FACTUAL INFORMATION

History of the flight

The pilot was undergoing a flight test for the initial issue of a multi-engine command instrument rating under the supervision of an Air Test Officer (ATO). The ATO was the owner, chief pilot, and chief flying instructor of the flying training school with which the private pilot was undertaking his training. He had been working long hours and had not taken a holiday for at least a year. 

The flight was from Archerfield to Kilcoy, Maroochydore, Brisbane, then return to Archerfield. Although a flight plan had been submitted, no contact with the controllers at Maroochydore had been made in order to arrange for the instrument approach training.

Some aerial work was conducted in the Kilcoy area prior to tracking to Maroochydore. At some point around, or shortly after leaving, Kilcoy the ATO fell asleep. When the aircraft was about 22 NM from Maroochydore the pilot under test made a position report and requested an airways clearance. He was instructed to track overhead Maroochydore at 4,000 ft and make a sector entry. Since the normal commencement altitude for an approach at Maroochydore was 3,000 ft, the controller was expecting the pilot to report overhead when ready to descend to 3,000 ft in preparation for an instrument approach.

The controller saw the aircraft east of the control tower after it had passed overhead. He anticipated that the pilot would soon request descent for the approach and had cleared other aircraft in such a way as to keep the airspace free for the approach. He did not speak to the pilot as he was aware that aircraft on instrument training can sometimes conduct operations in the holding pattern for some time before requesting an approach. After arriving over Maroochydore the pilot under test conducted the planned instrument approach. When the aircraft was about half way through the approach and turning inbound towards the aerodrome the ATO woke up. As the aircraft was then at the point in the approach at which he intended simulating an engine failure for the pilot under test, the ATO did this without comment.

The next transmission from the aircraft occurred on final approach for runway 18 when the pilot requested a landing clearance. The controller questioned how the aircraft had progressed to that point but issued a landing clearance and a clearance to continue the planned flight. The ATO deduced that the aircraft had descended without a clearance.

A few minutes prior to the pilot's request to land an aircraft had departed from runway 12 at Maroochydore and had turned left to track to the north-west to the training area. Since the controller was not aware of the presence of the aircraft so close to the circuit area, no separation standard had been applied to the departing aircraft. By coincidence, it is likely that the aircraft did not conflict.

Personnel information

The ATO held a commercial pilot licence with a current medical certificate. He claimed a total flying experience of 8,300 hours, and he had flown 20 hours during the month of the incident. He had been working at least six days a week for more than a year. Although he considered that his flight crew duty times did not contravene the current regulations, this calculation did not involve the additional time spent in managing the flying school.

The ATO said that for about four weeks prior to the incident he had been suffering from influenza but had not seen a doctor or taken himself off flying duties. He considered that his presence at work, and his flight test duties, were necessary in order to maintain the success of the business. He indicated that he had fallen asleep briefly on previous flights. Following the subject incident he had attended a doctor who informed him that he was suffering from bronchitis.

An accurate assessment of the pilot's activities and food intake in the days leading to the incident could not be made as the pilot could not remember his activities nor his meal intake. He had commenced work at 0800 on the day of the incident and other days had been unremarkable as far as his normal routine was concerned.

ANALYSIS

At the time of this incident the pilot under test was expected to be able to conduct the flight as a single pilot operation. His failure to obtain a clearance for the approach is considered a factor.

The ATO did not notice the failure to obtain a descent / approach clearance because he was asleep. He was suffering from fatigue and an illness. This is considered a factor.

The controller had observed the aircraft overhead at an appropriate time and therefore had no need to request position information from the pilot. He was anticipating a request for descent from the pilot and did not intend prompting the pilot unless the request was well overdue.

The ATO considered that he complied with the existing flight crew duty limitations if only his flying activities were considered. He considered that he was not within those limitations if his business work was considered. While flying can be a cause of an increase in fatigue, a person's fatigue state is determined by the total consideration of a person's waking / sleeping cycles and total activity. In this case, if the person's total lifestyle had been considered, he would not have been flying.

