The Cessna 337A (C 337A) was being used to conduct the final endorsement training flight of a company pilot. The instructor reported that he did not conduct a formal pre-flight brief with the student. He had presumed the student had adequate knowledge of the aircraft systems, although the student was not subject to a written systems examination and the instructor did not orally check the extent of the student's systems knowledge.

The student's previous training flight had been with another pilot in a G model of the Cessna 337, which used an electrical mechanism for raising and lowering the landing gear, whereas the C 337A used a hydraulic pump driven by the front engine to power the landing gear mechanism. The instructor's previous flight was also in the Cessna 337G.

During the third circuit of the endorsement flight, the instructor simulated a front engine failure by leaning the mixture of that engine. The instructor reported that he talked through and assisted with the engine shutdown checks as the student had limited multi-engine experience and was slow in responding to the simulated failure. The instructor also reported that he retarded the front engine's throttle following the engine shutdown but did not recall hearing the gear warning horn. The gear warning horn is normally actuated when either throttle is retarded below a point approximating 13 inches of manifold pressure while the landing gear is not down and locked. Landing gear extension had been intentionally omitted from the downwind pre-landing checks as the pilots had intended to lower the landing gear when the aircraft was settled on the correct final approach path. With the front engine shutdown, there was no hydraulic power available to lower the landing gear, so when the student selected the landing gear down during the final approach, it did not move. Neither pilot noticed the lack of a safe indication and neither looked outside to visually check the landing gear position.

Although neither pilot recalled hearing the horn sound, even during rear engine throttle retardation in the landing flare, the horn was later found to be operational. However, during a subsequent flight, it was discovered that the gear warning horn operated intermittently and that a microswitch required replacement.

Finals checks, including the checking of the landing gear position, were reported by the instructor as not being conducted due to the high workload during the final approach.

The pilots did not realise that the landing gear was not down until the belly-mounted cargo-pod hit the ground during the landing flare. The aircraft maintained a level attitude during the landing retardation whilst the instructor shut-down the rear engine. As the aircraft came to a stop, it rocked back on to the tail and the rear engine propeller struck stones at low RPM. The pilots then vacated the aircraft without further incident.

The instructor knew the student pilot both at work and socially, which probably influenced him to approach the training in an informal manner. Because both pilots had conducted their previous flying in a different model of the Cessna 337, the lack of formal pre-flight and systems briefings probably contributed to the accident.

Local Safety Action

The company has undertaken to introduce formal briefing requirements for all training programs and a training syllabus. An amendment to the theory examination on the Cessna 337, which is used by the company for endorsement purposes, has been incorporated. This amendment reflects the different landing gear operating requirements of the Cessna 337G and the Cessna 337A. As the two models are available to company pilots, the A model landing gear hydraulic requirements are to be placarded as a measure to reduce any future confusion.

The pilot of the C188 aircraft was carrying out spraying operations 12 km West of Clare. Due to his low experience level on the C188, the pilot was operating with a reduced internal chemical load of 600 litres rather than the maximum 757 litres. The pilot advised that on entry to a procedure turn at the completion of the fourth spray run he encountered excessive sink due to a tailwind.

The pilot attempted to arrest the sink rate by dumping the remaining chemical load and applying full power, however, due to late manoeuvering to avoid power lines this proved unsuccessful, and the aircraft impacted the ground left wing low. The pilot vacated the aircraft having suffered minor injuries in the accident.

The pilot of a Cessna 182 was conducting a local pleasure flight in the Ayers Rock mandatory broadcasting zone (MBZ). On departure from Ayers Rock to the Olgas at 1123 CST, the pilot transmitted his intention to track from Ayers Rock to the Olgas on high frequency (HF) 4693Hz. The transmission was faint and attempts by Adelaide Flight Information Service (FIS) to establish communications with the pilot on HF were unsuccessful. Adelaide FIS transmitted on the area frequency of 127.7MHz, requesting any aircraft on that frequency to respond.

The crew of a BAe146, on the ground at Ayers Rock, were monitoring the area frequency as well as the MBZ frequency. They assisted Adelaide FIS by transmitting an all stations broadcast on the Ayers Rock MBZ frequency of 126.7 MHz (as FIS are unable to transmit on or monitor an MBZ frequency) to all pilots listening on the frequency that a Cessna 182 was operating in the MBZ on an incorrect frequency.

