The pilot was conducting a flight to land three passengers onto the top of Mount Sonder. Prior to making an approach to the cleared area he carried out an engine power check which confirmed that the engine was developing sufficient power to accomplish a landing at the high altitude. The pilot then carried out an inspection of the landing area and completed all four legs of the circuit. While turning onto final approach for landing he noticed a rapid reduction of the manifold pressure indication from 26"hg to 20"hg, accompanied by a loss of engine power.

The pilot was unable to continue to the intended landing area, and was committed to a landing on the sloping, rocky mountain side.

As the pilot reduced the helicopter's forward speed prior to landing the tail rotor struck a rock, causing a yaw. The pilot immediately closed the throttle, and the helicopter came to a stop facing up the slope suffering substantial damage to the landing skids, and separation of the tail rotor blades.

No faults or malfunctions were found with the engine which may have contributed to the loss of power.

An inspection of the turbocharger revealed slight scuffing of the turbine wheel, but the assembly spun freely. The density controller and wastegate were removed for overhaul, obvious problems with these units being difficult to detect.

The reason for the loss of engine power could not be determined.

The trainee pilot was conducting circuits on Runway 29R at Bankstown in a Cessna 152. Late on final approach, she judged the airspeed as being too fast and selected full flap to slow the aircraft. She then saw that the aircraft was descending below the desired approach path and added power to correct. As the aircraft crossed the threshold, the pilot reduced power to idle and lowered the nose but then decided to execute a go around.

However, before power could be re-applied, the main landing gear struck the runway heavily and the aircraft bounced. The aircraft then pitched nose down, landing on the nosewheel, before bouncing once again. The pilot later reported that the force of the bounce had caused her right hand to rapidly increase the throttle setting just as the aircraft began to pitch nose down, accelerating the descent and causing the aircraft to land heavily on the nose wheel. The pilot closed the throttle, but the aircraft continued to oscillate in pitch, bouncing alternately on the main landing and nose gears. The propellor struck the runway numerous times before the nose gear partially collapsed. The aircraft came to rest approximately 150 m after the initial touchdown, after crossing the left edge of the runway.

The Boeing 737 was being radar vectored to a right base position for a runway 35 Instrument Landing System (ILS) approach. The aircraft was in instrument meteorological conditions and had been cleared to descend to 6,000 ft on a heading of 220 degrees, with an expectation of a right turn to intercept the localiser. When no response was heard from the crew of the B737, following an instruction to turn further right onto the base leg for runway 35, the controller repeated the instruction several times on backup radio equipment. Another aircraft in the area confirmed that all the radio transmissions had been clearly received. During this time, the B737 tracked outside controlled airspace below the minimum radar vectoring altitude. When communications were re-established some two minutes later, the controller issued the crew with an altitude alert and instructed them to climb the aircraft to 7,000 ft. The ILS was re-intercepted from the left, after which an approach and landing was carried out without further incident.

It was later determined that the co-pilot had inadvertently preselected the Canberra ground frequency instead of the relevant tower frequency whilst preparing for the arrival to Canberra. When nothing was heard on the radio for a period longer than expected, and cockpit instruments indicated that the aircraft was approaching the localiser track, the pilot in command became concerned about the position of the aircraft in relation to the surrounding terrain and instructed the co-pilot to transmit, "maintaining six thousand". The reply to this transmission was for the crew to contact Canberra Approach. At this time, it became apparent to the crew that the active frequency being monitored was Canberra Ground. Whilst there was no radar altimeter indication or ground proximity warning system alert, the crew commenced terrain avoidance procedures in conjunction with the altitude alert issued by the controller.

As a result of this occurrence the company has produced an article in its flight safety journal to emphasise the ongoing need for situational awareness at all times, and the requirement to pre-brief aspects of the approach, including safety heights and contingency plans, in the event of loss of communications.

The Piper Pawnee was spraying chemical in the local area. The strip being used was 350 m in length, and had several trees at the far end, some 16 m to the left of the departure path. There was a crosswind from the right of about 10 to 12 knots. The strip surface was soft, but the pilot reported he had not experienced any problems during a previous take-off, although the aircraft was unladen.

