Fuel exhaustion involving a Beech Aircraft Corp 200, VH-LKF, 90 km north-west of Perth Aerodrome, Western Australia, on 5 December 1996

Summary

The pilot reported that he completed some pre-planning for the flight on the evening before the occurrence. As the forecast passenger load was less than expected he rang the refuelling agent and requested an additional 200 lb of fuel be added to the aircraft to bring the total fuel load to 1850 lb. The additional fuel was not added as the programmed aircraft became unserviceable prior to refuelling. The replacement aircraft contained 1650 lb which was the standard load for the flight.

The pilot prepared a flight plan for the flight using his personal flight planning program. A comparison between this plan and one prepared using the operator's flight planning program indicates the pilot's fuel-burn figures were some 6% better than the operators. The pilot's figures indicated the aircraft would use 679 lb for the flight to Youanmi, excluding any use of reserve fuel, and it would need a minimum of 1,266 lb, on taxi at Youanmi, to meet all requirements, including reserves, for the return flight. Expected fuel burn for the return flight was 895 lb. As the aircraft taxied with 1,650 lb at Perth, approximately 300 lb needed to be added at Youanmi to meet the requirements. The pilot requested that 300 lb of fuel be provided at Youanmi, during his standard radio report to the operator on departure from Perth.

At Youanmi, fuel is supplied in 200 L drums. It is the pilot's responsibility to move the drums and pump the fuel into the aircraft. The pilot reported that he did not add the extra fuel as the gauges indicated there was 1,270 lb of fuel remaining and this was more than the minimum requirement. Although there was a discrepancy between the expected fuel burn on the flight up and the apparent actual burn, he indicated he did not consider it was significant. He assumed the difference was the result of a minor gauging problem. The pilot had a 15-minute wait before the passengers arrived, and he was able to depart for Perth.

The return flight was uneventful until top of descent. As the pilot commenced descent the right engine lost all power. During his trouble checks the pilot noted that both fuel gauges read 240 lb. He was unable to restart the right engine and the flight was continued on one engine. The pilot reported the engine shutdown to air traffic services and indicated that he suspected fuel starvation. The aircraft was cleared direct to Perth. Although the pilot believed fuel might be the problem, he decided not to divert into Pearce air force base but instead continued to Perth. He did however, request to track via overhead Pearce. The pilot later observed that had the second engine failed, he could have glided safely to either Pearce or Perth.

Following the aircraft's arrival in Perth, and after the passengers had disembarked, the fuel gauge indications were reported as 40 lb on the left and fluctuating between 100 and 180 lb on the right. The aircraft was defueled and 15 L (26 lb) removed from the left tank and 3 L (5 lb) from the right. When all fuel was drained from the aircraft the left gauge read 0 lb and the right gauge 125 lb.

The pilot's fuel planning figure indicated the aircraft would use 1,574 lb of fuel for the return flight to Youanmi, without including any of the variable and fixed reserves. The fuel drain indicated the aircraft actually used 1,619 lb. The pilot's flight plan indicates that the time intervals for some of the legs flown were longer than planned. In addition, there was the 6% difference in fuel burn between the two flight planning programs considered. It is not possible to determine, without additional research, the accuracy of the program used by the pilot. These differences probably account for the additional fuel used.

An engineering investigation determined that both fuel gauges had been replaced 3 days prior to the occurrence and a fuel calibration completed. This calibration had been completed using a system common to general aviation (the gauges were reset to zero and known amounts of fuel added to check the accuracy of the indications) but not recommended by the manufacturer. The gauging system was reported as serviceable after this calibration. Following the occurrence, the right gauge was reset to zero and another calibration was completed using the general method. A subsequent calibration using the manufacturer approved method (special test equipment) found that the right gauge was under-reading by 25 lb.

The reason for the false reading reported on the right gauge during and following the occurrence was not identified.

One of the purposes of fuel flight planning is to provide pilots with a means of cross checking the accuracy of their fuel gauges. It would be unlikely that any aircraft would burn 43% less fuel than expected on any one flight (379 instead of 679 lb). Consequently, it should have been obvious to the pilot that the gauge readings were unreliable when he checked the quantities at Youanmi, particularly in the light of his general and type experience. Why the pilot did not identify the discrepancy as significant could not be determined from the evidence available.

