Route. The crew had been issued with a clearance to descend to and maintain 6,000 ft. The flight paths of the two aircraft were to cross each other at approximately right angles, some 8 NM to the south-west of Sydney.

The crew of the B747 subsequently advised the Sydney Approach controller that they had received a Traffic Collision and Avoidance System Resolution Advisory (TCAS RA). The RA instruction to climb the aircraft had been followed by the crew and the aircraft reached a maximum altitude of 6,300 ft before returning to the assigned level. At that time the controller observed the radar return of the PA31 descending through 5,300 ft and queried the pilot as to his present level. The pilot replied that he was returning to 5,000 ft. Neither crew sighted the other aircraft.

Analysis of recorded radar data revealed there had been a breakdown in separation between the two aircraft. The minimum vertical separation between the B747 and the PA31 was 600 ft whilst the lateral separation was 1.7 NM. The required separation standards were 1,000 ft vertically or 3 NM laterally. The PA31 reached a maximum altitude of about 5,400 ft. The pilot of the PA31 later reported he had been distracted at the time his aircraft was approaching 5,000 ft and had subsequently climbed through his assigned level.

Occurrence summary

Investigation number 199701428
Occurrence date 03/05/1997
Location 15 km south-west of Sydney Aerodrome
State New South Wales
Report release date 03/06/1997
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 Piper Aircraft Corp
Model PA-31-325
Registration VH-OYO
Sector Piston
Operation type Business
Departure point Bankstown NSW
Destination Moorabin Vic
Damage Nil

Aircraft details

Manufacturer The Boeing Company
Model 747
Registration 9VSFC
Sector Jet
Operation type Air Transport High Capacity
Departure point Singapore
Destination Sydney NSW
Damage Nil

Fuel - Other involving a Piper PA-31-350, VH-XLA, 15 km west of Camden Aerodrome, New South Wales, on 1 May 1997

Summary

FACTUAL INFORMATION

The pilot in command of a scheduled passenger service from Sydney to Cootamundra, via Cowra, discontinued the flight with the assigned aircraft due to a mechanical problem experienced during engine start at Cowra. The chief pilot had also been on board the aircraft, observing the flight procedures of the pilot in command. The scheduled service was subsequently completed by the pilot in command using a substitute aircraft, VH-XLA, which had been dispatched from Cootamundra.

After landing at Cootamundra the aircraft was taxied to the fuel bowser and shut down. In anticipation that he would be refuelling the aircraft, the pilot in command left a written note for the next rostered pilot which stated that the main fuel tanks were full. At about this time the chief pilot chose to carry out a debrief of the flight with the pilot in command. The two men sat down in the rear of the aircraft to discuss the flight. Whilst the debrief was in progress, a company engineer boarded the aircraft and taxied it to the hangar for routine maintenance. The pilot in command reported that he was distracted by the debriefing and did not subsequently return the aircraft to the fuel bowser to complete the refuelling process. In addition, the maintenance release (MR) did not show that the aircraft had been flown from Cootamundra to Cowra and return, nor were details of the flight, and fuel remaining on board at the completion of the flight, documented in other company records. The operator had planned to use the same aircraft for the scheduled afternoon service to Sydney via Young and Cowra.

The pilot rostered for the afternoon service arrived at 1300 EST to carry out a pre-flight inspection. Company fuel policy for that service required a minimum of full main tanks. Fuel records indicated that the main fuel tanks of VH-XLA had been refilled on the previous evening, information which was supported by the note left by the previous pilot. One of the company engineers, who was queried by the pilot, was not aware that the aircraft had been flown that morning but added that the engines had been run at considerable power for about 10 minutes. The pilot later reported that his observation of the fuel gauges confirmed the tanks were close to full. However, he did not carry out a visual inspection of the fuel levels in the tanks prior to departure. The aircraft subsequently departed Cootamundra at approximately 1525.

During climb after departing Cowra, the pilot observed the fuel gauges indicating less than he would normally have expected at that stage of the flight. He elected to cruise at 7,000 ft, and reduced power in order to decrease fuel flows. The pilot also contacted the company head office about possible fuel gauge anomalies. As the aircraft approached Bindook, the pilot carried out a further check of the fuel gauges and chose to land at Camden as a precautionary measure. A PAN call was transmitted to Flight Service, and the passengers were advised that the aircraft would be landing at Camden due to a low fuel indication. The pilot executed a normal landing following a straight-in approach.