Prior to the next take-off the aircraft was loaded with chemical. The pilot subsequently reported that late in the take-off run, with the engine operating normally, the aircraft suddenly slowed and slewed left about 20 degrees, before again accelerating normally. The aircraft lifted off at approximately 65 knots, displaced to the left and further along the strip than on the previous take-off. The pilot reported he was unable to prevent the aircraft colliding with the trees located to the left of the normal departure path. This resulted in the aircraft rolling inverted and striking the ground. It is considered the left mainwheel may have struck a soft area of the strip during the take-off run, causing the initial left yaw and slight deceleration.

Pitch Black 96 operating procedures included a general exclusion of military activities in R244 above FL 290 unless acting in accordance with specific air traffic control instructions.  This exclusion was designed, amongst other things, to protect transiting civil air traffic.  DOGSTAR formation had no such air traffic clearance or instruction.

At 1535 CST and when approximately 32 NM south-east of Tindal aerodrome, the crew of the A340 reported a TCAS traffic advisory on unidentified aircraft crossing from left to right about 3 NM ahead and descending from a level approximately 800 ft above them.

Tindal centre were unable to immediately determine the callsign and flight details of the unidentified aircraft and coordinated with the Control and Reporting Unit (CRU) which would have had prior information on exercise aircraft.  The CRU were also unable to immediately identify the aircraft.

The crew of the A340 then saw the other aircraft and reported that they were twin tailed fighters.  They watched as the military aircraft passed in front of their aircraft at approximately the same level. No evasive action was required as they were able to monitor the progress of the formation clear of their projected flight path.  Shortly after, Tindal centre confirmed that the formation had been identified as DOGSTAR and that they were now under Tindal control and clear of the A340.

Radar analysis indicated that DOGSTAR formation passed at a distance of 4.9 NM in front of the A340 and had descended from approximately FL 363 to a level below the A340 during the period of the TCAS alert.  It also established that the occurrence happened in airspace between 25 and 33 NM from Tindal.

The appropriate separation standard in this airspace was either 3 NM horizontally or 2,000 ft vertically. This standard can only be provided when certain pre-conditions are met.  Some of these requirements were that both aircraft are radar identified, and both aircraft shall be on radio frequencies currently in use for radar control. These pre-conditions were not met in this case.  There was also a procedure where the CRU is allowed to provide a separation service in conjunction with the military air traffic controller in military restricted airspace, however, the pre-conditions for this procedure were not met.

Whereas the proximity did not reduce below the 3 NM criteria, a breakdown of separation did occur because the military aircraft were not operating under air traffic control instructions and were not in contact with either air traffic control or the CRU at the time of the occurrence.  Therefore, the terms and conditions set out in the Manual of Air Traffic Services for such a separation standard had not been met.

The crews of the F-15 aircraft had chosen to maintain a higher-than-normal altitude for their initial recovery track because of other exercise traffic involved in air-to-air refuelling in the vicinity of their formation.  They then obtained a radar "lock-on" on the A340 and, believing it to be another military aircraft returning for a recovery, positioned their aircraft to be number one in the recovery sequence.

ANALYSIS

The procedures set down for military exercise "Pitch Black 96" contained restrictions and requirements designed to ensure the protection of transiting civil aircraft. On this occasion, a pair of fighter aircraft contravened the procedures by maintaining an altitude above that approved, without informing either air traffic control or the CRU. This resulted in the aircraft flying in controlled airspace for approximately 60 track miles without an airways clearance and without being subject to a positive separation service.  It also resulted in a civilian aircraft not receiving a guaranteed separation service from the military formation.

SIGNIFICANT FACTOR

The crews of the military formation contravened the published procedures for military exercise "Pitch Black 96".

SAFETY ACTION

The military authorities immediately suspended the exercise and reviewed the safety procedures.  Local amendments were instigated before the exercise was allowed to continue.