Occurrence summary

Investigation number 199604019
Occurrence date 05/12/1996
Location 90 km north-west of Perth Aerodrome
State Western Australia
Report release date 14/01/1997
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Fuel exhaustion
Occurrence class Incident

Aircraft details

Manufacturer Beech Aircraft Corp
Model 200
Registration VH-LKF
Sector Turboprop
Operation type Charter
Departure point Youanmi WA
Destination Perth WA
Damage Nil

Forced/precautionary landing involving a Mooney M20J, VH-JDU, 59 km west-south-west of Wondai (ALA), Queensland, on 6 December 1996

Summary

The pilot reported that the aircraft was cruising at 7000 feet, when he heard a loud bang accompanied by severe vibration. He immediately transmitted a "Mayday". During a subsequent orbit, clear of cloud, the pilot saw a paddock with a likely landing strip. The throttle was closed and a glide approach commenced.

During the descent, the pilot noticed that the strip was obstructed with irrigation pipes. He then decided that the only viable alternative for a forced landing was on a nearby road. Vehicles were observed (headlights were on) travelling in the same direction and groups were widely spaced. During the landing roll (which was subsequently found to be downwind) the left wing struck a road speed sign at about 60 kts IAS.  The aircraft then slewed left off the road into a fence.

The pilot activated an Emergency Locator Transmitter which was fixed in the empennage. The transmissions were heard by the pilot of an overflying aircraft and reported to Brisbane Air Traffic Control.

The pilot later reported that the loss of power was due to a sudden failure of the No 3 cylinder barrel, occurring at the barrel to cylinder head shrink line.

Occurrence summary

Investigation number 199604007
Occurrence date 06/12/1996
Location 59 km west-south-west of Wondai (ALA)
State Queensland
Report release date 15/01/1997
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 Mooney Aircraft Corp
Model M20J
Registration VH-JDU
Sector Piston
Operation type Business
Departure point Longreach QLD
Destination Maroochydore QLD
Damage Substantial

Incorrect configuration involving an Airbus A340, 9V-SJD, 390 NM west-north-west of Sydney, New South Wales, on 5 December 1996

Summary

FACTUAL INFORMATION

The aircraft was being operated as a scheduled passenger service from Singapore to Sydney, with the co-pilot as the handling pilot. Whilst cruising at flight level (FL) 370 over the centre of the Australian continent, turbulence was encountered. A diversion of about 30 NM to the right of track was carried out to avoid local storms, before returning to the original track. The seat belt signs had been on for some time and the cabin crew needed to resume the meal service which had been in progress. The pilot in command (PIC) requested a clearance to climb to FL390, which was approved. Conditions were smooth and clear at the higher level so the seat belt signs were turned off and the meal service resumed. The aircraft was being controlled by the number two autopilot.

Later, prior to reaching the top of descent, the co-pilot commenced the pre-descent review and briefing, which included a review of the aircraft fuel status. When the fuel system synoptic display was selected on the electronic centralised aircraft monitor (ECAM), a lateral fuel imbalance was observed, with the left inner fuel tank about 800 kg heavier than the right. The PIC elected to correct the situation and the fuel imbalance checklist was reviewed. The checklist required that the four fuel crossfeed valves be opened by depressing the four fuel crossfeed valve switches on the centre overhead panel, then turning off the fuel pumps in the lighter tank. The valve positions are monitored by observing the fuel system synoptic on the ECAM screen on the centre instrument panel.

The engine driven hydraulic pump push button switches are also located on the centre overhead panel, immediately above the fuel crossfeed valve switches. These switches are similar to the fuel crossfeed valve switches and are activated by the same push-button switching action. The engine driven hydraulic pump push button switches are not guarded to prevent inadvertent activation. All valve positions are monitored on the respective fuel or hydraulic system synoptic displays on the ECAM, on the centre instrument panel. Standard operating procedures require that, when a switch is manually activated, the respective valve position is monitored on the ECAM before any further switching actions are performed. This procedure is to confirm that the correct selection has been made.