SIGNIFICANT FACTORS

1. The pilot in command fell asleep due to fatigue and illness.

2. The pilot under test conducted a descent and approach without a clearance.

SAFETY ACTION

The interpretation and application of flight and duty times has been raised as a safety concern in previous investigations and safety studies. More recently, the Bureau conducted a study of the safety of Australian regional airlines. The need for an understanding of, and pragmatic approach to, fatigue management principles was highlighted in that study. Safety action relating to this issue is currently being drafted.

FACTUAL INFORMATION

A Shorts SH36 aircraft had departed Williamtown on a flight to Brisbane. The crew were maintaining the aircraft at 9,000 ft outside controlled airspace and were in contact with Flight Service Area 5 (FIS 5).

A Dash 8 aircraft had departed Sydney on a flight to Taree. The crew were maintaining the aircraft at flight level (FL) 150 and were under the control of Brisbane Sector 15C.

The sector controller coordinated the overhead Williamtown position of the Dash 8 with FIS 5. This coordination included an estimate for Taree and advice that the crew would contact FIS 5 at "top of descent".

The flight service officer correctly calculated that the two aircraft would be in conflict and passed traffic information on the Dash 8 to the crew of the SH36. Although aware of a requirement to back coordinate with sector control when an aircraft leaving controlled airspace on descent required traffic information, the officer elected not to pass the information to the sector controller. She had calculated that there would be at least 3 minutes between the top of descent of the Dash 8 and the aircraft coming into conflict and therefore sufficient time for her to pass the traffic information to the crew.

The crew of the Dash 8 were cleared to leave controlled airspace on descent to Taree and were instructed to contact FIS 5 by sector control, immediately after they reported leaving FL150. They attempted to do this but were delayed by other airspace users transmitting on that frequency. They finally made their broadcast while passing 13,000 ft and at a rate of descent of 1,800 ft/min. The base of controlled airspace in the Taree area was 12,500 ft. The Aeronautical Information Publication required a crew to make their first broadcast on the flight information service frequency prior to leaving controlled airspace.

The flight service officer acknowledged the transmission from the crew of the Dash 8 and passed the traffic information on the SH36 and two other aircraft. By the time the crew had analysed this information and assessed that the SH36 was in direct conflict, their aircraft was passing between 11,000 ft and 10,500 ft. The pilot in command immediately amended the altitude selection to 10,000 ft and the automatic pilot commenced the level-off manoeuvre at 10,400 ft. The aircraft levelled off at 10,000 ft and the crew saw the SH36 in their 12-o'clock position. Both crews had been using Global Positioning System navigational equipment and were accurately "on track".

The two crews then established communication and mutual sighting. There was no breakdown of separation, and the crews completed a safe sighting and passing manoeuvre.

ANALYSIS

Analysis of the respective flight paths indicated that the aircraft avoided a direct conflict by approximately 30 seconds. Both crews agreed that their respective aircraft were on-track and the position of the SH36 was such that the closing speed and descent profile of the Dash 8 could have resulted in a mid-air collision had the rate of descent not been arrested.

The level-off of the Dash 8 was implemented as soon as the crew had analysed the position of the SH36 and before they achieved visual contact. Had they been delayed further in their attempts to contact FIS 5, the separation would have been significantly reduced.

The flight service officer had received the correct coordination from the sector controller and made a correct assessment of the conflict. However, her decision not to bother air traffic control with the need to pass traffic information was predicated on an assumption that the crew of the Dash 8 would call her at top of descent. If such a call was made, it would have given her more than 3 minutes to carry out the broadcast and this would probably have been sufficient for the task. However, such a timely call could not be guaranteed and on this occasion did not happen. The resultant delay reduced the time available for the crew to make an informed judgement about the traffic.

