Collision with terrain involving an Ayres S2R-T34, VH-JVE, Chinchilla (ALA), Queensland, on 2 November 1996

Summary

The aircraft was engaged in spraying operations over a crop of rock melons. The pilot had not previously sprayed crops at this farm. During one of the spray runs the right wing struck a thin metal pole located at the edge of the paddock. The pilot was able to maintain control of the aircraft and diverted to land safely at a nearby air strip.

The farmer who normally removed the steel pole had forgotten to remove it on this occasion or to notify the pilot of its location.

The 5 to 6 m high pole was constructed of 25 mm square steel tubing. The pilot later said that he saw the obstacle too late to avoid a collision.

Occurrence summary

Investigation number 199603576
Occurrence date 02/11/1996
Location Chinchilla (ALA)
State Queensland
Report release date 02/12/1996
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 Ayres Corporation
Model S2R-T34
Registration VH-JVE
Sector Turboprop
Operation type Aerial Work
Departure point Chinchilla QLD
Destination Chinchilla QLD
Damage Substantial

Forced/precautionary landing involving a Hughes Helicopters 269C, VH-KZR, 40 km east of Rolleston, Queensland, on 12 October 1996

Summary

The pilot stated that the helicopter was given a full daily inspection. The engine had full oil and there was approximately 55 litres of fuel on board. After start, the engine was kept at idle until oil temperature was about 75 degrees. the rotors were then engaged and warm up was continued at 2000 RPM and then 2500 RPM. The magneto check showed no rough running. After pre-take-off checks, the helicopter was brought to the hover and moved forward about 6 feet, then put back on the ground for about 3 minutes while a load was placed on board. The pilot stated that after checking that all nozzles were working and pre-take-off checks were complete, he brought the helicopter to the hover. At 3200 RPM the manifold pressure was 26 inches. Transition to forward flight was normal, and height and speed began to increase. At about 60 to 70 feet agl and about 40 knots the engine note changed, and the pilot noticed RPM had reduced to about 2700. The pilot lowered the collective and wound on full throttle. A landing straight ahead was carried out with some forward speed, and during the landing the main rotor struck the tail boom and severed it. The helicopter was fitted with an NARCO 10 Emergency Locator Transmitter, which did not activate during the heavy landing.

Subsequent examination of the engine failed to reveal any defect, but engineering opinion was that the engine malfunction was most likely due to a sticking valve.

Occurrence summary

Investigation number 199603557
Occurrence date 12/10/1996
Location 40 km east of Rolleston
State Queensland
Report release date 28/11/1996
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 Hughes Helicopters
Model 269C
Registration VH-KZR
Sector Helicopter
Departure point Barkala Sation
Destination Barkala Station
Damage Substantial

Breakdown of co-ordination involving a Boeing 747-400, 9V-SMQ, Alice Springs VOR, Northern Territory, on 29 October 1996

Summary

FACTUAL INFORMATION

An international B747 was enroute from Singapore to Melbourne over northwestern Australia at flight level (FL) 350. The B747 was under the control of a Brisbane sector controller using procedural control. The Brisbane controller was a team leader and he had commenced work at 2300 EST. He conducted a performance check on another controller until 0200 at which time the other controller left the console for a break. The team leader continued operating the position for approximately another two hours. The team leader felt well except for a minor cold condition which had developed that afternoon.

Generally, the work at the sector, on the evening shift, could be divided into approximately three periods. The first period was from 2300 until 0100 and this was the time when departure and position reports for aircraft intending to transit the sector were mainly received from northern air traffic control centres. The period from 0100 until 0200 was when the boundary positions were received. The last period from 0200 to 0400 was when the aircraft actually entered the sector and the crews contacted the sector controller. On the day of the incident the last period had finished at approximately 0300.

The B747 had been cleared to operate at FL350 and the crew had requested a preferred level of FL370 after 0320. The crew of the B747 reported their position at Curtin at FL350 and with an estimate for PAVKO of 0336. The team leader co-ordinated the position report with a Melbourne sector controller. PAVKO was the point at which control of the aircraft would be transferred from Brisbane to Melbourne air traffic control. The team leader intended to approve the crew of the B747 to climb to the higher level and to co-ordinate the level as FL 370 with the Melbourne controller. However, the team leader co-ordinated the level as FL350. The Melbourne controller incorrectly readback the level as FL370. Neither controller noticed the incorrect readback of the level. The Melbourne sector flight progress strip for the B747 indicated the aircraft was at FL350.