The PIC reported that he raised his hand and placed his right index finger on a fuel crossfeed valve switch. Before depressing the switch, the co-pilot remarked that the fuel management was under automatic control, and in the forward transfer configuration at the time. The PIC removed his finger from the switch to refer back to the fuel system synoptic on the ECAM but then decided to continue with the fuel imbalance procedure. He then depressed what he thought was the number one fuel crossfeed valve switch, then the remaining switches in succession, leaving his finger on the last switch. He observed the white switch lights illuminate as each switch was activated but neither of the crew monitored the valve positions on the fuel system synoptic on the ECAM. After depressing the last switch, the PIC observed the green hydraulic system low pressure warning on the ECAM, heard one warning chime, together with the master caution light and alarm, and also heard the auto-pilot disconnect warning. He looked up and saw that he had inadvertently pushed all four engine driven hydraulic pump push button switches off and immediately switched them all back on.

When the autopilot disconnected automatically, due to the reduction in hydraulic pressure, the aircraft began to pitch up and the stall warning sounded twice. The PIC advised the co-pilot that he was taking control of the aircraft and gave a nose-down command to his side stick control, but did not utilise his side stick priority push button. At the same time the co-pilot also gave a momentary nose-down command to his side stick control before realising that the PIC had control. The aircraft pitched down, then up, before level flight was regained and the auto-pilot was re-engaged. During the event the aircraft climbed about 350 ft before returning to FL390.

The loss of hydraulic pressure to the hydraulically powered flight controls and the prevailing aerodynamic forces acting on the airframe, resulted in the aircraft pitching nose up. This configuration could not be reversed until hydraulic power was restored. However, during this period both crew had instinctively moved their respective side stick controls to a nose-down command. As the side stick inputs are summed, this action resulted in a rapid pitch reversal as hydraulic pressure was restored, and required a further nose-up correction before level flight was regained.

The resulting negative and positive vertical accelerations which occurred caused unrestrained passengers and cabin crew in the rear of the aircraft to be thrown about and injured.

ANALYSIS

The investigation identified a safety deficiency in that there were several factors which increased the potential for the inadvertent activation of the engine driven hydraulic pump push button switches. The switches were not guarded; they were similar in appearance to the fuel crossfeed valve switches; and were activated by the same push button switching action. They were also located immediately above the fuel crossfeed valve switches on the centre overhead panel.

The PIC had initially placed his finger on a fuel crossfeed valve switch. However, before he activated it, his attention was drawn to the ECAM fuel system synoptic on the centre instrument panel, when co-pilot commented that the fuel system was in automatic forward transfer. Whilst his attention was drawn to the ECAM his finger moved slightly higher and was then positioned over an engine driven hydraulic pump push button switch. Deciding that he would continue with the fuel imbalance procedure, the PIC looked up to the centre overhead panel to what he thought was the fuel panel and depressed the switch to the off position. He then continued to depress the remaining three engine driven hydraulic pump push button switches to the off position. Neither of the crew were alerted to the incorrect selection at that time as the ECAM fuel system synoptic was still displayed.

As the aircraft was relatively new, there would have been minimal internal hydraulic system leakage. The aircraft was flying in still air so there was little demand on auto-pilot input to the various flying control hydraulic actuators. The hydraulic system accumulators continued to provide some residual pressure whilst the main hydraulic pressure was bleeding off, so it took some time before the hydraulic pressure depleted sufficiently to trigger the hydraulic system low pressure warning, though the hydraulic pump low pressure warnings had occurred. This time allowed the PIC time to switch off all the hydraulic pumps before a warning was observed and corrective action taken.

SIGNIFICANT FACTORS

1. The four engine driven hydraulic pump push button switches were not guarded to prevent inadvertent activation.

2. Inadvertent selection of the four engine driven hydraulic pump switches to the off position resulted in the loss of hydraulic system pressure to the hydraulically powered flight controls. The autopilot disengaged automatically due to the reduced hydraulic pressure.

3. The crew did not monitor the fuel crossfeed valve positions on the ECAM fuel system synoptic, following each switching action, in accordance with standard operating procedure.

