Runway excursion involving a Piper PA-32-300, VH-MAR, Burrum Community, Northern Territory, on 22 September 1996

Summary

The aircraft was on approach for landing with a 10 - 15 kt crosswind from the left. The pilot stated that he was holding the left wing down to counteract the crosswind, but as he commenced to flare prior to touchdown a stronger gust of wind moved the aircraft to the right.

The aircraft touched down at the side of the airstrip on its left main wheel, possibly in soft sand, while still moving sideways. This imposed a side load to the landing gear leg which sheared the attachment bolts allowing the leg to separate from the wing.

Occurrence summary

Investigation number 199603097
Occurrence date 22/09/1996
Location Burrum Community
State Northern Territory
Report release date 30/09/1996
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Runway excursion
Occurrence class Accident

Aircraft details

Manufacturer Piper Aircraft Corp
Model PA-32-300
Registration VH-MAR
Sector Piston
Operation type Private
Departure point Gove NT
Destination Burrum Community NT
Damage Substantial

Loss of control involving an Air Tractor AT-502, VH-DDH, Glen Ruff Downs, Western Australia, on 6 September 1996

Summary

It was reported that the aircraft was being used to spread powered fertiliser. There had been light rain prior to the accident flight and the wing surfaces were wet. During loading the wind momentarily lifted the sock, used to fill the hopper, clear of the aircraft and some powder was blown onto the upper surface of the right wing. The rain was not heavy enough to wash the powder off. The aircraft's weight was reported to be at its maximum for take-off. The average wind was a westerly at 8 kts with significant shifts reported as occasional squalls passed through.

The pilot commenced a take-off, with 10 degrees of flap set, towards the west and into wind. The strip slopped down and then up. As the aircraft accelerated the pilot flew the tail off the ground. Shortly afterwards the left wing also lifted, pivoting the aircraft over the right wheel. The pilot introduced left aileron to keep the wings level until he reached take-off speed. The aileron control reached the left stop at the same time as the aircraft became airborne. It continued to roll to the right and began to yaw right. The pilot introduced rudder and then brake in an attempt to stop the roll and yaw. The rudder made little difference, and the brakes were completely ineffective as the wheels were off the ground.

The pilot closed the throttle and, as the aircraft settled back onto the ground in a left-wing-high attitude, it collided with a fence. The aircraft ripped 76 m of fence from the ground before it cartwheeled and overturned.

The aircraft's flight manual contains a caution which indicates that aileron effectiveness is reduced when flaps are used for take-off. The pilot reported that he used flaps as the aircraft was at maximum weight and the strip length was restricted. The aerofoil section of the wings on the AT502 is designed for maximum efficiency. The aircraft manual indicates that any ice must be removed from the wing prior to take-off because of its effect on wing-produced lift. It is probable that the powder-contamination on the right-wing surface adversely affected its aerodynamic characteristics resulting in the roll experienced by the pilot. The pilot's ability to control the roll with aileron was reduced by his use of flap for take-off. The result was a roll and yaw which the pilot was unable to correct before the aircraft collided with the fence. It is possible that a squall-induced wind shift also contributed to the loss of control.

Occurrence summary

Investigation number 199603095
Occurrence date 06/09/1996
Location Glen Ruff Downs
State Western Australia
Report release date 17/11/1996
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Loss of control
Occurrence class Accident

Aircraft details

Manufacturer Air Tractor Inc
Model AT-502
Registration VH-DDH
Sector Turboprop
Operation type Aerial Work
Departure point Glen Ruff Downs WA
Destination Glen Ruff Downs WA
Damage Substantial

Airframe event involving a Cessna 210M, VH-TYG, Sandstone (ALA), Western Australia, on 18 September 1996

Summary

The pilot reported that the radio microphone failed as he approached Sandstone. Then the landing gear motor stopped working and the gear only extended about halfway when he lowered it on downwind. There was no response from the gear when the selector was subsequently moved to either the up or the down position. The pilot attempted to extend the gear using the alternate system however, the system pressure fell to zero after two or three cycles of the hand pump. He operated the pump for several more minutes without any appreciable result. At no stage did the gear lights indicate the gear was down.