The team leader asked the crew of the B747 if they would be requesting climb to FL370. The crew replied that they would shortly like to climb to the higher level. The team leader instructed the crew of the B747 to climb to FL370 with a requirement to reach that level by PAVKO. The crew reported to the team leader when the aircraft left FL350 on climb to FL370. Normally, an aircraft's change of level is co-ordinated with the next air traffic control agency. The team leader, however, thought he had previously co-ordinated the higher level with the Melbourne sector controller and consequently did not conduct any further co-ordination.

The team leader instructed the crew of the B747 to contact the Melbourne sector controller at PAVKO. When the aircraft reached PAVKO the crew of the B747 reported their position and level of FL370 to the Melbourne sector controller. The Melbourne sector controller had expected the aircraft to report at FL350. There had been an error in co-ordination.

ANALYSIS

The team leader may have relaxed after completing the busiest part of the shift. Additionally, the timing of the incident, the time spent at the position overall, the possible higher level of awareness required for the check and his minor cold, probably combined to the extent that his ability to concentrate adequately on the task was impaired to some degree.

The Melbourne controller may have had an expectation of the B747 being at FL370 due to previous experience and the fact that it is a standard level for aircraft flying a south-easterly route.

The relationship between the body's circadian rhythm and performance is well known. In this incident, the fact that both controllers were working during the early morning and were also approximately halfway through their shifts would probably account for their lack of concentration and the consequent mishandling of the co-ordination.

The team leaders mind-set relating to his intention to approve the crew of the B747 to climb to FL370 would have pre-disposed him to hearing what he expected to hear from the Melbourne controller. This is despite the fact that the team leader co-ordinated the correct level at the time.

SIGNIFICANT FACTORS

1. The team leader had been continuously operating the position for approximately four hours.

2. The incident occurred at a time of the day when errors in human performance are more likely.

Occurrence summary

Investigation number 199603545
Occurrence date 29/10/1996
Location Alice Springs VOR
State Northern Territory
Report release date 05/05/1997
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Breakdown of co-ordination
Occurrence class Incident

Aircraft details

Manufacturer The Boeing Company
Model 747-400
Registration 9V-SMQ
Sector Jet
Operation type Air Transport High Capacity
Departure point Singapore, Singapore
Destination Sydney NSW
Damage Nil

Loss of separation involving a Piper PA-31-350, VH-RDL and Boeing 747-438, VH-OJR, 93 km east-north-east of Sydney VOR, New South Wales, on 31 October 1996

Summary

The pilot of the Piper PA31 had submitted details for an IFR flight from Lord Howe Island to Sydney via MAGOO and CHEZA at 9,000 ft, estimating CHEZA (60 NM from Sydney on the 084 radial), at 1835. At 1825 the pilot called Brisbane Centre for a clearance and was instructed to squawk transponder code 2350. The aircraft was identified at 50 NM from Sydney, on the 059 radial. This placed the aircraft some 22 NM right of track, within controlled airspace, and in potential conflict with an outbound Boeing 747.

The pilot of the PA31 later reported that he had been initially tracking on a bearing from the Lord Howe Island NDB. However, at the time of the incident he was unable to receive any Sydney radio navigation aids, and was navigating on time intervals and dead reckoning. The PA31 was squawking transponder code 2000 prior to calling Brisbane Centre. The crew of the B747 did not receive any Traffic Alert and Collision Avoidance System (TCAS) warning. Brisbane radar did not record any transponder returns from the PA31 prior to the aircraft squawking code 2350.