SAFETY ACTION

As a result of the investigation into this accident, the Bureau of Air Safety Investigation issued the following safety advisory notice SAN960163:

"Airbus Industrie, Civil Aviation Authority (Singapore), Bureau Enquetes-Accidents (France), Civil Aviation Authority (UK), Transportation Safety Board (Canada), Federal Aviation Administration (USA) and the Civil Aviation Safety Authority (Australia) should note the circumstances surrounding this occurrence and the safety deficiency identified by BASI's investigations."

SAFETY ACTION BY MANUFACTURER

Airbus Industrie, as a result of this advisory notice, and subsequent investigations by their own staff, undertook the following safety actions:

1. Issued a notification to all operators of the aircraft type of the details surrounding the occurrence.

2. As an additional precautionary measure, Airbus Industrie has decided to develop a modification introducing a guard on each engine driven hydraulic pump push button switch.

Occurrence summary

Investigation number 199604000
Occurrence date 05/12/1996
Location 390 NM west-north-west of Sydney
State New South Wales
Report release date 30/07/1997
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Incorrect configuration
Occurrence class Accident
Highest injury level Serious

Aircraft details

Manufacturer Airbus
Model A340
Registration 9V-SJD
Sector Jet
Operation type Air Transport High Capacity
Departure point Singapore
Destination Sydney NSW
Damage Nil

Fuel starvation involving a Piper PA-32-300, VH-POA, 6 km north-west of Cobden (ALA), Victoria, on 8 December 1996

Summary

Factual information

The pilot had planned to fly from Moorabbin direct to Ocean Grove, then on to Warrnambool. Prior to departure he was advised that there was 40 litres of fuel in the left main tank and the right main tank was full at 91 litres. Both tip tanks were also full at 63 litres each.  Records held by the operator showed that the aircraft was consuming an average of 61 litres per hour. Accordingly, the pilot was advised to use the right main tank for one hour, then use the tip tanks, and go back to the fullest main tank for the landing.

The pilot loaded his five passengers, selected the right main fuel tank, started the engine, conducted engine runs and taxied for take-off. These actions took approximately 20 minutes. After take-off the pilot flew coastal from Moorabbin to Ocean Grove rather than direct as planned, then tracked direct for Warrnambool. Due to weather constraints, he cruised between 2,000 feet and 2,500 feet above mean sea level and also deviated from his track to avoid rain showers. He used a high-power setting of 24 inches of manifold pressure and 2,400 rpm, and did not lean the fuel mixture. Approximately 65 minutes after take-off, at a position about 15 minutes from Warrnambool, the engine suddenly failed. At low altitude over hilly terrain the pilot said he did not have time to conduct a proper assessment of the cause of the power loss, nor did he have time to carry out a successful restart procedure. The pilot forced landed the aircraft onto a sloping field, colliding with a fence before bringing the aircraft to a stop. The aircraft suffered substantial damage, however the six persons on board were uninjured.

Investigation disclosed that the right main fuel tank contained unusable fuel only, and the fuel feed system to the engine was empty. When the system was supplied with fuel the engine was started and ran satisfactorily. Tests indicated that the fuel quantity measuring system was serviceable.

The pilot advised that during the flight he did not maintain a flight log and did not monitor the right main tank fuel quantity. His planning had indicated that the flight would take about one hour and he had intended to change to the fullest tank prior to landing.

The recommended power charts contained in the pilots operating handbook, which was available to the pilot, did not cover the combination of parameters under which this flight was conducted.

Analysis

While the contents of the right main tank prior to departure could not be definitely established it was most probably full at 91 litres. The coastal track taken by the pilot could have added up to an extra ten minutes flying and his deviations from track to avoid showers would also have added to his flight time. While the flying school's flight sheets indicated that the average fuel usage was 61 litres per hour, this was attained by using recommended power settings and correct leaning procedures. It was calculated that the aircraft could use up to 88 litres of fuel per hour while flying at low altitude with high power and a rich mixture. This, coupled with the taxiing, take-off and climb fuel flows would have depleted the 91 litre contents of the tank after approximately one hour in flight, as occurred.

By operating the aircraft as he did, the pilot chose to fly outside of the recommendations contained in the pilots operating handbook. However, even flying in this manner had the pilot maintained a flight time log and a fuel usage log, and monitored the fuel quantity gauges, he would have become aware of the contents of the right main fuel tank before the fuel was depleted.

