Breakdown of co-ordination involving an Israel Aircraft Industries Ltd 1124A, VH-NJW, 93 km west-south-west of Brisbane Aerodrome, Queensland on 13 February 1997

Summary

Amberley airspace was de-activated during the previous night and was to become active for military operations at 0800 local time. At 0747 a controller at Amberley co-ordinated the activation with the Brisbane Approach Planner. The planner informed the radar operators and set the planner console to show pending status. The co-ordination was conducted by Amberley with the Sector 4 controller shortly afterwards. Between 0755 and 0815 the person filling the planner position changed on two occasions. The Brisbane Terminal Airspace Co-ordinator (TAC) had been expecting the Amberley airspace activation but had been in a conference during this time.

At 0815, the current planner received co-ordination on the departure of VH-NJW. The planner conducted the appropriate co-ordination with the Sector 4 controller. None of the radar maps were showing the Amberley airspace as active at this time. NJW subsequently departed and was transferred to the Sector 4 frequency. The Sector 4 controller had not queried the transfer as Amberley radar had been unserviceable, and the controller assumed that the alternative had been to direct the aircraft to Sector 4. Amberley Approach later enquired as to whether the Sector 4 controller had a radar return in the area about 50 NM west of Brisbane. The approach controller was informed that the aircraft was VH-NJW. There was no breakdown in aircraft separation.

An investigation by Airservices Australia found that the TAC position was not occupied at the time of the airspace activation. In addition, the quick changes of staff in the planner position resulted in the loss of the information to the later staff. The activation times were routinely co-ordinated between Amberley Approach and the Brisbane planner position. This was considered the most appropriate method. The investigation found that the planner had not ensured that the radar maps were set correctly at 0800.

Procedures were changed to log the Amberley airspace activation and de-activation times in the Airways Operations Journal. Annotations confirming that the radar consoles had been set correctly were also to be entered.

Occurrence summary

Investigation number 199700417
Occurrence date 13/02/1997
Location 93 km west-south-west of Brisbane Aerodrome
State Queensland
Report release date 25/03/1997
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Breakdown of co-ordination
Occurrence class Incident

Aircraft details

Manufacturer Israel Aircraft Industries Ltd
Model 1124A
Registration VH-NJW
Sector Jet
Operation type Charter
Departure point Brisbane QLD
Destination Jackson QLD
Damage Nil

Wheels up landing involving a Piper PA-31, VH-WZZ, Normanton Aerodrome, Queensland, on 13 February 1997

Summary

During a normal circuit at the destination aerodrome, the pilot selected the landing gear down. Following the selection, there was no indication that the gear was extending. The pilot recycled the gear selection several times but the gear position indications remained unchanged.

The pilot then operated the emergency gear extension system. The main landing gears indicated down but the nose gear light was out and the gear unsafe light was on. He repeated operation of the emergency extension system a number of times with the same result. A flyby inspection near people at the airfield confirmed that the nose gear was trailing aft of the locked-down position. The pilot alerted the local emergency services before making a landing approach.

During the landing roll, the pilot shut both engines down and lowered the nose of the aircraft. The nose gear did not support the nose of the aircraft which then scraped along the runway until the aircraft came to a stop. All three occupants left the aircraft safely. A maintenance investigation carried out by the company found a defect in the normal landing gear system. A defective O-ring at the right hydraulic oil filter had been displaced by hydraulic pressure allowing oil to escape.

The emergency gear extension system was used to extend the nose gear after the aircraft was lifted off the runway. The system operated normally and no fault could be found. It is possible that in-flight air loads prevented the pilot from extending the nose gear fully.

Occurrence summary

Investigation number 199700398
Occurrence date 13/02/1997
Location Normanton Aerodrome
State Queensland
Report release date 15/07/1997
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Wheels up landing
Occurrence class Accident

Aircraft details

Manufacturer Piper Aircraft Corp
Model PA-31
Registration VH-WZZ
Sector Piston
Operation type Charter
Departure point Cairns Qld
Destination Normanton Qld
Damage Substantial

Runway excursion involving a Skyfox CA25N, VH-LOY, Maroochydore/Sunshine Coast Aerodrome, Queensland, on 13 February 1997

Summary

The student pilot had been briefed and authorised to conduct solo circuit training. The runway in use was 36 and the wind was from 020 degrees at 10 to 15 kts. During the landing roll the aircraft encountered a gust of wind from the east. This caused the right wing to lift abruptly. Although the pilot applied full right aileron control, he was unable to arrest the aircraft's roll to the left. The aircraft then departed the runway before coming to rest inverted, on the western side of the runway.

