The aircraft was conducting an ILS approach to Townsville, which was under the influence of Cyclone Justin, centred about 180 km north. Weather conditions for the approach were a strong, gusting crosswind, moderate to severe turbulence, and heavy rain.

At the start of the approach the aircraft was high on the glideslope. As the approach progressed the aircraft descended until it was well below the glideslope. The first officer called the flying pilot's attention to the rate of descent, which was up to 3,000 ft/min. A short time later, when the aircraft was at 780 ft above ground level, about 500 ft below the glideslope, and with a descent rate of 2,000 ft/min, the first officer called for a go-around. The captain applied power, and the descent was stopped at about 700 ft above ground.

The aerodrome controller cleared the aircraft to climb to 3,500 ft for a further approach. However, the aircraft levelled initially at 4,000 ft before a descent to 3,500 ft was carried out. The aircraft landed off the second approach, conducted using the autopilot coupled to the ILS.

Following the take-off with 850 L of chemical for another spray task, the engine began to vibrate and lose power. The pilot dumped the load and conducted a forced landing into a paddock about 4 km from the departure airstrip. During the landing one main landing gear leg was torn off, the wings were creased, and the propeller was bent rearwards. After an examination of the engine the pilot found that the number 6 cylinder had cracked between the spark plug holes.

The helicopter was in a steady cruise at 80 kts at 1,500 ft above ground level when the pilot heard a loud bang. He immediately initiated auto-rotation and believed that there had been a failure of the tail rotor drive. The pilot attempted a landing in the nearest clear area but the nature and slope of the terrain coupled with some rotation of the helicopter resulted in it rolling over and sustaining severe damage during the landing.

Examination of the helicopter revealed that the intermediate flex plate failed. This flex plate consists of the front and rear yokes plus the flex plate itself, all joined by four bolts. The examination found that one of the two front lugs was missing. The adjoining flex plate lug was present and bent forward. The bolt joining the missing front yoke lug to the adjoining flex plate lug was also not present. Neither the bolt nor the front yoke lug were found at the accident site.

The hole in the flex plate lug, opposite the missing front yoke lug, was worn and enlarged suggesting that, after the bolt was liberated, the shaft's axis of rotation changed. Such an event would have led to failure of the tail rotor drive and given the symptoms described by the pilot.

The pilot had conducted a brief pleasure flight. He intended to land to the west on a 330 m grass airstrip on his own property. The strip ran east west with a 12.5 degree upslope to the west. He estimated the wind components to be 5 kt headwind and 15 kt crosswind. However, on short final, the aircraft encountered moderate turbulence and windshear. The pilot elected to overshoot, but because of the steep upslope, this required a turn north or south. He advised that from past experience in PNG, having landed on many bush strips, he would normally have turned into wind during an overshoot into a one-way uphill airstrip. However, on this occasion he inadvertently turned downwind and encountered more windshear and loss of airspeed.

With the aircraft facing downwind and very low in airspeed, he elected to land straight ahead in the paddock. During the latter part of the landing roll the aircraft nosewheel collided with a rock and the aircraft overturned. 

The pilot subsequently advised that the aircraft had recently undergone a complete overhaul and that had not contributed to the accident.

After completing pre-take-off checks in the northern runup bay for runway 29, the pilot of the Cessna 180 began taxying to the runway 29R holding point. As the aircraft moved forward and turned left onto taxiway K5 he saw a Piper Seneca to his right, in very close proximity, taxying along K5. The pilot of the Cessna braked sharply, however the nose of the aircraft pitched down, resulting in the propeller of the Cessna striking the left tailplane of the Seneca.

Weather conditions were fine, with no obstacles to visibility. Because of the high nose attitude of the aircraft and associated obstruction by the instrument panel, the pilot of the Cessna 180 did not see the approaching Seneca as he left the holding bay. When he did see the Seneca, he had insufficient time to prevent a collision.

The pilot reported that on departure from Coconut Island when he retracted the gear he heard an abnormal clunk. The gear unlocked light extinguished, but the pilot noticed that the aircraft was 10 knots slower in cruise indicating that the gear doors were not fully closed. On arrival at Horn Island the gear was selected down and there was no down indication for the left main gear. The pilot recycled the gear twice, changed gear indicator globes, tried sideslipping, and followed all procedures set out in the Emergency Checklist for failure of the main gear. A 500 ft flight over the airport and inspection from the ground confirmed all three wheels were extended but it could not be confirmed if they were locked. The pilot commenced an approach to runway 08 after emergency services were in place. After touchdown the left gear collapsed, and the aircraft came to rest off the left side of the runway but within the flight strip. The left gear retraction rod had failed during gear retraction at Coconut Island.