Significant factors

  1. The pilot did not use effective fuel management techniques.
  2. Engine power was lost when the fuel tank in use was allowed to run dry.

Occurrence summary

Investigation number 199604014
Occurrence date 08/12/1996
Location 6 km north-west of Cobden (ALA)
State Victoria
Report release date 28/01/1997
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Fuel starvation
Occurrence class Accident

Aircraft details

Manufacturer Piper Aircraft Corp
Model PA-32-300
Registration VH-POA
Sector Piston
Operation type Private
Departure point Moorabbin Vic
Destination Warrnabool Vic
Damage Substantial

Near collision involving a Piper PA-31-350, VH-OZV and Piper PA-34-200T, VH-PWQ, 6 km south of Moorabbin Aerodrome, Victoria, on 4 December 1996

Summary

VH-OZV departed Moorabbin from runway 35L and after making a left turn, commenced tracking in a southerly direction on climb to 9,000 ft. Three miles south of Moorabbin the pilot called RAS, but the aircraft was not identified because its transponder was not being interrogated. The RAS controller passed traffic information to the pilot of OZV on an aircraft two miles at 12 o'clock, also with no transponder return. The pilot of OZV sighted the other aircraft in his 11 o'clock position, 100 to 200 ft higher. He took evasive action, in the form of a left turn, to avoid a collision.

The conflicting aircraft was later identified as VH-PWQ, whose transponder suddenly started operating after traffic information was passed to OZV. The pilot of PWQ said that he flies from Berwick to Ballarat, as he was on this occasion, once a week, and transits via the coast south of Moorabbin at 2500 ft. He listens out on RAS and the appropriate Moorabbin tower frequency for traffic. However, he did not make a broadcast of his position, altitude and intentions on the Moorabbin tower frequency, as is required by AIP OPS 42.2.1. He heard OZV departing Moorabbin but never saw it, even when they passed in close proximity.

Occurrence summary

Investigation number 199603981
Occurrence date 04/12/1996
Location 6 km south of Moorabbin Aerodrome
State Victoria
Report release date 12/12/1996
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 Piper Aircraft Corp
Model PA-31-350
Registration VH-OZV
Sector Piston
Operation type Air Transport Low Capacity
Departure point Moorabbin Vi
Destination Devonport Tas
Damage Nil

Aircraft details

Manufacturer Piper Aircraft Corp
Model PA-34-200T
Registration VH-PWQ
Sector Piston
Operation type Private
Departure point Berwick Vic
Destination Ballarat Vic
Damage Nil

Wheels up landing involving a Beech Aircraft Corp 76, VH-AHY, Perth Airport, Western Australia, on 29 November 1996

Summary

The instructor reported that he and the handling pilot were engaged in introductory ILS training at the time of the accident. An instrument training hood was being used to simulate instrument meteorological conditions. The aircraft had been cleared for an ILS approach to runway 24. As the aircraft approached localiser intercept the pilots were asked to reduce the aircraft's approach speed. The instructor suggested that the handling pilot lower the landing gear and flap earlier than normal. Both believe the gear was selected down at this point.

After glideslope intercept the handling pilot had to be prompted several times to reduce power to keep the aircraft's speed below the maximum. The instructor was not concerned with this as he had expected there would be a tailwind on final approach. Final's checks were completed prior to reaching decision height and both pilots reported that they thought they saw the green lights which indicated the gear was down. During the approach both pilots reported hearing the outer and middle marker identification signals over the aircraft's speaker but neither reported hearing the landing gear warning horn. The hood was removed at decision height and the handling pilot continued flying to a landing.

The handling pilot reduced power steadily to idle as he flew the aircraft into the landing flare. As the aircraft settled towards the runway the instructor realised the gear was still up and he reached for the selector handle to confirm it was in the down position. He did not recall moving the lever. The aircraft settled onto its lower fuselage and slid to a stop. Neither pilot reported hearing the landing gear warning horn during the flare.

Post-accident inspection of the landing gear did not disclose any faults. The gear selector handle was found in the down position and the main gear had been released from its uplocks. When the aircraft was lifted from the runway, and power applied, the gear extended, and the landing gear warning horn sounded until the gear was locked down. The fact that the main gear had been released from its uplocks is an indication, from past experience, that the gear had been selected down after the aircraft had settled onto the runway.