Occurrence summary

Investigation number 199603548
Occurrence date 31/10/1996
Location 93 km east-north-east of Sydney VOR
State New South Wales
Report release date 02/04/1997
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 Piper Aircraft Corp
Model PA-31-350
Registration VH-RDL
Sector Piston
Operation type Charter
Departure point Lord Howe Island. NSW
Destination Sydney. NSW
Damage Nil

Aircraft details

Manufacturer The Boeing Company
Model 747-438
Registration VH-OJR
Sector Jet
Operation type Air Transport High Capacity
Departure point Sydney. NSW
Destination Los Angeles. USA
Damage Nil

Wheels up landing involving a Cessna 402B, VH-FCL, Darwin Aerodrome, Northern Territory, on 28 October 1996

Summary

On arrival at Crocker Island, during the prelanding checks, the left main landing gear would not lock down. The pilot diverted to Darwin where emergency services were available. He performed the emergency landing gear extension drill, but the left main landing gear was still not indicating down and locked. The pilot flew past the tower for a visual inspection of the landing gear by the tower controller who advised that the landing gear "appeared normal". When emergency services were in place, the pilot landed. As the aircraft slowed on the landing roll, the left main gear collapsed.

Subsequently engineers discovered that the left side brace centre bushing had seized on its bolt thereby preventing the left main landing gear leg from locking down. The operator's chief engineer has formally advised the Civil Aviation Safety Authority of the mechanical fault.

Occurrence summary

Investigation number 199603506
Occurrence date 28/10/1996
Location Darwin Aerodrome
State Northern Territory
Report release date 19/11/1996
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Wheels up landing
Occurrence class Incident

Aircraft details

Manufacturer Cessna Aircraft Company
Model 402B
Registration VH-FCL
Sector Piston
Operation type Air Transport Low Capacity
Departure point South Goulbourne Is NT
Destination Crocker Is NT
Damage Minor

Fuel exhaustion involving a Piper PA-34-200T, VH-JOD, 2.5 km south of Jandakot Aerodrome, Western Australia, on 23 October 1996

Summary

The pilot reported he took a number of tourism industry passengers on a familiarisation flight over a proposed tourist route between Jandakot and Cervantes. He was on the return flight to Jandakot, with his second group of passengers on board, when he was forced to land the aircraft in a paddock due to fuel exhaustion.

The pilot had accumulated a lot of flying hours, predominately in helicopters, but had limited twin-engine, fixed-wing aircraft experience. He had recently completed an endorsement onto the aircraft type and had flown a total of 7 hours in the aircraft at the time of the forced landing. This included the 5 hours flown during the familiarisation flights.

On the evening prior to the occurrence, the pilot had filled the fuel tanks in preparation for the familiarisation flights. Before departing Jandakot on the first leg, he had drained 40 L out of the fuel tanks due to weight restrictions. He was not able to visually check the contents once he had drained the fuel and did not note the level before he started the drain. He paid little attention to the fuel gauges enroute as he normally monitored fuel contents by using fuel flow and elapsed time.

During the return flight, the pilot elected to land at Cunderdin to correct a fuel imbalance which had appeared after he added 200 litres of fuel at Cervantes. He used a bucket and hose to transfer fuel between tanks. He reported that he was not aware of how fuel could be cross fed between tanks whilst airborne.

The pilot became concerned about the state of the fuel contents enroute to Jandakot. He was convinced there was sufficient to continue to his destination, which was, by then, the closest airfield. The aircraft was less than 3 km south of Jandakot when the engines stopped.

Calculations indicate that a total of 620 L had been added to the aircraft before and during the flights. At the reported fuel flow of 94 L/hour a total flight time of 6 hours 35 minutes should have been available. The engines stopped after 5 hours, leaving 150 L unaccounted for. The pilot reported there had been recent instances of fuel theft from the Jandakot apron. As he had refuelled the aircraft the evening before the flights, he suspected the missing fuel had been stolen during the night.

Occurrence summary

Investigation number 199603493
Occurrence date 23/10/1996
Location 2.5 km south of Jandakot Aerodrome
State Western Australia
Report release date 20/11/1996
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-34-200T
Registration VH-JOD
Sector Piston
Departure point Hyden WA
Destination Jandakot WA
Damage Substantial

Birdstrike involving an Aero Commander 500-S, VH-KAV, 28 km south-east of Perth Aerodrome, Western Australia, on 24 October 1996

Summary

The aircraft was engaged in low-level survey operations over an area of trees in the hills to the east of Perth. The pilot saw a pair of wedge-tail eagles and, despite evasive action, hit one of them. The aircraft sustained some damage which did not prevent the pilot safely tracking to and landing at Jandakot.

