The tug pilot released the glider from tow shortly after take-off because the glider did not appear to be climbing. The tug pilot advised that he had lifted of at approximately 55 knots, allowed for drift, let the speed stabilise at 70 knots, then commenced to climb. After he had climbed to about 100 feet above the strip he noticed that the glider was very low behind him. He stated that he made a radio call to the glider telling him to "come up". He noticed the speed was deteriorating below 55 knots, he had full forward elevator applied and the stall warning had activated. The tug pilot considered that the glider was excessively out of station and that if the tow continued it would affect the safe operation of the tug. He therefore released the tow rope. The tug completed a circuit and landed safely.

The glider pilot stated that he selected negative flap during his preparation for launch. He stated that the tug commenced its tow and lifted off after a normal ground run. The glider was skipping and not lifting off. He moved the flap back two notches, looked at the airspeed indicator and it showed around 55 knots. He stated that the "tug went up like a rocket" and climbed well above the glider. He pulled back on the control column to try to catch up with the tug. Shortly after this he heard the tow rope release.

After being released he turned left, flew for a few hundred metres before turning right, and then outlanded into a small field covered in stubble. Once on the ground the glider ground looped in the stubble and slid backwards into a fence. The glider was substantially damaged.

After the accident the glider was found to be configured with the flaps in the "negative flap" setting. This setting is a feature that is used to reduce drag during high-speed cruise. The negative flap setting can also be used in the first segment of a take-off roll to increase the low-speed effectiveness of the ailerons. When this procedure is employed the flaps are reconfigured to the take-off setting as soon as the wings are levelled and under positive aileron control. The continued use of the negative flap setting during take-off and climb seriously degrades the climb performance of the glider.

The pilot was not able to explain to the investigator from the Gliding Federation of Australia (GFA) why the flaps were still selected to an inappropriate setting. 

There is no evidence of the flaps having moved as a function of the accident sequence therefore it can be concluded that the pilot did not apply landing flap during the approach into the stubble field. It is probable that the flap setting was not changed during the take-off run. This would explain the lack of climb performance experienced during the take-off sequence.

The student had just completed a dual check and was taxiing for a period of solo circuit training. He reported that as he taxied along the taxiway he checked the holding point for conflicting aircraft but did not see any navigation or anti-collision lights. As the Cessna approached the holding point the pilot's visibility was affected by glare from the landing light of an aircraft on final approach and he did not see the Grob parked in front of him. The Cessna's propeller struck the tail of the Grob.

ACTUAL INFORMATION

A Boeing 737 (B737) was following a Boeing 767 (B767) for arrival at Brisbane. Both aircraft were from Cairns and were being radar vectored by the Sector 3B controller. The controller was undergoing a periodic check and had seven aircraft on frequency with five being radar vectored for sequencing. The periodic check required the controller's performance at the position to be monitored and assessed by another rated controller (check controller). The aircraft being vectored were in two groups that were approaching Brisbane via different reporting points; SMOKA and PERCH. There was a considerable number of radio transmissions and co-ordination calls relating to the management of the two traffic sequences. The two Boeing aircraft were the last two aircraft in the SMOKA sequence. The controller of an adjacent sector was required, by local instructions, to establish a 20 NM trail between arriving aircraft. This controller asked the Sector 3B controller if this was required. The Sector 3B controller replied that that this was not required. Sector 3B is required to establish a 15 NM trail between aircraft by 40 NM from Brisbane. The following B737 was maintaining a slightly higher groundspeed on descent than the B767 and the distance between the aircraft was reducing. The Sector 3B controller instructed the crew of the B767 to turn onto a heading of 090 degrees, for sequencing, which caused the aircraft to cross the intended track of the B737.

The check controller assessed that the separation would be maintained and continued to monitor the Sector 3B controller's actions. The Sector 3B controller reassessed the situation and instructed the crew of the B737 to maintain FL220. The B767 was on descent to FL170 and the Sector 3B controller instructed the crew to continue descent to FL130. The controller believed that the flight profiles of the aircraft, while complying with his instructions, would achieve vertical separation of 1,000 ft between the two aircraft. This would be attained by the B767 passing through FL210 prior to the horizontal separation reducing to less than 5 NM. A controller on an another position had been observing the situation, with the diminishing horizontal and vertical separation between the two aircraft, and queried the Sector 3B controller as to whether the latter was satisfied with the situation. The Sector 3B controller did not acknowledge this query but immediately instructed the crew of the B737 to turn right a further 10 degrees. He intended to maintain horizontal separation by vectoring the B737 behind the B767. The check controller assessed that the horizontal separation standard would be infringed while there was no vertical separation standard being applied and instructed the Sector 3B controller to issue traffic information to the crew. The provision of traffic information was in accordance with the Manual of Air Traffic Services (MATS). The MATS states that when a separation standard does not exist and in a controller's opinion the proximity of aircraft warrants, traffic information shall be issued to the relevant crews. The crew of the B737 were aware of the B767 and had been watching the aircraft as they approached. The crew of the B737 had reduced speed and as they were discussing that separation appeared to be reducing the Sector 3B controller issued traffic information. The two aircraft passed with horizontal separation of 3.8 NM and vertical separation of 600 ft. There was a breakdown of separation.

