Collision with terrain involving a WEATHERLY AVIATION COMPANY LTD 620A, VH-WEA, 3 km west-south-west of Blumson Farm, South Australia, on 28 August 1997

Summary

The aircraft was carrying out dusting operations and was on the second flight of the day. The pilot had done an obstacle evaluation flight prior to commencement of operations and had identified a row of mallee trees running north/south inside the eastern boundary fence. Running parallel to these trees in the paddock to be sprayed was a single power line.

The pilot made his first run to the west flying through a gateway and then under the power line as there was sufficient clearance and it provided the optimal approach for this swath run. The reciprocal run was then commenced to the east and the pilot began his pull up with a view to clear both the power line and the trees. During this manoeuvre the pilot heard a light thud and believed that he had contacted the power line. As the aircraft appeared to be handling normally, the pilot elected to return to the airstrip to inspect for damage.

Approximately 450 metres past the paddock fence, the aircraft suddenly pulled to the right in a steep nose down attitude and impacted the ground sustaining substantial damage. After evacuating the aircraft, the pilot observed that the power line was still attached to the aircraft landing gear and had not broken. He stated that the local Electricity Trust representative later informed him that the power line was of a three-strand high tensile steel construction that was designed specifically not to be cut or broken. This was evidenced by the ineffectiveness of the aircraft cable cutting devices and the severe damage that they sustained without severing the power line.

Occurrence summary

Investigation number 199702805
Occurrence date 28/08/1997
Location 3 km west-south-west of Blumson Farm
State South Australia
Report release date 10/10/1997
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Collision with terrain
Occurrence class Accident
Highest injury level Minor

Aircraft details

Model 620A
Registration VH-WEA
Sector Piston
Operation type Aerial Work
Departure point Blumson Farm SA
Destination Blumson Farm SA
Damage Destroyed

Collision with terrain involving a Robinson R22 Beta, VH-JNN, 5 km east-north-east of Gamboola (ALA), Queensland, on 11 August 1997

Summary

The pilot was moving the helicopter in an attempt to prevent cattle from crossing a water channel. During an attempt to reduce airspeed quickly he flared with a 15 kt tailwind, resulting in the main rotor overpitching. The helicopter was levelled but one skid entered water adjacent to the edge of the stream, and the other skid landed on the bank. The skid in the water sank into the sandy bottom and the helicopter slowly rolled on to its side. Considerable damage was caused to the rotor blades and airframe when the blades contacted the water.

An emergency locator transmitter was carried but did not activate during the impact sequence.

Occurrence summary

Investigation number 199702815
Occurrence date 11/08/1997
Location 5 km east-north-east of Gamboola (ALA)
State Queensland
Report release date 04/09/1997
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Collision with terrain
Occurrence class Accident

Aircraft details

Manufacturer Robinson Helicopter Co
Model R22 Beta
Registration VH-JNN
Sector Helicopter
Operation type Aerial Work
Departure point Gamboola QLD
Destination Gamboola QLD
Damage Substantial

Abnormal engine indications involving a British Aerospace PLC BAe 146-300, VH-EWM, Tamworth, New South Wales, on 19 August 1997

Summary

The pilot reported that the number three engine was shut down after the oil pressure indicator showed erratic movement and then dropped to zero. The low oil pressure light did not illuminate. The flight continued for an uneventful landing at the planned destination. Post flight examination confirmed erroneous oil pressure indication. The oil pressure transducer for the number three engine oil pressure gauge was replaced and the aircraft returned to service without further incident.

Occurrence summary

Investigation number 199702795
Occurrence date 19/08/1997
Location Tamworth
State New South Wales
Report release date 02/09/1997
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Abnormal engine indications
Occurrence class Incident

Aircraft details

Manufacturer British Aerospace
Model BAe 146-300
Registration VH-EWM
Sector Jet
Operation type Air Transport High Capacity
Departure point Canberra ACT
Destination Brisbane QLD
Damage Nil

Security related involving a Boeing 737-476, VH-TJL, 60 km south-east of Brisbane Aerodrome, Queensland, on 27 August 1997

Summary

The aircraft was on descent towards Brisbane via Jacobs Well. The crew reported seeing glare from what they believed was a laset light east of the Brisbane - Gold Coast highway near the Gold Coast.