The eagle had hit the left wing and caused compression of the leading edge outboard of the left engine.

Occurrence summary

Investigation number 199603492
Occurrence date 24/10/1996
Location 28 km south-east of Perth Aerodrome
State Western Australia
Report release date 31/10/1996
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Birdstrike
Occurrence class Accident

Aircraft details

Manufacturer Aero Commander
Model 500-S
Registration VH-KAV
Sector Piston
Operation type Aerial Work
Departure point Jandakot WA
Destination Jandakot WA
Damage Substantial

ANSP info/procedural error involving a Boeing 737-376, VH-TAJ, 10 km south-east of Melbourne Aerodrome, Victoria, on 14 October 1996

Summary

FACTUAL INFORMATION

The crew of a B737, en route from Perth to Melbourne, requested an arrival on runway 34 after receiving the automatic terminal information service (ATIS) information 'W', which indicated that runway 27 was available for arrivals and runway 34 was available for departures. During the period between the crew receiving the ATIS and requesting runway 34, the aerodrome information changed. The latest ATIS information 'V', which the crew copied, indicated that Melbourne aerodrome was operating on runway 27 for departures and runway 16 for arrivals. The crew was advised that runway 34 was not available, due to the operations on runway 16, and was assigned a standard arrival route (STAR) clearance and runway 16. The crew did not hear the assigned runway because of radio interference and requested confirmation from the sector controller that the runway was 27. The sector controller replied that runway 27 was the assigned runway. The sector controller annotated runway 27 on the flight progress strip for the aircraft. The crews of subsequent aircraft were assigned runway 16 by the sector controller.

The crew of the B737 had not advised the sector controller of the code and receipt of the ATIS, nor had the controller verified that the crew had received the latest ATIS.

When the non-duty runway was assigned, the controller was required to annotate the "ops data" line of the aircraft's label on the radar display with the assigned runway. The "ops data" line for the B737 was not annotated with runway 27. Once the runway and the arrival clearance had been issued by the sector controller, there were no further checks to confirm the aircraft's arrival clearance or assigned runway.

The crew had previously requested track shortening and thought that the sector controller was actioning this request by assigning a runway which required fewer track miles to run to a landing. The crew transferred to approach control and continued to track in accordance with the cleared route. Overhead Essendon aerodrome, the crew continued to track eastwards for a left base to runway 27. The approach controller was expecting the B737 to turn left, to the north, for a left base to runway 16. The approach controller cancelled the standard arrival route and radar vectored the B737 for runway 16. As the B737 approached the centreline of runway 27, the crew requested from the controller the runway to which the aircraft was being radar vectored. The approach controller advised them that the vectors were for runway 16. The aircraft landed on runway 16. There was no breakdown of separation.

ANALYSIS

Initially, the sector controller issued the correct STAR and runway to the crew of the B737. However, when the crew queried the assigned runway, the controller replied with the incorrect runway and then annotated the flight progress strip with the wrongly assigned runway. The reason for the controller assigning the incorrect runway and not amending the "ops data" line of the label could not be determined.

The crew of the B737 did receive the latest ATIS but believed that the sector controller was providing them with their previously requested track shortening by assigning them runway 27. Consequently, they did not query the runway assignment with the Approach controller.

SIGNIFICANT FACTORS

1. The controller did not confirm that the crew of the B737 had received the latest ATIS.

2. The sector controller did not confirm the arrival runway, as indicated in the latest ATIS, when queried by the crew.

3. The sector controller did not amend the "ops data" line of the B737's label on the radar display with the assignment of the non-duty runway.

Occurrence summary

Investigation number 199603442
Occurrence date 14/10/1996
Location 10 km south-east of Melbourne Aerodrome
State Victoria
Report release date 11/06/1997
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category ANSP info/procedural error
Occurrence class Incident

Aircraft details

Manufacturer The Boeing Company
Model 737-376
Registration VH-TAJ
Sector Jet
Operation type Air Transport High Capacity
Departure point Perth WA
Destination Melbourne VIC
Damage Nil

Near collision involving a Piper PA-31-350, VH-OCF and Skyfox CA25N, VH-ZVC and Skyfox CA25N, VH-DLY, Maroochydore/Sunshine Coast Aerodrome, Queensland, on 9 October 1996