The phrase "top of descent" was used by the controller to indicate a transfer of the aircraft to FIS 5 as soon as practicable after the crew reported leaving their cruising level. The regulations allowed the crew to report vacating a level up to 1 minute after the event. A further delay in making the broadcast then occurred due to other airspace users making authorised transmissions. This delay could not be accurately estimated and was always going to be of unknown duration.

The flight service officer considered that the phrase "top of descent" meant exactly that and made an assessment based on this belief.

SIGNIFICANT FACTORS

1. The flight service officer elected not to coordinate the traffic information on the SH36 to the crew of the Dash 8 with Sector Control.

2. The flight service officer expected the crew of the Dash 8 to contact her at "top of descent".

3. The crew of the Dash 8 were delayed in making the initial broadcast on FIS5 due to frequency congestion.

SAFETY ACTION

Airservices Australia Northern District Office issued a local instruction (NDO 97/191) on 29 August 1997 which specified improved procedures for the transfer of communications to flight information service frequencies when an aircraft is on descent from controlled airspace.

As a result of this and other occurrences, the Bureau of Air Safety Investigation is developing recommendations relating to the provision of timely traffic information by air traffic services and for flight crews to develop separation assurance techniques.

Any recommendations arising will be published in the Bureau's Quarterly Safety Deficiency report.

The flight was a dual training exercise for a type endorsement. Some upper air work had been completed in the training area before the aircraft was flown to Camden for circuits and landings.

The instructor reported that during the third touch and go sequence, after a normal landing, the student had applied take-off power but then inadvertently selected the landing gear up, instead of the flaps. The instructor immediately closed the throttles as the right main landing gear collapsed. The aircraft slewed through 180 degrees before coming to rest on the flight strip. Both occupants vacated the aircraft without injury.

A Dash 8 had departed Sydney for Port Macquarie NSW. The crew was maintaining the aircraft at flight level 170 and reported that they were ready for descent. The sector 15 C controller issued instructions for the aircraft to leave controlled airspace on descent and for the crew to contact flight service for the portion of the flight to be conducted outside controlled airspace.

The boundary of controlled airspace was 12,500 ft and the crew contacted FIS 5 prior to that level. The flight service officer received the transmission but had not had any coordination on the flight from sector 15 C. Fortunately, there were no immediate traffic conflictions, and the flight service officer had time to peruse his flight strips and pass relevant traffic information to the crew of the Dash 8.

The sector 15 C controller, who was under training, had not passed the flight details regarding the Dash 8 to FIS 5. However, a tick had been placed on the flight progress strip indicating that the coordination had been completed.

While the Dash 8 had been en-route, the military airspace under the control of Williamtown air traffic control became active and this action required coordination between sector 15 C and Williamtown control, which included information on the Dash 8. This activity resulted in a short-term, high workload situation involving several conversations with Williamtown air traffic control.

At approximately the same time, a second training officer prepared to take over the training responsibilities from the original training officer. This handover/takeover took place at the console with both officers "plugged in" to the monitor jacks. This had the effect of the second training officer being unable to hear anything through his headset until the first officer removed his headset from the jack.

The crew of the Dash 8 received their instruction to contact flight service immediately after the first training officer unplugged from the console and he did not hear this transmission. The second training officer looked at the flight progress strip as the instruction was being given and, seeing that the strip notation indicated that the coordination had been completed, believed all appropriate action had been taken.

Neither the first training officer nor the trainee could remember when or why the notation was made on the flight progress strip indicating the completion of the coordination with FIS 5 but, on reflection after the occurrence, the training officer remembered that it had not been done.

There was no breakdown in separation.

FACTUAL INFORMATION

The pilot of the Cessna 172 (C172) landed the aircraft on runway 31R and vacated the runway at the A2 taxiway intersection. However, the pilot became confused by the numerous taxiway options for his return to the parking area and entered runway 35R, using it as a taxiway in a northerly direction. Runway 35R was not in use at the time and was therefore available for taxiing. Whilst on runway 35R the pilot did not notice that his aircraft had entered runway 31R. He had not requested, nor had he received, a clearance from air traffic control to use runway 31R.