As the radio was inoperative, the pilot decided to land at Sandstone rather then return to Kalgoorlie. He observed that, although the main landing gear was down, it was not as far forward as it usually was when locked. On touchdown, the main wheels were dragged backwards and the aircraft slid to a stop on its lower fuselage.

No gear faults were identified during the post-accident inspection or at the time of the repair. The system has worked normally since the accident.

Occurrence summary

Investigation number 199603122
Occurrence date 18/09/1996
Location Sandstone (ALA)
State Western Australia
Report release date 21/11/1996
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Accident

Aircraft details

Manufacturer Cessna Aircraft Company
Model 210M
Registration VH-TYG
Sector Piston
Operation type Business
Departure point Kalgoorlie WA
Destination Standstone WA
Damage Substantial

Loss of separation involving a Boeing 747-200, SX-OAE and Cessna 172P, VH-LOR, Brooklyn VTC Approach Point, Victoria, on 25 September 1996

Summary

A Boeing 747 was being radar vectored for Melbourne runway 34 when radar controllers noticed an unidentified aircraft at 2,400 ft in controlled airspace (CTA) where it should not have been above 1,500 ft outside controlled airspace. The departures south controller immediately instructed the Boeing 747 pilot to turn right 60 degrees due to conflicting traffic. Melbourne radar advisory service (RAS) gave a general broadcast to any aircraft heading up the western lane to descend immediately to 1,500 ft, but there was no response. Both aircraft passed within approximately 1 mile and 700 ft.

With advice from Essendon Tower, RAS identified the offending aircraft near Brooklyn as VH-LOR and instructed the pilot to descend to 1,500 ft. About 5 minutes later, 2 miles west of Mount Cottrell, LOR climbed above 2,500 ft into CTA without a clearance and was again corrected by RAS.

A student pilot was flying LOR on his second solo navigational exercise. He subsequently advised that he must have made errors in navigation because each time he inadvertently penetrated CTA he thought he was much further west where the base of the CTA was higher.

The student pilot was required to undergo more dual instruction before the next solo navigational flight.

Occurrence summary

Investigation number 199603066
Occurrence date 25/09/1996
Location Brooklyn VTC Approach Point
State Victoria
Report release date 02/10/1996
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 Cessna Aircraft Company
Model 172P
Registration VH-LOR
Sector Piston
Operation type Flying Training
Departure point Essendon Vic
Destination Hamilton Vic
Damage Nil

Aircraft details

Manufacturer The Boeing Company
Model 747-200
Registration SX-OAE
Sector Jet
Operation type Air Transport High Capacity
Destination Melbourne Vic
Damage Nil

Runway excursion involving a PZL Warszawa-Okecie M-18A, VH-NID, 80 km south-east of Mullewa (ALA), Western Australia, on 19 August 1996

Summary

The pilot reported that he had been concerned about the performance of the aircraft's brakes and, following the first flight for the day, he had checked the pads for wear. They appeared to be serviceable with as much as 10 mm of pad material remaining. During the landing roll following the second flight, the aircraft yawed to the left. Corrective action using rudder and brake had no affect and aircraft continued to yaw to the left until it departed the 15 m-wide flight strip and collided with a fence and tree.

A technical investigation disclosed that the brake system was fitted with spacing washers designed to prevent the brake pads being worn down to their backing plates. This prevented damage to the brake discs. The spacing washers were set so that around 10 mm of the pads remained when the brakes reached their maximum wear limit. The operator and pilot were not aware of this limitation and assumed from the amount of pad material remaining that the brakes were still serviceable. When the pilot applied the brakes to prevent the aircraft yaw, movement was restricted by the spacing washers, and he was unable to obtain effective braking.

Occurrence summary

Investigation number 199603087
Occurrence date 19/08/1996
Location 80 km south-east of Mullewa (ALA)
State Western Australia
Report release date 21/11/1996
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Runway excursion
Occurrence class Accident

Aircraft details

Manufacturer PZL Warszawa-Okecie
Model M-18A
Registration VH-NID
Sector Piston
Operation type Aerial Work
Departure point 80 km SE Mullewa WA
Destination 80 km SE Mullewa WA
Damage Substantial

Loss of separation involving an Airbus A300-B4-203, VH-TAC and Airbus A320-211, VH-HYI, 3.2 km north of Melbourne Aerodrome, Victoria, on 24 September 1996

Summary

FACTUAL INFORMATION

A trainee was operating the Departures North sector.  He was supervised by an inexperienced training officer who had only recently gained an on-the-job training instructors (OJTI) rating and was training his first student in the approach departures role. The training officer had not previously worked with the trainee and therefore was unfamiliar with his capability or potential.