Summary

Two CA25 aircraft, VH-ZVC and VH-DLY, were operating in the circuit using runway 18. The pilots, both solo students, had been communicating with each other on the mandatory broadcast zone (MBZ) frequency. The pilot of ZVC had just turned final when DLY was turning base. The pilot of ZVC had reported base for a full stop landing. The pilot of DLY also reported base for a full stop landing. At no time did either pilot hear any other aircraft transmissions. As ZVC touched down the pilot became aware of a large twin engined aircraft approaching head on at high speed after it had landed on runway 36. The pilot of ZVC applied full power and went around passing over the top of the twin. The pilot of DLY was unaware of the presence of the twin and landed just as it was exiting the runway. As the twin engined aircraft VH-OCF taxied onto the apron the pilot apologised to the other pilots on the MBZ frequency.

The pilot of OCF said that he was flying on a scheduled service from Brisbane to Maroochydore. Whilst enroute he noticed the wind was from the north-east and planned his approach to land on runway 36. The pilot stated that during the descent he made a number of transmissions approaching the MBZ but heard no response. The Maroochydore MBZ has the same lateral dimensions as the control zone. He did not consider it unusual that there was no response, as frequently there is no other traffic, and if there is, he is usually advised by Brisbane Centre. After having cancelled SAR with Brisbane Centre, and when lined up on short final for runway 36, the pilot detected movement at the far end of the runway. He said a small dark object had risen from the ground which he initially thought was a bird, but he then realised it was a small aircraft. He then noticed another aircraft on final approach for runway 18 as he vacated runway 36. He then noticed that his VHF was selected to 124.8 mhz instead of the MBZ frequency 124.4 mhz.

Occurrence summary

Investigation number 199603419
Occurrence date 09/10/1996
Location Maroochydore/Sunshine Coast Aerodrome
State Queensland
Report release date 27/11/1996
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-OCF
Sector Piston
Operation type Air Transport Low Capacity
Departure point Brisbane
Destination Maroochydore
Damage Nil

Aircraft details

Manufacturer Skyfox Aviation Ltd
Model CA25N
Registration VH-DLY
Sector Piston
Operation type Flying Training
Departure point Maroochydore
Destination Maroochydore
Damage Nil

Aircraft details

Manufacturer Skyfox Aviation Ltd
Model CA25N
Registration VH-ZVC
Sector Piston
Operation type Flying Training
Departure point Maroochydore
Destination Maroochydore
Damage Nil

Fuel exhaustion involving a Cessna 150G, VH-KPD, Forest Vale, 65 km north of Mitchell, Queensland, on 26 October 1996

Summary

The pilot had just bought the aircraft and was delivering it to his home. The previous owner had not flown the aircraft extensively and was unable to assist with performance and fuel information. As a result, the owner used the cruise performance information available in the pilot's handbook. This information showed an endurance of 7.9 hours and a range of 845 miles.

After refuelling to full tanks at Hughenden the pilot intended flying to Barcaldine and refuelling there. The turbulence enroute was considerable so the pilot elected to depart early the next morning to avoid the turbulence. He dipped the tanks and found that they were over half full. Since he considered that this would give him four hours of endurance he departed for Roma without refuelling. The ground speed obtained during the flight would have required a flight time of 223 minutes to Roma. While enroute, the engine failed due to fuel exhaustion. He conducted a forced landing on a road and obtained fuel to complete the flight.

The pilot later learned that the endurance figures quoted in the handbook were optimistic. He also found that the actual fuel used during flights was much higher than he had expected. By completing full flight plans he has been able to establish accurate fuel consumption figures for his aircraft.

After the landing the pilot attempted to activate the ELT using the remote control on the aircraft instrument panel. The unit did not operate because of a flat Lithium battery in the remote-control unit. After the battery was replaced, the unit was able to function correctly.

Occurrence summary

Investigation number 199603465
Occurrence date 26/10/1996
Location Forest Vale, 65 km north of Mitchell
State Queensland
Report release date 09/12/1996
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 Cessna Aircraft Company
Model 150G
Registration VH-KPD
Sector Piston
Operation type Private
Departure point Barcaldine QLD
Destination Roma QLD
Damage Nil