At 1125, when the BAe146 was taxiing at Ayers Rock to depart for Cairns, the crew was advised that communications with the Cessna 182 had not been established. Eight minutes later, the pilot of the BAe146 reported departing Ayers Rock, and that he had narrowly avoided colliding with another aircraft.

At 1139, the pilot of the Cessna 182 again transmitted on HF4693 reporting, "Ayers Rock 0200 on climb to 5,000 ft track 060 degrees". Adelaide FIS requested the BAe146 crew to retransmit the Cessna's position report on the Ayers Rock MBZ frequency for the benefit of other aircraft operating in the MBZ. At the same time, the pilot of the Cessna 182 transmitted on 127.7MHz, advising that he had experienced radio problems and that the matter had been resolved.

During the course of the investigation, the Cessna 182 pilot advised that he had observed the BAe146 during its take-off roll on runway 13. In addition, there was conflicting evidence from the pilots of both aircraft on the estimated distance between the aircraft at the time of passing. The pilot-in-command of the BAe146 estimated the distance as 250 metres to 300 metres whereas the Cessna 182 pilot's estimation was four to five miles. There were no other witnesses.

On the day before the incident, after arriving at Marla, the Cessna 182 pilot had not been able to establish communications with Adelaide FIS using very high frequency (VHF). He had then cancelled his SARTIME with Adelaide FIS using HF.

The following day the pilot flew the aircraft to Ayers Rock. During this flight and on the incident flight, the pilot had not repositioned the transmitter selector from HF to VHF. On departure from Ayers Rock, the pilot transmitted his flight details on HF, which meant that each of his transmissions could not be heard by other pilots listening on the MBZ VHF frequency. The Cessna 182 pilot had followed the Scenic Flight Routes procedure in the Enroute Supplement Australia (ERSA) by tracking to the Ayers Rock aerodrome at 4,000 ft. The Cessna pilot overflew the aerodrome as he watched the BAe146 depart on runway 13.

The pilot of the Cessna overflew the airfield, maintaining 4,000 ft as the BAe146 turned left on climb after departing runway 13. The BAe146 came into confliction with the Cessna while turning left on climb to set heading for Cairns. The BAe146 pilot was aware that a Cessna was in the MBZ and experiencing radio problems. Under the Civil Aviation Regulations, it is the responsibility of individual pilots operating in an MBZ to maintain visual separation with other aircraft.

The Cessna pilot to did not establish the reasons for his radio problems until approximately 16 minutes after his original transmission at 1123. This was after monitoring a transmission from the BAe146 to FIS which stated, "is that Cessna 182 not VHF equipped or what is going on". This transmission was made after the near miss.

SAFETY ACTION

In response to recent similar occurrences the Bureau of Air Safety Investigation developed Interim Recommendation (IR) 970110 which was forwarded to Airservices Australia and the Civil Aviation Safety Authority on the 4 July 1997. The Interim Recommendation stated:

"The Bureau of Air Safety Investigation recommends that Airservices Australia and the Civil Aviation Safety Authority:

1. implement methods for the timely dissemination of the MBZ or CTAF frequency to pilots;

2. implement methods of providing to pilots confirmation of the correct selection and operation of an MBZ or CTAF frequency;

3. examine the requirement for the establishment and operation of traffic alerting services at all aerodromes during RPT operations;

4. examine the provision of additional radar coverage in the Bundaberg area; and

5. examine the provision of surveillance for other locations serviced by RPT operations."

The following response was received from Airservices Australia on 1 September 1997:

"Reference is made to the Bureau's Air Safety Interim Recommendation No IR970110 which relate to communications procedures for MBZ and CTAF. With regard to Interim Recommendation 1, Airservices have issued a NOTAM instructing pilots to report the frequency to which they are changing as part of the "Changing To" call. The frequency quoted is, whenever practicable, recorded by ATS for the information of other pilots. Airservices do not intend providing the MBZ or CTAF frequency to pilots on an individual basis as a matter of routine. Other methods of disseminating the MBZ or CTAF frequency, e.g. via AWIB broadcast will be taken into consideration. It should be noted however, that the longevity of this procedure is not great, given the likely directions of Airspace 2000 and introduction of the National Advisory Frequency (NAF) in Class G airspace. Interim Recommendations 2 and 3 fall within the CASA areas of responsibility for a response. Interim Recommendations 4 and 5 relating to the provision of additional surveillance in the Bundaberg area and for other locations serviced by RPT will be considered by Airservices."

No response has been received from the Civil Aviation Safety Authority.