The crew of a Cessna 550 aircraft had planned for a flight from Essendon, Vic to Bankstown, NSW at flight level (FL) 370. The aircraft departed and was given an initial altitude restriction of FL 200 by air traffic control (ATC). The crew were transferred to Melbourne Inner North control and the controller, having no conflicting traffic in the projected flight path of the C550, issued a climb instruction to FL 370. The pilot thought that the controller had said FL 300 and read back FL 300. This incorrect read back was not detected by the controller, who had indicated a read back of FL 370 on his flight progress strip.

Shortly after, the Inner North controller transferred the crew of the C550 to the en-route sector, Melbourne Sector 2. On first contact with Sector 2, the crew reported that they were on climb to FL 300. The Sector 2 controller considered this to be an unusual level and immediately contacted the Inner North controller to confirm the assigned cruising level. He was told that this was FL 370. The Sector 2 controller then asked the crew of the C550 if they would prefer FL 370 and, on receiving a positive reply, issued a climb instruction for the crew to climb to FL 370. This was correctly read back by the pilot and the flight proceeded to Bankstown without further incident.

It is normal operating practice for Sector 2 control to not have any planned levels on their flight progress strips. All aircraft coming into this sector are already under radar control and this rule reduces co-ordination between sectors and the number of level changes that may need to be recorded on the strip.

SIGNIFICANT FACTOR

The pilot of the C550 and the Inner North controller did not exercise sufficient vigilance in their radio listening techniques.

The pilot reported that he conducted an aerial inspection of the strip prior to landing to ensure the runway was clear. Just after touch down the passenger alerted the pilot to the presence of an animal running towards the aircraft from the right side. The pilot was unable to manoeuvre the aircraft in time to prevent it colliding with a deer. The pilot and both passengers were able to exit the aircraft safely once it came to a halt.

Post flight examination showed substantial damage to the aircraft's propeller, engine mounts and nose landing gear assembly.

The clearance was annotated on the departure flight progress strip and ticked as being read back correctly by the crew. The DEP P controller then passed the flight progress strip to the departure north radar (DEP N) controller in readiness for the departure request from the aerodrome controller (ADC). The clearance issued to the B747 was not notified to the tower controllers. To reduce coordination between the tower and DEP P, the tower controllers assume jet aircraft are issued with an appropriate clearance for the runway and destination. Controllers were aware that occasionally the incorrect SID was issued; however, the error was usually detected by the radar controller or the flight crew, prior to the aircraft departing, when they realised that the assigned departure clearance and runway were incompatible.

The crew requested and was issued with a taxi clearance approximately 15 minutes later. The taxi clearance was for runway 16R. The crew were aware that the issued SID was not applicable for a departure from runway 16R but believed that air traffic control (ATC) would not issue an incorrect SID. The crew did not clarify with ATC the use of the WMD 7 SID with runway 16R.

The crew reported ready for departure to the ADC. In turn, the ADC advised the DEP N controller that the B747 was ready for departure from runway 16R and requested departure instructions. The DEP N controller notified the ADC that the B747 was "Unrestricted". That is, there were no conflictions with other traffic and the aircraft could depart in accordance with the issued SID. The DEP N controller did not detect the incorrect SID annotated on the flight progress strip as he issued departure instructions to the ADC. The DEP N controller did not further annotate the flight progress strip to indicate that the B747 had been issued with an unrestricted departure clearance. This annotation was required by the Manual of Air Traffic Services (MATS).

The ADC then instructed the crew that the B747 was cleared for take-off. The B747 departed from runway 16R and tracked in accordance with the SID, which required the aircraft to turn left. The B747 crossed the departure path of runway 16L. The ADC observed the B747 as it turned left and immediately notified the DEP N controller that the aircraft was turning left across the departure path of runway 16L. At the same time, the crew of the B747 had contacted the DEP N controller, but they did not read back the assigned altitude. As the DEP N controller checked the flight progress strip to confirm the terms of the clearance, he saw that the crew had been issued with the incorrect SID. The DEP N controller confirmed with the crew that they were tracking via the WMD 7 SID. After ensuring there were no conflictions with other traffic, he cancelled the SID and re-cleared the crew to track direct to Coolangatta then Brisbane.

There was no aircraft departing from runway 16L at the time.