The pilot exited the aircraft safely. The aircraft was not fitted with an emergency locator transmitter.

Occurrence summary

Investigation number 199700414
Occurrence date 13/02/1997
Location Maroochydore/Sunshine Coast Aerodrome
State Queensland
Report release date 25/03/1997
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 Skyfox Aviation Ltd
Model CA25N
Registration VH-LOY
Sector Piston
Operation type Flying Training
Departure point Maroochydore QLD
Destination Maroochydore QLD
Damage Substantial

Missed approach involving a Cessna 172RG, VH-KPL, Cairns Aerodrome, Queensland, on 11 February 1997

Summary

The aircraft was forced to go around from short final after three fire tenders were unable to vacate the runway as instructed. Four fire tenders were previously cleared to enter the movement area in order to conduct a response time test to the threshold of runway 33. The controller permitted the exercise after considering the aircraft traffic in the area. His expectation was that the tenders would would be able to clear the runway (to grassed areas outside the flight strip) immediately when requested. When the controller instructed the tenders to vacate the runway he was advised that they were restricted to operations on the sealed areas only. The surrounding ground was too soft.

The aircraft landed safely a short time later, after the fire vehicles had moved to the taxiways.

Notification procedures were then put in place at Cairns, so that air traffic control staff would be made aware of any restrictions to the movement of fire vehicles due to surface conditions.

Occurrence summary

Investigation number 199700376
Occurrence date 11/02/1997
Location Cairns Aerodrome
State Queensland
Report release date 15/07/1997
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Missed approach
Occurrence class Incident

Aircraft details

Manufacturer Cessna Aircraft Company
Model 172RG
Registration VH-KPL
Sector Piston
Operation type Private
Departure point Cairns QLD
Destination Cairns QLD
Damage Nil

Hard landing involving a Cessna 182Q, VH-CJM, Meekatharra Aerodrome, Western Australia, on 10 February 1997

Summary

The pilot reported that he had completed his night rating in January and had decided to practice his night flying techniques. After completing an inspection of a mine site, he returned to the circuit for landing practice. He had completed one satisfactory touch-and-go landing and was on an approach for a full stop landing when the accident occurred. He reported he was unhappy with the approach and decided to complete a go-around from about 30 ft above ground level. Having opened the throttle, the pilot moved his right hand to the trim wheel to remove the significant amount of nose-down trim that was still applied. As he did so the throttle returned to idle and the combination of low power and nose-down trim caused the aircraft to touch down heavily. The nosewheel, firewall and propeller were damaged. The pilot then brought the aircraft to a stop on the runway.

The throttle friction had been set so that it was loose. This contributed to the power reduction when the pilot removed his hand from the throttle. The pilot also reported that he had concentrated his attention on the area of the runway near the expected point of touchdown and not the far end as he had been taught. As a result, he did not recognise the last-minute descent until it was too late to recover.

Occurrence summary

Investigation number 199700382
Occurrence date 10/02/1997
Location Meekatharra Aerodrome
State Western Australia
Report release date 12/02/1997
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Hard landing
Occurrence class Accident

Aircraft details

Manufacturer Cessna Aircraft Company
Model 182Q
Registration VH-CJM
Sector Piston
Departure point Meekatharra WA
Destination Meekatharra WA
Damage Substantial

Wheels up landing involving an Amateur Built HH-1, VH-AFW, Serpentine (ALA), Western Australia, on 3 February 1997

Summary

The pilot was familiarising himself with the Sidelinger replica Hurricane before continuing with a flight test program that had already been partly completed by another pilot. He conducted one circuit and landing with the landing gear down. After a short break he took off again and departed the airfield for aerial work. After take-off he retracted the landing gear and noted a normal gear-up cockpit indication.