The flight was being conducted as a command check of the handling pilot, who occupied the left control seat. The pilot in command was the non-handling pilot. During an asymmetric circuit, with the left propeller feathered, the landing gear was lowered on mid-base at a height of about 600-700 ft. Because of the aircraft configuration, primary attention was given to the approach path while awaiting the build-up of the landing gear down-line hydraulic pressure.

At about 400-500 ft, the hydraulic landing gear lever was returned to the neutral position after both pilots confirmed the landing gear down-line pressure was above 500 PSI. The landing gear latch lever was then moved from the spring lock to the positive lock position without having first monitored the green landing gear light. The handling pilot called for the final flap setting (3/4 flap) as the aircraft descended below the 300 ft commit height, below which a go-around would not be attempted. Having made the final flap selection, the non-handling pilot then checked the green light, and the landing gear down-line pressure for 500 PSI minimum.

He noticed that the red unsafe landing gear light was illuminated but had experienced this situation before, with a red light showing and the landing gear warning horn sounding (the warning horn on this occasion was not operating). He assumed that the problem was due to a micro switch and felt that a safe landing could be made if the landing gear pressure was kept above 500 PSI, and the brakes used gently. The decision was made to continue to land after visually checking that the right landing gear was down. A lack of time and the state of the left sliding cockpit window did not allow for a visual check of the left landing gear.

Consideration was given to raising the latch lever and moving the hydraulic lever to "crack" the landing gear, and then selecting down again to re-lock. However, the aircraft was approaching the threshold, and the pressure was above 500 PSI with the landing gear hydraulic lever in neutral. On touchdown, the pilot in command observed the pressure at 500 PSI and immediately pushed the hydraulic lever down to keep the pressure up. This enabled the aircraft to roll the length of the runway, slowing to walking pace. During the final roll out, the flaps were selected up, resulting in the right landing gear very slowly retracting. As this occurred, the handling pilot closed the right mixture control. The propeller was almost stationary as the aircraft settle onto one blade.

A post-flight inspection found that the right landing gear spade lock had been locked out before the landing gear had completed the extension cycle. This action prevented the hook on the extension jack from engaging the spade lock and closing the micro switch. The action of retracting the flaps whilst the landing gear hydraulic selector was down, allowed hydraulic pressure to bleed from the landing gear down line, resulting in inadvertent retraction.

FACTUAL INFORMATION

A Boeing 767 (B767) aircraft departed Perth for Melbourne on climb to the flight planned level of flight level (FL) 370. The aircraft was being controlled by Melbourne Sector 1. This position was a procedural control position which used flight progress strips (FPSs) to manage aircraft separation. A number of FPSs were required for each aircraft under control. The FPSs designated the planned route of an aircraft.

After reporting at RERON, a position southeast of Perth, the crew requested a change of level to FL330. The change of level was approved by the Sector 1 controller. The controller annotated the new level of FL330 on the B767's FPSs.

While the Sector 1 controller was receiving coordination on three other aircraft from Perth Flight Service the crew of the B767 requested a change of level to FL350. The Sector 1 controller approved the change of level and then completed the coordination. The controller did not annotate the B767's RUFLE position FPS, the last FPS for the aircraft, with the amended level. This FPS indicated that the B767 was to operate at FL330.

The Sector 1 controller transferred the B767 to Perth Flight Service (FS) to maintain communications via High Frequency (HF) radio. The FS operator passed the B767's RIDLE position to the Sector 1 controller after the crew reported at that position. The aircraft's level of FL350 was reported to, and correctly read back by the Sector 1 controller.

The Sector 1 controller was then relieved at the position by another controller. The two controllers conducted a handover/takeover of the position. The relieved controller could not remember conducting a final check of the FPSs, as was his normal practice, before leaving the position.

The crew of the B767 reported to the new Sector 1 controller that the aircraft was now back on Very High Frequency (VHF) radio and was at position ROMPA at FL350 at 54 (time 1754 UTC). The Sector 1 controller coordinated the position report to Adelaide Sector 4 but read the level of FL330 from the RUFLE FPS. The Adelaide Sector 4 controller read back and annotated the B767 FPS with FL330. During this coordination sequence the Sector 1 controller was interrupted by a transmission from another aircraft.

The crew of the B767 subsequently transferred to Adelaide Sector 4 and reported at RUFLE at FL350. There was no breakdown of separation.

Sector 1 was combined with Sector 5. Traffic was light and less than normally experienced at the position for the time of day. The first controller had worked until 1300 ESuT that morning and then returned for the evening "Doggo" shift at 2300. He had two hours sleep in the afternoon and felt rested. He operated the position from approximately 0300 to 0445.

ANALYSIS

There were two opportunities to correct the error after the relieving controller assumed responsibility for the position. The first being when that controller started operating at the position and the second when the crew of the B767 reported at ROMPA at FL350. However, the incorrect annotation on the RUFLE FPS was not detected.