The instructor reported that he was acting as safety pilot, searching for other traffic and maintaining a visual watch until the landing. As a result, he did not closely monitor the handling pilot's actions in the cockpit. Therefore, he could not be sure the handling pilot actually moved any of the selectors in the direction which he had indicated.

The surface wind was reported as blowing from 030 degrees at around 5 knots. With this wind it is unlikely there was a tailwind on final and the problem with speed control was probably an indication that the gear was still up. It could not be determined why the warning horn did not sound, or if it did, why the pilots didn't hear it.

It is evident that the landing gear was either not selected down, when speed was being reduced, or it was selected up again during the approach. Past investigation indicate that it is possible for a pilot working under stress, as can be evident during a practice precision instrument approach early in their training, to reverse a selection thinking they had selected it correctly. This error is more likely if the system had previously been selected out of sequence, as it was in this case. Consequently, the gear may have been selected up just before glideslope intercept rather than down, as would have been the normal action.

Previous investigations also indicate that pilots sometimes see what they expect to see (a mindset) rather than the actual indication. This may explain their observation of the green landing gear lights when there probably weren't any.

Occurrence summary

Investigation number 199603913
Occurrence date 29/11/1996
Location Perth Airport
State Western Australia
Report release date 05/12/1996
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 Beech Aircraft Corp
Model 76
Registration VH-AHY
Sector Piston
Operation type Flying Training
Departure point Perth WA
Destination Perth WA
Damage Substantial

Airspace incursion involving a British Aircraft Corporation 167, VH-RBA, 9 km south-south-east of Kempsey Aerodrome, New South Wales, on 1 December 1996

Summary

FACTUAL INFORMATION

The aircraft had been flown from Archerfield to Port Macquarie for an air display and, on this flight the radar transponder had failed. At the completion of the display, the pilot departed Port Macquarie a few minutes after another similar type of aircraft which was also returning to Queensland. The transponder was unserviceable for this flight. Prior to commencing the flight from Port Macquarie the pilot arranged for the pilot of the other aircraft to make the appropriate radio transmissions for both aircraft, and inform air traffic services (ATS) of their intentions. Those transmissions were not monitored by the incident pilot.

No taxi calls or preliminary information that the aircraft had an unserviceable transponder were received and understood by ATS staff. The first communication with ATS was a call on departure from Port Macquarie, at 1430ESuT. In this series of transmissions the pilot indicated that he was climbing to flight level 260 (FL260) and that he had submitted a flight plan with a departure time of 1630. His estimated time time over Kempsey was 1438. The pilot was instructed to remain outside controlled airspace (OCTA) as he was not yet identified on radar, and to confirm that he would be tracking clear of the Coffs Harbour controlled airspace steps. After some delay the pilot reported that he might need a clearance through the steps. He was again instructed to remain OCTA.

When asked to squawk ident, the pilot used a military term to report that his transponder was not working. The controller asked him to confirm that the aircraft was not transponder equipped. Upon confirmation, the controller informed the pilot that a clearance into controlled airspace was not available without a transponder, considering that they had been given no taxi details in advance of departure from Port Macquarie. The pilot informed the controller that the taxi calls had been made by the other aircraft which had departed a few minutes ahead of him. However, the controller did not have this information.

At 1436 the pilot reported his position as five miles south of Kempsey and passing FL160 on climb to FL250. The controller reminded him that he had been instructed to remain OCTA. In the area between Port Macquarie and Kempsey the lower limit of controlled airspace was FL125. The pilot was then instructed to hold over Kempsey and maintain FL160. At 1437 the pilot again reported that he was five miles south of Kempsey at FL160. Upon being informed that he would not be given a clearance to Archerfield, the pilot responded immediately that he would go OCTA. The instruction hold over Kempsey at FL160 was re-affirmed. The pilot suggested that he could go east to Point Lookout, whereupon the controller confirmed with him that Point Lookout was to the northwest of Kempsey. After this the pilot offered to go to the west of the Coffs Harbour steps. The requirement to remain over Kempsey at FL160 was re-stated. 