On return to the airfield, the pilot selected the landing gear down but received an unsafe gear cockpit indication. He checked the landing gear circuit breaker was in and then cycled the selector lever twice more but without success. He then attempted to lower the landing gear using the emergency lowering method. He reported, however, that the emergency lowering system would not operate.

Committed to a gear up landing, the pilot elected to land on the 270 degree grass strip. The pilot said that he approached at minimum speed and touched down tail wheel first with throttle closed and the fuel and electrical systems secured. The aircraft then skimmed along on the underside air scoop before eventually nosing forward and damaging the propeller and air intake. The owner subsequently reported the cause of the landing gear failing to lower via the normal system was a faulty selector switch. The reason why the emergency lowering system would not operate was not determined.

Occurrence summary

Investigation number 199700353
Occurrence date 03/02/1997
Location Serpentine (ALA)
State Western Australia
Report release date 03/04/1997
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Wheels up landing
Occurrence class Incident

Aircraft details

Manufacturer Amateur Built Aircraft
Model HH-1
Registration VH-AFW
Sector Piston
Operation type Private
Departure point Serpentine WA
Destination Serpentine WA
Damage Minor

Ditching involving a Bell 47G-5, VH-JGF, Wiawera Station, South Australia, on 7 February 1997

Summary

The pilot was assisting in flood rescue operations and was directed to a homestead where several people had climbed onto its roof to escape from the fast-flowing flood waters, which had risen to the height of the roof line.

He approached the homestead at a height of about 2m above the water level, then hovered the helicopter alongside the roof to allow an elderly person to board. This person had had a safety rope attached to him to prevent him from slipping off the steeply pitched roof. As he climbed onto the skids his weight moved the helicopter slightly sideways, and the rope snagged on the roof causing the helicopter to descend. The pilot was unable to arrest the downward movement in the height available before the helicopter struck the water and sank.

All occupants escaped, the pilot recovered the ELT and activated it.

Occurrence summary

Investigation number 199700355
Occurrence date 07/02/1997
Location Wiawera Station
State South Australia
Report release date 28/02/1997
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Ditching
Occurrence class Accident
Highest injury level Minor

Aircraft details

Manufacturer Bell Helicopter Co
Model 47G-5
Registration VH-JGF
Sector Helicopter
Operation type Aerial Work
Departure point Tikalina Station SA
Destination Wiawera Station SA
Damage Substantial

Loss of separation involving a Boeing 747-338, VH-EBT and Boeing 727-277, VH-ANA, 37 km west of Melbourne Aerodrome, Victoria, on 3 February 1997

Summary

FACTUAL INFORMATION

A Boeing 747 (B747) aircraft departed from runway 16 at Melbourne for Bangkok on climb to 3,000 ft. Runway 27 was the nominated departure runway but the aircraft required a departure from runway 16 for operational reasons. Additionally, the crew advised that they could not comply with the requirement to not exceed 250 kts below 10,000 ft. The crew of the B747 tracked the aircraft via a standard instrument departure (SID) that required them to turn right and intercept the outbound track, to the northwest of the aerodrome.

Shortly after the B747 became airborne the aerodrome controller (ADC) requested departure instructions, from the DEP N controller, for a pending Boeing 727 (B727) aircraft departure to Adelaide from runway 27. The B747 was climbing slowly and would cross the intended track of the B727. The ADC suggested to the DEP N controller that the B727 be maintained at 3,000 ft, on departure, after the crew of the B747 had been approved to, and had climbed that aircraft above 4,000 ft. However, the DEP N controller believed that the B727 would climb faster than the B747 and he intended to radar vector that aircraft behind the B727. The DEP N controller approved the departure of the B727 on the planned track. He then approved the crew of the B747 to climb to FL200 and cancelled the speed restriction. He also instructed the crew to cancel the SID and to turn left onto a heading of 270 degrees.

The DEP N controller had been operating at the console for approximately three hours. A busy traffic period had just finished, and traffic numbers were reducing. Traffic levels were moderate when the B727 departed.