Two hundred litres of fuel were added to the main fuel tanks in order to complete the flight, but the pilot was unable to start the left engine. Ground transport was subsequently used to take the passengers to Sydney. A further 182 L were added to fill the main fuel tanks, bringing the total amount of fuel added at Camden to 382 L. The combined usable fuel capacity of the main tanks is 402 L.

An engineering examination of the aircraft did not reveal any anomalies with the fuel system or fuel quantity gauges which may have contributed to the incident. It was determined that the pilot had used an incorrect start procedure at Camden, causing problems in starting the left engine. Fuel calculations, based on the company fuel policy, indicated that the aircraft had departed Cootamundra with approximately 250 L on board, equivalent to about two-thirds of the combined fuel capacity of the main tanks. The actual fuel required for the flight, including 113 L of standard reserves, was calculated to be 358 L.

The pilot held a valid licence and ratings for the operation being undertaken. He had commenced full-time employment with the company on 24 January 1996 after working part-time with the same company since early 1995. He had accumulated 1,275 hours in Piper Chieftain (PA31) aircraft, all of which had been flown in company aircraft.

The pilot believed that fuel would not be visible in the main tanks, as viewed through the filler caps, if any more than a few minutes of fuel had been burned. This did not appear to be a view held by other company personnel. Moreover, the pilot indicated that had he visually inspected the tanks prior to departure from Cootamundra, and not been able to see fuel, he would still have concluded he had sufficient fuel based on all other available information and the knowledge that the engines had been run for approximately 10 minutes during maintenance checks. A number of operators of Chieftain aircraft were consulted, all of whom said that a total of some 300 L remained in the main fuel tanks when fuel was just visible on the sloping bottom surface of each tank.

The company aircraft checklist required that, as a minimum, the fuel gauges/contents are to be checked prior to start-up and during the pre-take-off procedure. However, the pilot confirmed that following his first observation of the gauges during the pre-flight inspection, he did not check the gauges again until he had departed Cowra. He reported that he had experienced a high workload on this flight, due to a full complement of passengers and a significant amount of baggage to deal with and had overlooked this check. Since he also assumed the main fuel tanks had been full when the aircraft departed Cootamundra, he did not expect the fuel gauges/contents to be a checklist item requiring close and frequent attention.

ANALYSIS

The responsibility of ensuring that there was sufficient fuel to complete the flight rested with the pilot of the afternoon service. However, the incident resulted from a chain of errors and omissions involving a number of company personnel, which ultimately led to insufficient fuel being on board the aircraft to complete the scheduled flight from Cootamundra to Sydney.

In the first instance, the MR had not been certified by the pilot who ferried the substitute aircraft to Cowra. In the second instance, the pilot in command who had completed the scheduled flight in the substitute aircraft, did not complete the flight details nor certify the MR. In addition, the pilot in command was normally in the habit of completing the note, which indicated that the main tanks were full, before leaving his control seat immediately prior to refuelling. However, his normal routine had been interrupted when the chief pilot chose to debrief him before he had time to complete all required administrative and refuelling tasks. His pre-occupation with the chief pilot's critique of his flight subsequently led to these tasks being forgotten.

As a result of the oversights which occurred during the morning, the supporting documentation available to the pilot rostered for the afternoon service did not indicate that a flight had taken place in the aircraft earlier that day. The note left by the pilot of the earlier flight indicated that the main fuel tanks were full. In addition, the pilot's understanding of the fuel system was incorrect. This is considered to be the most significant factor in the chain of events. It was ultimately his responsibility to determine that there was sufficient fuel for the flight. He did not carry out a visual check of the main fuel tanks. However, even if fuel had not been visible, his assessment of the fuel quantity would not have altered. Because of his inadequate knowledge of the fuel system, such an observation would not have alerted him to the discrepancy between the fuel documentation and the actual fuel contents.

The pilot's understanding of the aircraft's fuel system differed with that of his peers within the company, and with other operators of the aircraft type. In addition, this understanding was inconsistent with the general view held by other company personnel that he displayed competence and professionalism in his flying duties. The investigation was unable to resolve this inconsistency.

It was determined that the fuel gauges should have indicated a maximum of three-quarters full at the time of the pre-flight inspection. It is considered probable that the pilot's observation of the fuel gauges reading close to full prior to departing Cootamundra was strongly influenced by the other fuel-related information available to him prior to departure. This expectation was then carried throughout the rest of the flight until he finally became aware of the apparently low-reading fuel gauges after leaving Cowra. Even at that stage he thought the readings were incorrect but wisely decided to land at Camden as a precaution.

SIGNIFICANT FACTORS

1. The maintenance release had not been certified, and details of the morning flight in the substitute aircraft, including flight times and fuel remaining, had not been documented.