The light was not known to CASA. Consequently, there was no NOTAM concerning the light. CASA advised that it had also received a report concerning the light from a helicopter operator and intends to conduct a night flight to determine the position of the light and then proceed with NOTAM or other action as appropriate.

Occurrence summary

Investigation number 199702796
Occurrence date 27/08/1997
Location 60 km south-east of Brisbane Aerodrome
State Queensland
Report release date 02/09/1997
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Incident

Aircraft details

Manufacturer The Boeing Company
Model 737-476
Registration VH-TJL
Sector Jet
Operation type Air Transport High Capacity
Departure point Sydney NSW
Destination Brisbane QLD
Damage Nil

Operational non-compliance involving a Fairchild SA226-TC, VH-KGX, 6 km south-east of Brisbane Aerodrome, Queensland, on 22 August 1997

Summary

The aircraft had been radar vectored for a pilot intercept of the outbound track. The controller had monitored the aircraft's track, which indicated compliance with the planned track. Later the aircraft was observed diverging from track and potentially in conflict with an overflying aircraft. The controller instructed the pilot of the diverging aircraft to adopt a new heading to avoid a loss of separation. A subsequent report from the pilot indicated that he had been using the course deviation indicator bar to maintain track. The bar had later moved to one side, and he had turned to centre the bar. He later found that the bar was giving erroneous indications compared with the RMI needle.

Occurrence summary

Investigation number 199702794
Occurrence date 22/08/1997
Location 6 km south-east of Brisbane Aerodrome
State Queensland
Report release date 04/09/1997
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Operational non-compliance
Occurrence class Incident

Aircraft details

Manufacturer Fairchild Industries Inc
Model SA226-TC
Registration VH-KGX
Sector Turboprop
Operation type Charter
Departure point Brisbane QLD
Destination Windorah QLD
Damage Nil

Flight control systems involving a Cessna 402C, VH-UCD, Palm Island (ALA), Queensland, on 15 August 1997

Summary

The pilot reported that the flaps became asymmetric when full flap was selected at about 300 ft on final for landing at Palm Island. The pilot immediately returned the flap selector to the previous position and carried out a "go around". The flight returned for an uneventful landing at Townsville. Post flight examination found the right flap extend cable had failed in the radius of a pulley. The cable was due for special inspection in approximately 20 hours flight time.

The maintenance organisation, Operator and CASA Airworthiness in Townsville were all contacted concerning this incident. The maintenance organisation is currently submitting a Major Defect Report detailing the failure. The maintenance organisation will be recommending to CASA that the affected cables be placed on a shorter special inspection period or be replaced at short time intervals.

Occurrence summary

Investigation number 199702788
Occurrence date 15/08/1997
Location Palm Island (ALA)
State Queensland
Report release date 02/09/1997
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 Cessna Aircraft Company
Model 402C
Registration VH-UCD
Sector Piston
Operation type Air Transport Low Capacity
Departure point Townsville QLD
Destination Palm Island QLD
Damage Nil

ACAS warning involving a Boeing 737-476, VH-TJN, Brisbane Aerodrome, Queensland, on 30 August 1997

Summary

The aircraft was being radar vectored to short final approach runway 01. ATC had advised that a Cessna 210 aircraft was conducting aerial work near the runway. The B737 crew could clearly see the Cessna, and it did not threaten safety. Just before turning on to final approach, a TCAS resolution advisory was triggered by the Cessna. The approach and landing continued uneventfully.

Occurrence summary

Investigation number 199702786
Occurrence date 30/08/1997
Location Brisbane Aerodrome
State Queensland
Report release date 02/09/1997
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category ACAS warning
Occurrence class Incident

Aircraft details

Manufacturer The Boeing Company
Model 737-476
Registration VH-TJN
Sector Jet
Operation type Air Transport High Capacity
Departure point Melbourne VIC
Destination Brisbane QLD
Damage Nil

Collision with terrain involving an Amateur Built D5, VH-CPD, Serpentine (ALA), Western Australia, on 31 August 1997

Summary

The pilot in command and aircraft owner was restricted to flying with a co-pilot because of his age (79). The pilots were carrying out practice for a spot-landing competition to take place later that day.