The pilot reported that he completed an inspection of the strip prior to landing. It appeared fully serviceable. As the aircraft approached the end of its landing roll it entered an area of soft soil. This overloaded the nosewheel structure which collapsed, allowing the propeller to strike the ground.

The pilot in command of a Boeing 737 carried out a rejected take-off on runway 34L, due to a suspected tyre failure as the aircraft approached the take-off decision speed. The crew were subsequently able to vacate the runway safely and stop the aircraft on taxiway B4, despite both tyres on the left main landing gear being deflated. The runway was closed by ATC and a pavement inspection found considerable tyre debris. The passengers were subsequently disembarked onto the taxiway and transported to the terminal.

The operator reported that a subsequent inspection of the aircraft found that both tyres on the left main landing gear, as well as the outer left wheel, had been destroyed. The inner left wheel had also suffered damage. The mainwheel gear door was holed, and the left-wing flap dented. One passenger was reported to have sustained a minor cut to the head when an overhead panel had been dislodged.

While the mode of tyre failure is yet to be conclusively determined, the operator has indicated that the damage is consistent with the left mainwheel outer tyre having suffered foreign object damage prior to or during the take-off roll, resulting in deflation at high speed. It is considered that the left inner tyre then failed as a result of heat stress following the rejected take-off.

The pilot of VH-WTX was returning from a scenic tour, along with a number of other aircraft. Approaching the aerodrome, the radio of an aircraft on the ground became jammed on continuous transmission. The pilot of WTX was then unable to establish the position of the other traffic by radio and conducted an orbit to visually contact the traffic. During this time, he selected the landing gear down. A short time later, the aircraft landed with the landing gear in the retracted position.

Post flight inspection revealed that the landing gear circuit breaker had tripped.

The pilot indicated that he could not positively recall checking that the landing gear was down and locked. He also said that the landing gear warning horn did not operate when the throttle was closed for landing.

The aircraft was departing from runway 16 and had been cleared via a RADAR THREE DEPARTURE CRENA to Perth, with an assigned heading of 290. This procedure requires the aircraft to turn after passing 4 DME. VH-HYF was observed on radar to commence a right turn at about 2 DME.

The crew reported that the correct procedure had been briefed. As the aircraft passed 3 DME, the non-flying pilot was occupied on the radio and the flying pilot commenced the turn without checking the departure chart. The non-flying pilot noticed the error when he had completed the radio communications and advised the flying pilot.

The crew reported that the 3 red "in transit" lights remained illuminated when the gear was selected down for landing. The down and locked green indicators were also illuminated at the same time. The gear was cycled several times after which normal gear down indications were obtained. Post flight examination found a faulty micro switch in the landing gear selector handle. The switch was replaced and the aircraft returned to service without further incidence.

During a maintenance investigation for an oil leak on the aircraft's Jabiru 2200cc engine, it was discovered that two flywheel-to-crankshaft retention cap screws had failed. The remaining four retention cap screws also showed signs of impending failure. The engine had operated for approximately 226 hours.

The operator had previously experienced a complete failure of all six retention cap screws, during start-up, on another 2200cc engine that was fitted to this aircraft. This failure occurred at approximately 274 engine hours. The operator had also experienced problems with cracking of the engine rocker assemblies.

Although the aircraft was operated under Australian Ultralight Federation (AUF) requirements, the aircraft type was certificated to operate as an Australian registered aircraft. However, the Jabiru 2200cc and 1600cc series engine types had not been certificated, but were accepted for use in Australia under the auspices of CAO 101.55. This aircraft was one of the first to be fitted with the Jabiru 2200cc series engine.

SAFETY ACTION

As a result of this occurrence, technical personnel from the Bureau of Air Safety Investigation met with CASA to discuss the Jabiru engine certification issue, and the flywheel cap screw failures. CASA advised that both the Jabiru 1600cc and 2200cc engines were currently undergoing certification. The Jabiru 2200cc engine is to comply with JAR 22H. CASA indicated that they will consider the Jabiru engine flywheel retention cap screw failures as part of the certification process.

The Bureau of Air Safety Investigation will continue monitoring the certification of the Jabiru 1600cc and 2200cc engines.

The crew reported that they received a cockpit warning during climb passing through FL 310. In accordance with company procedures the flight was returned for an uneventful landing at the departure runway.

Post flight examination found the number 3 Air Data reference Unit had failed. The unit was replaced and all systems tested normal. The aircraft then returned to service without further incident.