He did not see any signage that indicated that he was approaching the active runway and did not notice the gable markers that were set back from the crossing point of the two runways. A Piper PA28 had just taken off from runway 31R and passed over the C172 at a height of about 50 ft. A second PA28 on final approach to runway 31R was sent around by air traffic control.

SAFETY ACTION

During the course of the investigation the Bureau of Air Safety Investigation issued the following recommendation relating to this occurrence:

R980057

(issued 25 May 1998) "The Bureau of Air Safety Investigation recommends that the Civil Aviation Safety Authority review the adequacy of movement area guidance signs and markings, particularly at runway-to-runway intersections. The review should focus initially on Moorabbin Aerodrome and other aerodromes with multiple runways and complex taxiway systems."

The pilot had completed a charter flight at Blackwater and was returning the aircraft to the company base at Emerald. Another company pilot, not endorsed on type, was the sole passenger.

Enroute to Emerald the pilot decided to do some low flying over a wheat crop. The aircraft struck a 3-phase power line about halfway across the paddock. The aircraft was arrested by the wires and came to rest upright in a fallowed part of the paddock. No one was injured.

The pilot reported that he arrived at Daly River Police Station at 0745 CST and picked up his passenger who was a NT police officer. The passenger's equipment was loaded on board and the helicopter departed the police station at 0810.

The pilot flew approximately 1.5 NM northwest and landed on the pinnacle of an 800 ft high ridge. He said he frictioned all the controls down and secured the helicopter, before assisting the passenger to unload his equipment. The pilot said he and the passenger were about 10 m from the helicopter, and he had just turned to head back towards it when the left skid lifted off the ground about 2.5 to 3 ft. This subsequently caused the main rotor blades to strike the ground. The helicopter rolled over to the right and caught fire. The passenger was struck by flying debris resulting in cracked ribs.

Wind at the time of the accident was gusting from 25 to 35 kts from the south-east. The helicopter was facing a southerly direction on the edge of the mountain range.

The pilot reported that the aircraft floated about half the length of the 1130 m strip before he decided to take the aircraft around for another circuit. When he retracted the third stage of flap, the left wing dropped, and the aircraft veered off runway heading. The pilot then lowered the nose of the aircraft in an attempt to increase air speed, but when he saw that a collision with trees was imminent, he closed the throttle. The aircraft ran through a boundary fence and came to rest among saplings about 100 m further. None of the three occupants were injured.

The emergency locator transmitted, installed in the rear fuselage, did not activate.

The pilot was spraying crops adjacent to the Leigh River. The river meanders through a steep sided valley oriented approximately north-south, with the crop being sprayed located above the west ridge of the valley. The pilot advised that he had refuelled the aircraft and refilled the hopper.

The wind was gusting from the south-west and he was on a spray run, tracking to the south, at 5 ft above the ground, when a gust of wind caused the left wing to drop. The pilot advised that he was unable to stop the wing hitting an embankment and the aircraft rolled into the valley, coming to rest upright, substantially damaged and burning.

The pilot suffered a broken ankle and burns but was able to extricate himself. The aircraft was destroyed.

The student pilot was returning after a solo flight to the training area. The runway in use had a seven knot crosswind from the left. The pilot used 20 degrees of flap and approached at 65 kts. His initial flare was too high, so he reduced power and lowered the nose. A high sink rate developed, and the pilot pulled back on the control wheel before the aircraft bounced into the air. The nose was again lowered and a high sink rate followed by a bounce was experienced. This sequence was repeated on another two occasions before the aircraft nose struck the ground and the aircraft flipped on to its back.

No emergency locator transmitter was fitted to the aircraft.