The pilot reported that his first approach was lower than normal, and he had to apply power in an attempt to reach the runway threshold. Although the wind was blowing directly down the runway, at about 5 kt, there was some turbulence, and he believed there was a downdraft on late, final approach.

The pilot was concentrating his attention on touching down on the threshold markers, as practice for landing on his selected spot, when the co-pilot called "up, up". Immediately after the call, the aircraft collided with the top rail of a cattle holding yard, crashed to the ground, slid across a road and through the airfield boundary fence and onto the runway, where it came to a stop.

The major factor in the accident was that the pilot was concentrating all his attention on achieving his selected touchdown point (tunnel vision) and was not situationally aware in that he was not observing the other required parameters, height above the ground, glide-path angle and obstacle clearance, as he allowed the aircraft to descend well below a safe glidepath. It is possible that a downdraft may have increases the rate of descent in the last seconds of flight.

Occurrence summary

Investigation number 199702773
Occurrence date 31/08/1997
Location Serpentine (ALA)
State Western Australia
Report release date 11/11/1997
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Collision with terrain
Occurrence class Accident
Highest injury level Minor

Aircraft details

Manufacturer Amateur Built Aircraft
Model D5
Registration VH-CPD
Sector Piston
Operation type Flying Training
Departure point Serpentine WA
Destination Serpentine WA
Damage Substantial

Airspace related - Other involving a Dassault Falcon E, VH-HFJ, 37 km west-south-west of Alice Springs VOR, Northern Territory, on 22 August 1997

Summary

An aircraft was flight planned to track from Alice Springs direct to Ayers Rock. When the plan was being processed by flight data staff, the routing was checked with a supervisor. The staff were instructed to generate flight progress strips to indicate that the aircraft would track via ANGAS. (Preferred routes for the area are via ANGAS to Ayers Rock and direct to Alice Springs from Ayers Rock). Approaching Alice Springs, the crew became aware that an aircraft was tracking from Ayers Rock to Alice Springs and would present a confliction for their descent. After passing Alice Springs, in order to give the controller adequate time to make arrangements, they informed the controller that their descent point would be 75 NM from Ayers Rock, whereupon the controller issued a descent clearance. The crew questioned whether the other aircraft would be a confliction. They indicated that their flight plan had been to track direct from Alice Springs to Ayers Rock. The aircraft was then issued with a clearance to track via ANGAS.

No operating limitation for the route from Alice Springs was evident on the enroute chart, so the pilot had planned via the direct track. After the incident he found that the preferred route was via ANGAS.

Occurrence summary

Investigation number 199702792
Occurrence date 22/08/1997
Location 37 km west-south-west of Alice Springs VOR
State Northern Territory
Report release date 02/09/1997
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Airspace related - Other
Occurrence class Incident

Aircraft details

Manufacturer Dassault Aviation
Model Falcon E
Registration VH-HFJ
Sector Jet
Operation type Charter
Departure point Cairns QLD
Destination Ayers Rock NT
Damage Nil

Loss of separation involving a de Havilland Canada DHC-8-102, VH-WZI and Saab SF-340A, VH-KEQ and Saab SF-340A, Unknown, 9 km west of Cowes, Victoria, on 26 August 1997

Summary

FACTUAL INFORMATION

A Dash 8 had departed Melbourne on a flight to Wynyard, Tasmania and was climbing to flight level (FL) 170 via Cowes, a reporting point and navigational aid south-east of Melbourne en-route to Wynyard. A SAAB 340 had departed Wynyard for Melbourne and was also tracking via Cowes, maintaining FL160. The crew had been instructed to descend to FL130 "when ready". The Melbourne Inner South controller had recognised that there was a potential conflict and coordinated, with the departures controller, for the Dash 8 to be radar vectored to the left of track. This action would provide radar separation between the aircraft to allow both crews to change level without infringing the separation standards.