The reason for these errors not being detected or why the first controller did not annotate the RUFLE FPS could not be ascertained. It was probable that the physiological effects due to the early time of day and the low level of activity combined to reduce the controllers' vigilance and/or use of standard practices.

SIGNIFICANT FACTORS

1. The Sector 1 controller did not annotate all the B767 FPSs with the approved level of FL350.

2. The relieving controller did not detect the error in the RUFLE FPS during or after the handover/takeover.

At about 200 ft after takeoff the engine began to run roughly. The pilot elected to abandon the takeoff so that the aircraft could be landed on the remaining length of runway. After a high flare for landing the aircraft touched down heavily. The left landing gear leg was broken off and the aircraft came to rest off the left side of the runway.

The relative humidity was assessed as being around 80% and there had been recent light rain at the aerodrome. The pilot reported that the aircraft manufacturer considered carburettor icing as the cause of the rough running.

FACTUAL INFORMATION

An instrument flight rules (IFR) Cessna 310 (C310) departed South Grafton for Kempsey on climb to 7,000 ft. The pilot in command (PIC) had originally planned to operate from South Grafton to Coffs Harbour and then to Kempsey. He had advised flight service (FS) of the amended plan prior to departure. FS had passed the amended flight plan details to Coffs Harbour tower. The operator at the FS position responsible for the area had recently conducted a handover/takeover. Two FS areas were combined on the console. This was normal practice when traffic numbers reduced to a level that could be managed by a single operator. Traffic was light to moderate across the combined areas. The PIC of the C310 reported a departure time of 20 (0820 UTC) and on climb to 7,000 ft to the FS operator. The departure report transmission was the first to be received by the FS operator on this shift and he was unable to clearly hear the departure report. He increased the air-ground volume and requested the PIC of the C310 to confirm the aircraft's planned level. The FS operator did not request the PIC to repeat the departure report. The FS operator believed the departure time was 12 after he checked the console clock to confirm the time. He then annotated the flight progress strip (FPS) departure box for the flight of the C310 with 12. (The console clock was adjusted and operating correctly and these transmissions were made at a time when the clock would have displayed 0821.)

The FS operator co-ordinated the departure time and level for the C310 with the aerodrome controller (ADC) at Coffs Harbour tower. Based on the departure time of 0812 and the time interval for the flight of the C310, the FS operator calculated that the aircraft's estimate for Kempsey was 0838. The ADC had the same estimate, based on the departure report from the FS operator. The aircraft's actual estimate, based on the correct departure time of 0820, was 0846. The ADC was responsible for providing separation between IFR aircraft in controlled airspace (CTA) from ground level to 10,000 ft. Coffs Harbour tower controllers used visual and procedural methods to separate aircraft in CTA. There was radar coverage down to approximately 6,000 ft in the vicinity of Coffs Harbour, but there was no radar display installed in the tower. Radar was used by controllers located in Brisbane for separation in the CTA above 10,000 ft in the Coffs Harbour area. The track of the C310 crossed the CTA steps to the south-west of Coffs Harbour and the PIC required a clearance from the ADC. While co-ordinating the departure from South Grafton, the FS operator asked the ADC if he required the PIC to transfer to the Coffs Harbour frequency immediately.

The ADC suggested that the PIC remain on the FS frequency. The Aeronautical Information Publication (AIP) states that "Except in special circumstances, pilots of aircraft are required to comply with the radio communication requirements appropriate for the "Classes of Airspace-Services and Requirements" table. The table indicates that the pilot of an IFR aircraft operating outside controlled airspace (OCTA) must report to air traffic control, prior to entering CTA, and request a clearance. The PIC had conducted similar flights and had transferred to the ADC's frequency to obtain a clearance through controlled airspace. Therefore, he was expecting to transfer to the ADC frequency when the aircraft was west of Coffs Harbour. There was no equipment limitation or other reason for the PIC of the C310 not communicating directly with the ADC. The ADC issued a clearance for the aircraft to track from Grafton to Kempsey at 7,000 ft and requested the FS operator to advise him when the PIC required descent. The FS operator issued the clearance to the PIC. The PIC readback the assigned level and queried the FS operator regarding when to transfer to the Coffs Harbour frequency.

The FS operator advised that there was no requirement to transfer frequency at this stage and requested the PIC to advise the aircraft's descent point. A short time later a new operator assumed responsibility for the FS position. The PIC of the C310 requested a change of level to 6,000 ft and the FS operator co-ordinated the change in level with the ADC. The ADC recleared the C310 at 6,000 ft and this clearance was issued by the FS operator. The PIC reported that the aircraft's descent point was 26 NM by distance measuring equipment (DME). The FS operator advised the ADC of the aircraft's descent point. The ADC was expecting a BAe146, operating a regular public transport flight, to taxi at Coffs Harbour for departure and assessed that the flight may conflict with the C310. The ADC asked the FS operator "Where is he now please" (meaning the C310). The FS operator, in turn, requested the PIC of the C310 to report his DME distance. The PIC advised that the aircraft was at 19 DME. This distance was consistent with the expected position of the C310 based on the incorrect departure time and estimate for Kempsey.