2. The pilot in command of the morning flight had written a note stating that the main fuel tanks were full but was distracted from his duties and did not complete the refuelling process.

3. Other documentation indicated that the main fuel tanks were full.

4. The pilot rostered for the afternoon flight did not visually inspect the fuel tanks, nor would he have changed his assessment of the fuel quantity if he had, given the information he had available to him and his incorrect understanding of the fuel system of the aircraft.

5. Due to a high workload, the pilot did not check the fuel quantity gauges in accordance with company procedures prior to departure from both Young and Cowra.

SAFETY ACTION

As a result of this occurrence, and in consultation with the Civil Aviation Safety Authority, the company has reviewed its policies and procedures in relation to the checking and documentation of fuel quantities in PA31 aircraft. The company Maintenance Control Manual was amended to ensure that a visual inspection of the fuel tanks was included in the pre-flight inspection.

Occurrence summary

Investigation number 199701407
Occurrence date 01/05/1997
Location 15 km west of Camden Aerodrome
State New South Wales
Report release date 26/11/1997
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Fuel - Other
Occurrence class Incident

Aircraft details

Manufacturer Piper Aircraft Corp
Model PA-31-350
Registration VH-XLA
Sector Piston
Operation type Air Transport Low Capacity
Departure point Cowra NSW
Destination Sydney NSW
Damage Nil

Loss of separation involving a Boeing 737-377, VH-CZC and Fokker B.V. F28 MK 1000, VH-ATG, 24 km south-east of Sydney Airport, New South Wales, on 1 May 1997

Summary

FACTUAL INFORMATION

The crew of a Fokker Fellowship (F28) aircraft had flight planned to conduct navigation aid calibration of the Sydney runway 16L instrument landing system (ILS). Runways 16L and 16R were nominated for arrivals and departures. The crew received a clearance for a radar departure from runway 16R. The departures controller's intention was to radar vector the F28 to the east and north of the aerodrome for an intercept of the 16L ILS from the north. The F28 departed from runway 16R, heading 170 degrees, on climb to 3,000 ft. When the F28 was 8 NM south of the aerodrome the departures controller instructed the crew to turn left onto a heading of 120 degrees, to parallel the RWY 16L departure track. The controller had six aircraft on frequency, with a number of pending departures for both runways. He planned to vector the F28 across the RWY 16L departure track between two B737s departing from runway 16L. The first B737 took off with an instruction to turn left onto a heading of 060 degrees. The F28 was also instructed to turn left heading 060 degrees. The controller assessed that the F28 could cross the RWY 16L departure track ahead of the second B737, which had also taken off, and instructed the F28 to turn onto a heading of 020 degrees.

The crew of the second B737 had earlier been issued with a West Maitland 7 SID, on climb to 5,000 ft. The SID required the aircraft to track 155 degrees until reaching 600 ft, and then to turn left to intercept the 126 degrees radial of the Sydney VHF omni-directional radio range (VOR) navigation aid. The B737 crew were subsequently re-cleared to climb to their planned level of FL210 immediately after departure. The controller observed the reducing distance between the F28 and the second B737, but believed the B737 would climb above the F28, and that the vertical separation standard of 1,000 ft would be achieved prior to the distance reducing to less than the required lateral standard of 3 NM. However, when the B737 reached 3,000 ft the crew levelled the aircraft to accelerate to 250 kts. As the nose of the B737 was lowered the pilot in command observed the F28 at the 11 o'clock position, at a distance of 1 to 2 NM and slightly below their level. Just prior to the distance between the aircraft reducing to less than 3 NM, when the vertical separation was 300 ft, the controller instructed the crew of the F28 to turn right onto a heading of 040 degrees. He then instructed the crew of the B737 to turn right onto a heading of 180 degrees. The aircraft passed with less than the minimum vertical and lateral separation standards. Aircraft departing to the north and east were normally instructed to to depart from runway 16L, if that was operationally acceptable. The F28 had been parked overnight at Sydney aerodrome on the tarmac adjacent to the threshold of runway 16R. There was no operational reason for the aircraft not to have used RWY 16L for departure.

ANALYSIS

The controller relied on his understanding of B737 performance to establish vertical separation between that aircraft and the F28. The lack of application of separation assurance techniques provided no alternative means to maintain separation when the B737 was unable to attain the expected altitude. The controller had a number of aircraft under his control and this aspect should have been a prompt for him to ensure separation was assured between aircraft. Had a clearance been issued for the F28 to depart from runway 16L it is unlikely that the incident would have occurred.