A Boeing 737, enroute to Brisbane and an A300 enroute to Sydney, both departed from RWY 27 at Tullamarine via a DOSEL 4 standard instrument departure (SID) with a requirement to maintain 5,000 ft.  This was to accommodate an AC50 which had departed Essendon on track to Horsham via overhead Melbourne.  After vertical separation was achieved between the AC50 and the two jets, the pilot of the AC50 was instructed to turn onto a heading of 280 degrees and the crew of the Boeing 737 instructed to initially climb to 6,000 ft and then 7,000 ft as the levels became available.  When these two aircraft were laterally clear of one another, the Boeing 737 was cleared to climb to FL200. The A300 was maintained at 6,000 ft.

Shortly after, the controller’s attention was drawn to a potential conflict between the Boeing 737 and an inbound SA227 from Mildura.  The trainee turned his attention to an inbound A320 tracking via a 27 ARBEY STAR assigned 6,000 ft.  This aircraft was now in conflict with the A300 which was maintaining 6,000 ft and was turning right in compliance with the DOSEL 4 SID.   The training officer recognised the conflict and told the trainee to instruct the crew of the A300 to climb.  For reasons unknown, the trainee did not instruct the A300 to climb - nor did the training officer choose to use the 'B' System handset, which would have enabled him to override the trainee's communications and climb the A300.

The trainee then instructed the A300 to turn left onto 340 degrees.  Both the trainee and the training officer agreed that the aircraft seemed to be slow in commencing the turn.  Because of this, the crew was further instructed to turn immediately onto a heading of 310 degrees and the crew of the A320 to turn left immediately heading 090 degrees. The pilot of the A320 reported sighting the A300 and the two aircraft passed within 2 NM at the same level.  There was a breakdown of separation.

ANALYSIS

The 27 DOSEL 4 SID does not provide separation assurance with the 27 ARBEY STAR once the departing aircraft climbs above 5,000 ft.  In such instances, controllers are required to ensure that the vertical separation is maintained until lateral separation is established.

Neither the trainee nor the training officer applied separation assurance techniques.  The controllers relied upon the performance of the A300 to climb above incoming aircraft.  However, because of the AC50 from Essendon, which was tracking overhead Melbourne, the A300 was held at 6,000 ft, resulting in a lower altitude than normal at the position at which the DOSEL 4 SID requires a turn.   In resolving the conflict between the AC50 and the A300, the controllers failed to recognise in time the conflict between the A300 and the A320.

SIGNIFICANT FACTORS

  1. The training officer was inexperienced in the approach departures training role.
  2. The training officer chose not to use an override system for radio transmissions.
  3. The training officer failed to adequately monitor the trainee and to correct the situation as it developed.
  4. Neither controller applied adequate separation assurance techniques.

Occurrence summary

Investigation number 199603045
Occurrence date 24/09/1996
Location 3.2 km north of Melbourne Aerodrome
State Victoria
Report release date 14/02/1997
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 Airbus
Model A300-B4-203
Registration VH-TAC
Sector Jet
Operation type Air Transport High Capacity
Departure point Melbourne, VIC
Destination Sydney, NSW
Damage Nil

Aircraft details

Manufacturer Airbus
Model A320-211
Registration VH-HYI
Sector Jet
Operation type Air Transport High Capacity
Departure point Adelaide, SA
Destination Melbourne, Vic
Damage Nil

Hard landing involving a Piper PA-34-200T, VH-BDT, Amberley Aerodrome, Queensland, on 14 September 1996

Summary

The pilot elected to go around from final approach for runway 23 when he noticed that the windsock had swung to favour runway 35. He reported that the approach for runway 35 was normal and estimated the wind speed and direction at about 10-15kts from 300 degrees. Soon after the main wheels had contacted the runway the aircraft became airborne again, both throttles were closed at this point. The aircraft dropped back onto the runway and bounced hard. The nosewheel then contacted the runway heavily and the windscreen popped out. The aircraft was taxied clear of the runway and all three persons exited the aircraft without injury.