ANALYSIS

The Sector 3B controller increased his overall workload by cancelling the requirement for the adjacent sector controller to establish all aircraft in a 20 NM trail. The establishment of a 20 NM trail by the adjacent sector controller would have assisted the Sector 3B controller in managing his workload. His level of work and complexity was compounded by having to achieve the required spacing between aircraft and to manage the two arrival sequences. He did not recognise that the horizontal separation between the B737 and the B767 was reducing. Also, he did not employ appropriate separation assurance techniques before issuing radar vectors to the crew of the B767 that would cause that aircraft to cross in front of the B737 with minimal horizontal separation. The intervention by another controller prompted both the Sector 3B and the check controller to act to maintain separation. However, the turn provided to the crew of the B737 was too late and the check controller was required to instruct the Sector 3B controller to pass traffic information to the crew. The situational awareness of the crew of the B737 assisted in the safe resolution of the incident.

SIGNIFICANT FACTORS

1. The Sector 3B controller cancelled the requirement for the adjacent sector controller to establish aircraft in a 20 NM trail.

2. The Sector 3B controller did not use appropriate separation assurance techniques.

3. The check controller and the Sector 3B controller were slow to react to the reduction in separation between the two aircraft.

FACTUAL INFORMATION

The training pilot was conducting training for a pilot in command who was new to the Boeing 767 aircraft and its electronic cockpit concept. Under instructions from the training pilot, the trainee inserted the expected approach and landing information into the flight management computer (FMC), whilst the aircraft was maintaining cruise altitude. This expectation was based on the training pilot's previous experience, where a RIVET 4 STAR with a CULLERIN transition for a landing on runway 34R was normally applied to aircraft arriving from Melbourne.

There were no runway allocations issued to the crew until approximately seven minutes after commencing the descent. At this time, they were first given the information that they were being vectored to left base for a runway 34L independent visual approach. This was acknowledged by the crew. They were advised again during the descent sequence that they would be landing on runway 34L. The crew acknowledged this instruction as well.

After the crew was instructed to continue for a visual approach to runway 34L, the aircraft was observed to track to intercept the runway 34R extended centreline. Eventually, the crew was advised that they appeared, on radar, to be tracking for the incorrect runway. They adjusted the flight path to intercept the extended centreline for runway 34L and completed an uneventful landing.

The Bureau of Air Safety Investigation has previously recommended to Airservices Australia and the Civil Aviation Safety Authority in interim recommendation IR950213 of 2 January 1996, that aircrew read back runway assignments, especially in parallel runway operations. The responses (July 1996) to this recommendation advised that a complete review of phraseology was underway to bring Australian phraseology into line with ICAO, as far as practicable. Both organisations expected that the results from this review would address BASI concerns regarding runway readback. This review was not complete at the time of the occurrence.

ANALYSIS

The training pilot was concentrating on instructing the new pilot in the duties associated with operating the Boeing 767 and did not become alerted to the assignment of a runway that was different to his expectation. Had he been required to read back the runway allocation, it is probable that he would have recognised the unexpected runway and the need to update the data in the aircraft's FMC.

The balloon with 1 pilot and 10 passengers on board departed at about 0650 from Royal Park for a flight over Melbourne city. The pilot intended to land at Port Melbourne, a distance of approximately 7 kilometres. The pilot said that he was advised that at Essendon, 4 kilometres to the northwest the weather was overcast with a 1 knot northerly wind at 1000 feet and the surface wind was calm. After take-off the balloon climbed to 900 feet and the pilot estimated that he was drifting south at 2 knots. As the flight proceeded across the docks he noticed significant ripples on the water surface and significant movement of trees. He estimated that a surface wind of 10 knots had developed in his planned landing area. Because of the wind speed the pilot was forced to make a rapid descent and land before reaching the shore of Port Philip Bay. He force landed the balloon onto the third floor of a building under construction adjacent to the shoreline of the Bay. Although the balloon dragged across the concrete construction and skidded into a safety railing there was no injuries to the persons on board. The pilot disembarked 6 passengers and attempted to lift off and descend to ground level alongside the building.

During this manoeuvre the vent line snagged and the canopy started to deflate. As the canopy deflated it was ripped by construction materials resulting in the basket having to be manhandled to the ground. Weather station readings taken at 0300 indicated that the wind at 1,000 feet was from the northwest at 10 knots. Actual weather readings taken from automatic weather stations around Melbourne approximately 45 minutes prior to departure of the balloon showed the surface winds were generally from the north to northeast averaging 5 knots. By 0900 the surface winds had increased to 10 knots The pilot considered that the incident occurred because of an extremely rapid and localised katabatic wind had developed in the landing area. He plans to increase the volume of his balloon and to increase his fuel capacity to allow him to overfly Port Philip Bay should he experience increasing winds again. The police advised that this is not the first time that this operator has had problems landing in Port Melbourne. The balloon had landed on the same building site some weeks prior to this event, and in a previous event the balloon with passengers on board had overshot the landing area, flown out over the Bay, and was subsequently towed back to shore by a police vessel.