SIGNIFICANT FACTORS

1. The controller's expectation that the B737 would climb 1,000 ft above the level of the F28 before lateral separation reduced to less than 3 NM.

2. The controller's lack of application of separation assurance techniques.

3. The departure of the F28 from runway 16R when runway 16L was available meant that the F28 would have to cross the departure track of runway 16L in order to carry out its intended operation.

Occurrence summary

Investigation number 199701405
Occurrence date 01/05/1997
Location 24 km south-east of Sydney Airport
State New South Wales
Report release date 28/08/1997
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 Fokker B.V.
Model F28 MK 1000
Registration VH-ATG
Sector Jet
Departure point Sydney NSW
Destination Sydney NSW
Damage Nil

Aircraft details

Manufacturer The Boeing Company
Model 737-377
Registration VH-CZC
Sector Jet
Operation type Air Transport High Capacity
Departure point Sydney NSW
Destination Coffs Harbour NSW
Damage Nil

Total power loss involving an Amateur Built Dragonfly, VH-HVE, 15 km south-west of Seymour, Victoria, on 26 April 1997

Summary

The pilot reported that during cruise at 2,300 ft the engine gradually lost power until he was committed to a forced landing. During the forced landing the aircraft flew through the tops of 40 ft trees and then under a powerline. The aircraft then hit and killed two sheep, ran through a depression, became airborne again and finally hit the ground heavily before coming to a stop. The engine is a sealed rotary liquid cooled unit which can only be dismantled at the manufacturer's facility in England. A post-accident inspection revealed a coolant hose had detached from the water pump but it could not be determined if this initiated the engine failure or was a result of the accident. Traces of internal seal material were found in the exhaust system so it is possible that a seal failure initiated the engine failure. The owner does not intend to return the engine to the manufacturer for dismantling.

Occurrence summary

Investigation number 199701398
Occurrence date 26/04/1997
Location 15 km south-west of Seymour
State Victoria
Report release date 02/05/1997
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Accident

Aircraft details

Manufacturer Amateur Built Aircraft
Model Dragonfly
Registration VH-HVE
Sector Piston
Departure point Mangalore Vic
Destination Moorabbin Vic
Damage Substantial

Runway excursion involving a Piper PA-23-250, VH-EGA, 10 km north-west of Maitland (Luskintyre), New South Wales, on 25 April 1997

Summary

The pilot had planned the flight for an early morning departure from a private airstrip. He had calculated the take-off weight, with four passengers, to be below the maximum allowable for the take-off length available. The weather was fine and clear, with a light crosswind on the gently down sloping grass strip selected for take-off. The grass had been mown short but was wet from a heavy dew.

During the take-off run the pilot became concerned that the aircraft was not accelerating normally, so he closed the throttles and applied maximum braking. However, he was unable to stop the aircraft before it overran the strip end and collided with a fence, rupturing a fuel tank and causing minor damage to the engine cowlings and landing gear doors.

No defects were found with the aircraft that may have affected its performance. It is likely that the wet grass would have increased the take-off distance required and also decreased the aircraft's braking efficiency when the take-off was rejected.

Occurrence summary

Investigation number 199701322
Occurrence date 25/04/1997
Location 10 km north-west of Maitland (Luskintyre)
State New South Wales
Report release date 06/05/1997
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Runway excursion
Occurrence class Accident

Aircraft details

Manufacturer Piper Aircraft Corp
Model PA-23-250
Registration VH-EGA
Sector Piston
Operation type Private
Destination Mount Isa QLD
Damage Substantial

Forced/precautionary landing involving a Robinson R22 Beta, VH-LOH, Keeroongooloo, 100 km south-east of Windorah, Queensland, on 26 April 1997

Summary

The aircraft had been operating on the mustering flight for about 45 minutes. With the helicopter at 70 feet above the ground and 50 kts indicated airspeed, the pilot reported that he had just commenced a climbing turn to approach a small mob of cattle when he heard a loud noise from the rear of the cabin. The engine oversped and the rotor speed decayed. A forced landing was conducted but the pilot was unable to retain adequate rotor speed to prevent a heavy landing.

Occurrence summary

Investigation number 199701307
Occurrence date 26/04/1997
Location Keeroongooloo, 100 km south-east of Windorah
State Queensland
Report release date 27/06/1997
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 Robinson Helicopter Co
Model R22 Beta
Registration VH-LOH
Sector Helicopter
Operation type Aerial Work
Departure point Keeroongooloo QLD
Destination Keeroongooloo QLD
Damage Substantial