Post flight examination found there was significant damage to the nosewheel assembly, the windscreen had separated, and the right propeller had contacted the runway.

The pilot advised that he had subsequently obtained a wind trace from the Amberley met office which indicated that winds were gusting from 290 degrees between 5-18 kts, at the time of the accident.

Occurrence summary

Investigation number 199603048
Occurrence date 14/09/1996
Location Amberley Aerodrome
State Queensland
Report release date 01/10/1996
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Hard landing
Occurrence class Accident

Aircraft details

Manufacturer Piper Aircraft Corp
Model PA-34-200T
Registration VH-BDT
Sector Piston
Operation type Business
Departure point Canberra ACT
Destination Amberley QLD
Damage Substantial

Hard landing involving a Cessna 172N, VH-EIB, Charleville Aerodrome, Queensland, on 23 September 1996

Summary

The pilot reported that he had flown a normal circuit and approach to land on runway 30. He did not monitor the airspeed adequately on the approach, with the result that the aircraft began to stall at about 10 feet above the runway. Power was applied to correct the descent, however the aircraft "ballooned" and then landed heavily. When the pilot taxied the aircraft off the runway, he thought the nose wheel tyre was deflated.

Post flight examination found that the tie down ring on the underside of the rear fuselage had broken off. The nose landing gear assembly was badly damaged, with sheared rivets at the top of the leg casting, and the engine firewall was buckled. The right side of the nose wheel fork had spread and was abraded by contact with the runway surface.

In describing the event the pilot insisted that it be called an act of "gross stupidity".

Occurrence summary

Investigation number 199603044
Occurrence date 23/09/1996
Location Charleville Aerodrome
State Queensland
Report release date 26/09/1996
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Hard landing
Occurrence class Accident

Aircraft details

Manufacturer Cessna Aircraft Company
Model 172N
Registration VH-EIB
Sector Piston
Operation type Business
Departure point Quilpie QLD
Destination Charleville QLD
Damage Substantial

Wheels up landing involving a Piper PA-31, VH-JRA, Roma Aerodrome, Queensland, on 20 September 1996

Summary

Sequence of events

The aircraft entered the circuit on a left downwind leg for runway 18 from the south. The pilot was aware of another aircraft approaching from the north. The pilot said that the downwind checks were delayed because the speed of the aircraft was too high to lower the landing gear. He became somewhat distracted looking for the other aircraft entering the circuit. The pilot felt sure that he had lowered the landing gear. He said that neither he nor his passenger heard the landing gear warning horn before the propellers struck the bitumen runway surface.

A post-flight inspection of the landing gear did not find any fault in its operation.

Analysis

The pilot probably forgot to lower the landing gear when he became distracted.

Occurrence summary

Investigation number 199603027
Occurrence date 20/09/1996
Location Roma Aerodrome
State Queensland
Report release date 01/10/1996
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 Piper Aircraft Corp
Model PA-31
Registration VH-JRA
Sector Piston
Operation type Private
Departure point Bankstown NSW
Destination Roma QLD
Damage Substantial

Wheels up landing involving a Piper PA-28R-180, VH-CHC, Ingelara (ALA), Queensland, on 22 September 1996

Summary

Following a short flight in the local area, the pilot joined the circuit for a landing. He noticed that the strip was occupied by 2 large bulls, but he continued with the approach and overflew the animals to chase them off the strip. In this he was successful. He completed another circuit and landed the aircraft with the landing gear retracted.

The pilot later said that he thought he had selected gear down and had seen 3 greens but later conceded that he may have omitted to lower the landing gear.

Post-flight examination confirmed that the landing gear was fully retracted on landing and its operation could not faulted.

Occurrence summary

Investigation number 199603026
Occurrence date 22/09/1996
Location Ingelara (ALA)
State Queensland
Report release date 01/10/1996
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 Piper Aircraft Corp
Model PA-28R-180
Registration VH-CHC
Sector Piston
Operation type Private
Destination Ingelara QLD
Damage Substantial