Subsequently, at 1440 the pilot was cleared to track direct from Kempsey to Grafton and leave controlled airspace on descent to 9,500 ft, with a requirement to reach FL120 by 20 NM south of Coffs Harbour. The pilot then reported leaving FL160 on descent. At 1442 the pilot was transferred to the Coffs Harbour Tower frequency and was asked his distance from Coffs Harbour. The pilot responded that he was at 12,000 ft. No further monitoring of the flight was conducted.

The pilot reported that he conducted the remainder of the flight to Archerfield below 10,000 ft and in areas where high density light aircraft traffic could be expected. Visibility was also reduced due to smoke haze. He considered that he was forced to fly through the Casino - Ballina mandatory broadcast zone and then through the Archerfield training area. In his opinion this was less safe than flying in controlled airspace at a level without much traffic.

The pilot claimed that events which occurred during his earlier southbound flight had affected his actions during the northbound flight. On the flight to Port Macquarie, the pilot had been left with the impression that the Williamtown restricted area between Kempsey and Port Macquarie was active but uncontrolled. He did not appear to be given any descent clearances on that flight, he was simply reporting leaving levels on descent. He had not been instructed to call Williamtown at all. He later departed from Port Macquarie with the consideration that the same situation applied. That led him to believe that he could climb unrestricted within the restricted area, until north of Kempsey.

Recorded communications for the period covering the flight from Coffs Harbour to Port Macquarie indicated that the pilot reported over Coffs Harbour at 1041 ESuT, maintaining FL190 and estimating Port Macquarie at 1053. The pilot was then asked to report at 11 NM south of Coffs Harbour. At 1045 the pilot was issued with a clearance to leave controlled airspace on descent. This was acknowledged with his distance from Coffs Harbour. The acknowledgement was out of context with the clearance just issued. A minute later the pilot reported maintaining FL190 and he was again issued with the clearance to descend. This was then acknowledged correctly. At 1050 the controller asked if the aircraft had left FL190. The pilot subsequently reported having left FL190 at 1051.

Also, prior to departing Archerfield, the pilot had obtained the appropriate Notices to Airmen (NOTAMs), which would inform him of short notice or temporary changes to airspace and facilities enroute. These NOTAMs indicated that the Williamtown restricted areas were not active. The pilot was using the enroute chart which was to become valid on 5 December 1996, some days after these flights. The restricted area identification numbers around Williamtown were altered on these charts from those that were actually current.

ANALYSIS

Prior to his departure from Port Macquarie the pilot made no attempt to make some arrangement for a flight inside controlled airspace without a transponder. He did not update his planned departure time. Although he made an arrangement, with another pilot, to provide taxiing information at Port Macquarie, this was not understood by the flight service officer as a notification of a pending departure and, consequently, the officer did not co-ordinate with air traffic control. As a result, the controller was presented, at no notice, with an aircraft on which no information was held and which could not be monitored on radar. In addition, he soon learned that the aircraft was well inside controlled airspace.

After the pilot arranged a clearance which would allow the aircraft to leave controlled airspace, he then elected to fly below 10,000 ft through airspace likely to contain numerous aircraft. A number of alternatives for routes away from known traffic areas could have been used, as could a higher cruise level. Had advance arrangements been made, it was likely that a flight inside controlled airspace would have been possible

The pilot was using the incorrect enroute charts for the date. As a result, he was not able to correlate the NOTAMs with the restricted areas on the chart, and was not fully aware of the situation concerning the Williamtown restricted areas. His reported concept that the restricted areas were active but not controlled by military controllers should have led him to confirm the actual situation with air traffic services.

The controller for the flight to Port Macquarie had issued a descent clearance which was not initially understood by the pilot. Subsequently, the pilot reported leaving his cruising level, which was the only call required by the controller. This happened some two minutes before his arrival time at Port Macquarie. The controller had queried his level because a descent should normally have been initiated some time earlier.

SIGNIFICANT FACTORS

1. The pilot planned the flights using invalid charts.

2. There was a mechanical failure of the aircraft's radar transponder.

3. The pilot did not update his planned departure time prior to departure.

4. The pilot did not make prior alternative arrangements for flight without a transponder.

5. The pilot entered controlled airspace without a clearance. 6. The pilot did not select a route and altitude intended to avoid known areas of light aircraft traffic.