The pilot had underestimated the wind speed that he would encounter on this flight. Even though the surface winds were calm at Essendon and Royal Park, the actual wind at 1,000 feet was ten knots (as reported at 0300), and this, coupled with a surface wind of 5 knots increasing to 10 knots as the morning progressed, was not the ideal conditions to undertake a flight into an area characterised by very little open landing spaces adjacent to a large expanse of water. The operator's intention is to increase the flight endurance of the balloon and fly across the Bay. This would need careful consideration as some of the land areas at the south end of the Bay are narrow, and the flight path may put the balloon into the mouth of the Bay. It may be that a take-off more to the north of the city would preclude the need to consider an overwater flight.

The pilot reported that the aircraft departed with eight imperial gallons (36 litres) of fuel indicated on the fuel gauge for a one hour aerobatic training flight. The aircraft had just been refuelled, with 20 litres being added to a calculated 25 litres remaining. The flight was authorised for one hour on a planned fuel burn of 24 litres/hour and a calculated quantity of 45 litres useable.

The aircraft departed the training area 55 minutes after engine start with the fuel gauge (believed to be inaccurate/completely unreliable below 5 imperial gallons) flickering around the empty position. The pilot rejoined the circuit on the upwind leg for runway 09. During the descent prior to turning crosswind, at about 1,200 ft above the ground, the engine failed. The pilot elected to land straight ahead on the runway remaining. During the descent the engine regained power momentarily, which resulted in a potential overshoot of the runway. The pilot commenced a series of 'S' turns to lose height in an attempt to touch down prior to the upwind threshold.

As he flared, the engine again regained power momentarily. The aircraft finally touched down in the grass overrun area where it ran through a ditch and then into a fence.

The pilot had planned to conduct a series of tourist flights from the helipad at the rear of the Lodge. A 20 m diameter pad had recently been cleared for the operation. The pad was covered with short grass however, it was surrounded by grass up to 0.5 m high. A shrub-like weed was also woven into the tall grass. Only one passenger was carried on the first of the tourist flights and the helicopter performed as expected. On the second tourist flight, this time with two passengers on board, the pilot flew the helicopter to a 1 m hover and then departed towards the east. As it moved through translational-lift the helicopter descended and the right skid entered the 0.5 m-high grass around the helipad. The grass retarded the helicopter, and the leading edge of the skid made contact with the ground. The helicopter started to roll to the right. The pilot attempted to stop the roll by reducing power. When this was unsuccessful, he increased power to the maximum and attempted to fly out of the roll. This was also unsuccessful, and the helicopter ended up rolling onto its right side.

The helicopter was loaded to just under its maximum weight. The pilot misjudged the amount of excess power that would be available under the prevailing conditions, and he was unable to keep the helicopter clear of the grass during the departure. The scrub-like weed provided sufficient retardation for the right skid to dig into the ground starting a roll to the right. The pilot's description indicates the helicopter had probably entered a condition known as dynamic rollover (Aviation Safety Digest No. 95, 1975, pg. 25) before he started recovery action. As a result, his actions did not work.

The pilot was conducting a routine food and medical supply flight to several outstation settlements. Visual meteorological condition (VMC) existed when he departed, but with storm activity observed along the route, and a cyclone in the area. Approximately 1.5 minutes from the destination a rapid deterioration in the weather conditions to below VMC prevented the pilot from landing so he decided to divert to Oenpelli.

He was again confronted by deteriorating weather conditions making further diversions necessary. He notified Adelaide Flight Service of the diversions and then attempted to return to his departure aerodrome, which also proved impossible.

After spending sometime dodging around storms and heavy rain in an attempt to find a suitable airstrip, then faced with the approach of evening and fading daylight, he decided his safest action would be to find a suitable area for a precautionary landing. He was unable to re-establish contact with Adelaide Flight Service to advise his intentions.

He found a relatively flat area on top of an escarpment, but during the landing roll the aircraft struck light timber causing the right wing to detach and the aircraft to roll onto its right side. The pilot and passenger evacuated the aircraft, then activated the ELT which was monitored by Airservices Australia SAR via satellite, and their location known. Because of the cyclone and adverse weather conditions a search could not be initiated until the next morning.

They spent the night in the aircraft to shelter from continuous heavy rain, then rescued next morning by helicopter.

After take-off the flight attendants seated at the rear of the aircraft reported a bang followed by abnormal noises from the area of the rear airstairs. Shortly afterwards the flight crew observed that the lower aft body overheat light had illuminated. The appropriate drills were carried out, and the warning light extinguished when all bleeds were closed. The aircraft returned for an immediate landing.

Maintenance investigation found that a titanium duct flange had ruptured upstream of the right-wing anti ice valve. Failure of the flange is a known problem. A special inspection for cracks in the weld zone had been introduced many years ago and, in 1990, after an evaluation of service history, the inspection period was increased from 1,000 cycles to 2,000 cycles. The failed flange was nearly at the 2,000-cycle threshold and had failed approximately 60 cycles and just 12 days before the inspection was scheduled.

The operator is continuing checks to confirm the mode of failure of the flange and is reassessing the compliance period.