The ADC believed that the aircraft was to the south-west of Coffs Harbour. The ADC issued a clearance for the C310 to leave the CTA on descent, which was relayed by the FS operator to the PIC. The aircraft's actual position was to the north-west of the aerodrome, outside controlled airspace and approaching the CTA steps. The BAe146 had planned to Sydney and the intended track crossed the track of the C310 approximately 17 NM south-west of Coffs Harbour. The ADC co-ordinated a departure clearance for the BAe146 with Brisbane Sector 15 (SEC15) and advised the controller that the aircraft would depart at 36. The SEC15 controller issued departure instructions to the ADC and the crew of the BAe146 was subsequently issued a clearance to depart Coffs Harbour on climb to an amended level of FL160. Using procedural control, the ADC was required to issue instructions to the crews of aircraft to establish and maintain either a lateral, vertical or longitudinal separation standard. There were a number of procedures which could have been used by the controller to separate the C310 and the BAe146. The BAe146 departed and the crew reported their departure to the ADC. The SEC15 controller contacted the ADC and advised him that there was an aircraft on radar to the southwest of Coffs Harbour at 16 NM, that had just entered the CTA step. The radar display had displayed a secondary surveillance radar (SSR) code 2000 squawk indicating that the unknown aircraft was at 6,000 ft. The SEC15 controller asked the ADC whether he was aware of any other aircraft.

The ADC advised that he was aware of a C310 estimating Kempsey at 38, and as the time was then 38, the C310 should be OCTA. The ADC then requested the crew of the BAe146 to report their level. The crew reported that the aircraft had left 7,000 ft. There had been no instructions by the ADC to establish a lateral or time standard to separate the aircraft. The BAe146 had passed through the level of C310 while both aircraft were in the area of conflict. There had been a breakdown of separation. ANALYSIS It was probable that the FS operator did not hear the departure time and estimated the time incorrectly after checking the console clock. The operator's misreading of the clock may have been due to the similarity of the last two digits and the transposition of the "2" and "1". He only requested the PIC to repeat the aircraft's intended level and consequently missed an opportunity to confirm the departure report. Had the FS operator requested the PIC to repeat the entire departure report it was likely that the error would have been detected. The ADC sought to establish the position of the C310 through the FS operator. However, the ADC did not explicitly request "the pilot to report position". The ADC used imprecise and non-standard phraseology to the FS operator. Had the ADC used standard phraseology it was likely that the FS operator would have requested and obtained a position report from the pilot consisting of a distance and direction from Coffs Harbour. This information would have clarified the position of the C310 for the ADC. Consequently, he would have issued instructions to maintain separation. However, the report of "19 DME" from FS confirmed the ADC's expectation that the C310 was to the south-west of Coffs Harbour, approaching the descent point and would be shortly leaving CTA. The FS operator requested a DME distance from the PIC when the ADC asked where the aircraft was. By inference, the request was for a position report; yet the FS operator reduced the request to one element of a position report.

Consequently, another opportunity was lost to compare the actual and expected positions of the aircraft. The PIC was prepared for and expected to change frequency from FS to Coffs Harbour Tower frequency to obtain a clearance. Had the FS operator and the ADC operated in accordance with standard procedures; the PIC would have transferred to the tower and communicated directly with the ADC. This would have reduced the possibility of the misunderstanding of the position information requested by the ADC from the pilot. If the PIC had transferred to the tower frequency it is likely that the ADC would have requested the PIC to either report leaving CTA, or a level or a DME distance that would have established the aircraft OCTA, before clearing the crew of the BAe146 to depart. Alternatively, the ADC would have assumed that they were both in CTA and would have issued appropriate instructions to separate the aircraft. Either of these measures would have ensured the two aircraft remained separated. The operation of the SSR transponder in the C310, and the consequent display and the recognition of the symbol on the Brisbane sector radar display, by the controller, provided an increased level of safety for the air traffic system.

SIGNIFICANT FACTORS

1. The FS operator misheard the departure report and did not request the PIC of the C310 to repeat the report.

2. The FS operator misread the console clock.

3. The ADC did not use correct phraseology when requesting the position of the C310 from the FS operator.

4. The FS operator did not request the PIC to "Report position".

5. The FS operator and the ADC did not follow standard operating procedure when they agreed to leave the PIC of the C310 on the area frequency.