After the B727 departed the DEP N controller cancelled the speed restriction below 10,000 ft and approved the crew to track direct to Bordertown on climb to FL200. These measures were meant to assist in increasing the horizontal distance between the two aircraft which were on near parallel westerly tracks with the B747 to the south of the B727.

When both aircraft were approximately 20 NM to the west of Melbourne and at similar levels, the DEP N controller assessed that he could radar vector the B747 behind the B727. He instructed the crew of the B747 to turn right onto a heading of 340 degrees. As the crew was turning the aircraft, the DEP N controller observed that the separation standard of 3 NM was going to be infringed. He instructed the crew of the B747 to turn left onto a heading of 240 degrees. Both crews reported sighting the other aircraft. Separation reduced to 1.5 NM horizontally and 700 ft vertically before radar separation was re-established. There was a breakdown of separation.

ANALYSIS

The DEP N controller did not establish vertical separation between the two aircraft before attempting to radar vector the B747 behind the B727. An instruction to the crew of the B747 to maintain a level 1,000 ft below the level of the B727 would have caused a minor delay to the climb of the B747 but would have ensured that separation was maintained.

SIGNIFICANT FACTORS

1. The DEP N controller did not use appropriate separation assurance techniques.

Occurrence summary

Investigation number 199700295
Occurrence date 03/02/1997
Location 37 km west of Melbourne Aerodrome
State Victoria
Report release date 05/10/1997
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 The Boeing Company
Model 727-277
Registration VH-ANA
Sector Jet
Operation type Air Transport High Capacity
Departure point Melbourne, VIC
Destination Adelaide, SA
Damage Nil

Aircraft details

Manufacturer The Boeing Company
Model 747-338
Registration VH-EBT
Sector Jet
Operation type Air Transport High Capacity
Departure point Melbourne, VIC
Destination Bangkok, Thailand
Damage Nil

Incorrect configuration involving a Beech Aircraft Corp V35A MK II, VH-FWY, Archerfield Aerodrome, Queensland, on 6 February 1997

Summary

The pilot reported that after a normal landing and landing roll, whilst watching for the next exit from the runway, he accidentally raised the gear switch instead of the flap switch. The gear retracted and the aircraft slid to rest on the runway.

Occurrence summary

Investigation number 199700330
Occurrence date 06/02/1997
Location Archerfield Aerodrome
State Queensland
Report release date 25/03/1997
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Incorrect configuration
Occurrence class Incident

Aircraft details

Manufacturer Beech Aircraft Corp
Model V35A MK II
Registration VH-FWY
Sector Piston
Operation type Private
Departure point Archerfield
Destination Archerfield
Damage Minor

Flight control systems involving a Robinson R44, VH-JFK, Southport Aerodrome, Queensland, on 29 January 1997

Summary

Sequence of Events

Following an extended period of hovering practice and a circuit, the student remarked that the lateral trim was heavy. The instructor flew another circuit. He noticed that increasing left cyclic control pressure was required to prevent the helicopter from rolling right. At about 150 ft AGL a loud metallic "springing" noise was heard and a reaction felt through the controls and airframe. The cyclic pressures returned to normal. The helicopter was landed safely and closed down.

An after-flight inspection found that the lateral trim springs had parted, and right cyclic control was restricted to about 50% of the normal control authority.

Safety Action

Following this incident, the Civil Aviation Safety Authority was notified and made two submissions for the manufacturer to take urgent action. The manufacturer had been aware of a potential problem involving undue wear on a shaft in the trim assembly which could cause binding. A service letter, SL-13, which called for an inspection at each 100-hour inspection and annually was issued prior to this incident. Service Bulletin, SB-19, which called for a mandatory inspection of the trim shaft to determine the minimum diameter of the shaft was issued on 16 April 1997. Time of compliance was within the next 50 flight hours or by 31 May 1997, whichever came first.

Occurrence summary

Investigation number 199700274
Occurrence date 29/01/1997
Location Southport Aerodrome
State Queensland
Report release date 03/04/1997
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Flight control systems
Occurrence class Incident

Aircraft details

Manufacturer Robinson Helicopter Co
Model R44
Registration VH-JFK
Sector Helicopter
Operation type Flying Training
Departure point Southport ALA QLD
Destination Southport ALA QLD
Damage Minor