Occurrence summary

Investigation number 199603944
Occurrence date 01/12/1996
Location 9 km south-south-east of Kempsey Aerodrome
State New South Wales
Report release date 26/05/1997
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Incident

Aircraft details

Manufacturer British Aircraft Corporation
Model 167
Registration VH-RBA
Sector Jet
Operation type Private
Departure point Port Macquarie NSW
Destination Archerfield QLD
Damage Nil

Fuel exhaustion involving a Piper PA-25-235, VH-SSP, 19 km south of Anakie, Victoria, on 28 November 1996

Summary

The aircraft was involved in spraying operations. The pilot reported that at the end of the third load for the day, while pulling out of the final spray run and banking to the right, the engine failed suddenly and completely. The pilot rolled the wings level and flew towards a farm track at an oblique angle. While slewing the aircraft around to the left to align it with the track, the left wing hit a wire fence. This slewed the aircraft further to the left where it ran into another fence and nosed forward hitting the propeller on the ground.

When the aircraft was inspected after the accident, there was only half a litre of fuel drained from the entire fuel system. The flight time since the last refuel was consistent with fuel exhaustion. After the accident, the engine was started and ran normally.

Occurrence summary

Investigation number 199603906
Occurrence date 28/11/1996
Location 19 km south of Anakie
State Victoria
Report release date 18/12/1996
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Fuel exhaustion
Occurrence class Accident

Aircraft details

Manufacturer Piper Aircraft Corp
Model PA-25-235
Registration VH-SSP
Sector Piston
Operation type Aerial Work
Departure point 10 NM S Anakie Vic
Destination 10 NM S Anakie Vic
Damage Substantial

Birdstrike involving a Fairchild SA227-DC, VH-WAJ, Bronzewing (ALA), Western Australia, on 27 November 1996

Summary

The crew reported that, following touchdown from a normal approach, they observed an unidentified object about a third of the way down the runway. As the aircraft approached the object it was identified as an emu which was close to the strip. The beta lights were confirmed, and maximum reverse and braking were applied. At the same time the aircraft was moved to the right of the strip and away from the emu. The emu followed the aircraft and was struck by the left propeller as the aircraft decelerated through about 50 kts. It was thrown into the side of the fuselage. The pilot-in-command secured the left propeller and engine and the landing and taxi in were completed on one engine.

The aerodrome had been inspected by a ground agent about 15 minutes prior to the aircraft's arrival and there was no sign of the emu. The strip is surrounded by an animal-proof fence however the three gates are not self-closing. It was reported that the passenger gate had been left open overnight. It is likely the emu entered the aerodrome during the night and remained hidden until it was disturbed by the aircraft.

SAFETY ACTION

The aerodrome owner advised they are fitting self-closing devices to all the gates.

Occurrence summary

Investigation number 199603899
Occurrence date 27/11/1996
Location Bronzewing (ALA)
State Western Australia
Report release date 29/11/1996
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Birdstrike
Occurrence class Accident

Aircraft details

Manufacturer Fairchild Industries Inc
Model SA227-DC
Registration VH-WAJ
Sector Turboprop
Operation type Charter
Departure point Perth WA
Destination Bronzewing WA
Damage Substantial

Unsecured door involving a Bellanca 8KCAB, VH-DEC, 26 km south-east of Archerfield Aerodrome, Queensland, on 27 November 1996

Summary

The pilot reported that the upper half of the aircraft's cabin door separated in flight. The incident occurred when the top front latch came loose, at about 110 kts during the pullout from an aerobatic manoeuvre. The slipstream then pulled the window outwards, and it was torn off. As it departed the Perspex window and top door frame struck the lower surface of the right wing, tearing the fabric and fracturing 5 ribs.

The pilot was able to land the aircraft safely at Archerfield. He said that control of the aircraft was not greatly affected by the damaged wing.

Occurrence summary

Investigation number 199603886
Occurrence date 27/11/1996
Location 26 km south-east of Archerfield Aerodrome
State Queensland
Report release date 20/12/1996
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Accident

Aircraft details

Manufacturer Bellanca Aircraft Corp
Model 8KCAB
Registration VH-DEC
Sector Piston
Departure point Archerfield QLD
Destination Archerfield QLD
Damage Substantial