ANALYSIS

The DEP P controller problems with the flight plans, his probable failure to amend the clearance labels on the flight progress strip bays, his inability to check clearances on the strips issued to the two departure radar controllers and the towers lack of a request to confirm the clearances for aircraft that had taxied prior to the change in runway, did little to reinforce the change of runways in his mind. It is possible that the culmination of these events was to remove the physical and mental cues that normally assist controllers to remember changes. Consequently, he inadvertently issued a runway 34L SID to the crew of the B747.

The DEP N controller's reading of the flight progress strip should have detected the incorrect SID. The controller may have checked the flight progress strip but misread, or did not appreciate the clearance annotation due to an expectation of another clearance.

The crew of the B747 knew the clearance was not suitable for the assigned runway yet continued the flight without clarifying the situation with ATC. A major safety aspect of the aviation system is the regular communication between flight crew, groundcrew and air traffic services personnel to ensure all parties understand the others intention. In this incident the flight crew, when faced with the incorrect SID, explicitly trusted ATC when they should have sought clarification.

The SIDs can be grouped according to the planned enroute track and there are a number available for aircraft to depart to the north, west and south. Some of these SIDs are common to both runway 16R and 34L. For example, heavy aircraft departing either to the south or to the west can be issued with a SID which is applicable for both runway 16R or 34L. However, for departures to the north there is no similar runway common SID. There is a specific SID for runway 34L but there are no SIDs for runway 16R. Consequently, northbound heavy category aircraft requiring the use of runway 16R/34L must be issued with a new clearance when the runway is changed. Alternatively, the aircraft can be issued with a standard radar departure (SRD) which is applicable for departures from either runway.

Amendment of the SIDs to provide a common clearance for northbound aircraft for use with either runway 16R or 34L would reduce the possibility for error by controllers and flight crew. The use of the common runway 16R/34L SRD for all northbound heavy category aircraft would also reduce the possibility of future errors.

SIGNIFICANT FACTORS

1. The DEP P controller inadvertently issued the incorrect clearance to the crew of the B747.
2. The crew of the B747 did not clarify the issued clearance with air traffic control.
3. The DEP N controller did not notice that the clearance on the departure flight progress strip was incorrect.
4. The was no common SID for use with either runway 16R and 34L for northbound heavy category aircraft departures.

SAFETY ACTION

Local safety action

As a result of problems with SIDs and other departure clearances, Airservices Australia has initiated a review of Sydney departure procedures.

It was reported that the flight had initially been planned as a circuit training exercise. When the wind was reported as a 20 kt crosswind the flight was cancelled. As the aircraft taxied back to the parking area the pilots received a report that the crosswind had dropped to 15 kt. They then decided to take-off and complete some upper air work.

Shortly after the aircraft became airborne, with the pilot-under-instruction at the controls, it encountered a strong wind gust which caused it to roll to the right and descend. The instructor took over control of the aircraft and attempted to correct the situation. Although the aircraft apparently started to respond the instructor assessed that his input was not correcting the situation quickly enough and he closed the throttle, held the control column back and allowed the aircraft to descend to ground level.

The aircraft impacted nose first, to the right of the flight strip, before sliding to a stop and overturning.

The Bureau of Meteorology reported that the wind was gusting between 12 and 21 kt and changing direction from 340 to 010 degrees at the time of the take-off. The pilots were using runway 06L.

The amphibious aircraft had been imported in kit form and assembled by the owner. Several uneventful flights had been conducted in the landplane configuration. The aircraft was then operated from a nearby river for water handling evaluation, and for the owner to obtain a floatplane endorsement. On the fourth take-off, just before the aircraft was about to lift off the water, it rapidly nosed over and sank. The owner managed to escape from the aircraft immediately, but the training pilot was temporarily trapped and had to be cut from his seat belt. Neither of the occupants were injured in the accident.

Inspection of the wreckage revealed that the forward section of the planning hull had failed. The failed section then acted as a water scoop, which resulted in the rapid nose over. A subsequent investigation of the wreckage by the manufacturer confirmed that the fibreglass reinforced plastic hull did not meet design specification. Two of the required three layers of woven glass cloth had been omitted from both sides of the foam core during the manufacture of the hull, greatly reducing its strength.