The crew of the Dash 8 requested, and were given, permission to climb to and maintain FL150. When the controller issued the left turn instruction, the crew of the Dash 8 asked if a right turn was available. The controller checked the route on a longer range radar scale and decided that the direct track to Wynyard would be adequate for radar separation purposes and would be a shorter track for the aircraft. A new instruction was then issued for the crew to track from their present position direct to Wynyard. The controller had, in fact, looked at the wrong track and destination when changing radar range scales and had mistaken a geographical point on the Tasmanian coast as Wynyard, when it was actually Smithton.

Wynyard was not displayed on the map. When the Dash 8 commenced the turn, the controller realised the mistake but thought that there would be sufficient distance between the crossing flight paths to provide the required radar separation. Meanwhile the crew of the SAAB 340 had commenced descent and, as vertical separation was reducing, the controller realised that the aircraft would pass with less than the required standard. The crew of the SAAB 340 were instructed to turn right 20 degrees in an attempt to maintain the standard but the turn proved to be insufficient and a breakdown of separation occurred. Radar analysis indicated that the aircraft passed with 4.7 NM horizontal separation and a vertical separation of 900 ft.

The required standard was either 5 NM horizontally or 1,000 ft vertically. A second SAAB 340 had departed Devonport, Tas. on a flight to Melbourne and was on a similar track to the first SAAB 340. This SAAB was approximately 15NM behind the leading SAAB and the crew had just commenced descent from FL160 in accordance with the controllers instructions. Approximately 80 seconds after the initial incident, the radar separation between the Dash 8 and this second SAAB 340 reduced to 3.5NM with the radar indicating that the aircraft had passed each other with 900 ft vertical difference.

The controller had issued descent instructions to the crew of the SAAB 340 which negated the existing vertical separation standard of 1,000 ft. However, the crews had reported sighting and passing each other's aircraft. The controller had established this visual contact by obtaining a report from the crew of the Dash 8 that "we have the SAAB passing on our left hand side".

ANALYSIS

The radar map showed a track and destination for Smithton but no information at all for Wynyard. Whereas Wynyard was a regular destination, traffic to Smithton was infrequent in controlled airspace. Although the controller promptly detected the initial error, track shortening was allowed to proceed. Although actively monitoring the developing situation, the decision to allow unrestricted climb and descent did not provide separation assurance. When the track of the Dash 8 also conflicted with the second SAAB 340, there was a vertical separation standard in existence.

However, the controller authorised descent for the SAAB 340 with only minimal radar separation. The controller had based separation on pilot reports of mutual sighting. Whereas the SAAB crew could have been safely expected not to miss-identify the Dash 8 aircraft, the Dash 8 crew may have been referring to the first of the two SAAB aircraft.

SIGNIFICANT FACTORS

1. The Inner South controller mistakenly identified the location of Smithton on the radar display map as that of Wynyard.

2. The Inner South controller did not use adequate separation assurance techniques.

3. The Inner South controller misjudged the radar separation between the Dash 8 and SAAB 340 aircraft.

SAFETY ACTION

As a result of the investigation, Airservices Australia Southern District management put in place amendments to the radar display map that indicate the location of Wynyard for controller reference.

Occurrence summary

Investigation number 199702770
Occurrence date 26/08/1997
Location 9 km west of Cowes
State Victoria
Report release date 20/07/1998
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 De Havilland Canada/De Havilland Aircraft of Canada
Model DHC-8-102
Registration VH-WZI
Sector Turboprop
Departure point Melbourne Vic.
Destination Wynyard Tas.
Damage Nil

Aircraft details

Manufacturer Saab Aircraft Co.
Model SF-340A
Registration Unknown
Sector Turboprop
Departure point Devonport Tas.
Destination Melbourne Vic.
Damage Nil

Aircraft details

Manufacturer Saab Aircraft Co.
Model SF-340A
Registration VH-KEQ
Sector Turboprop
Departure point Wynyard Tas.
Destination Melbourne Vic.
Damage Nil