The helicopter was being ground run after two of the three rotor blades had been refitted. The aircraft apparently experienced ground resonance and the main rotor struck the ground. The aircraft rolled over and came to rest against a tree. The sole male occupant was admitted to hospital.

Enquiries revealed the person operating the helicopter did not hold a pilots or engineers licence. The helicopter had apparently been purchased on behalf of another person with the intention of shipping it out of the country.

Since the person who was running the helicopter was released from hospital he has been pursued by the CASA for questioning but has disappeared.

Ground running of helicopters must be performed by a licenced helicopter pilot, and if the helicopter is tied down, may be performed by a licenced engineer.

During climb, passing 5,300 ft, a loud bang was heard. The pilot initially thought the noise to be a birdstrike, however it was noticed that the inner cowl on the left engine had fallen from the aircraft. The pilot elected to return to Brisbane. Post flight inspection revealed that the cowl had torn off along the hinge line and had struck the fuselage forward of the entry door causing denting and scoring of the fuselage skin.

The aircraft had undergone maintenance on the previous day, but no work had been done on the left engine, and there was no known reason for the left engine cowl to be unfastened. The copilot, who performed the daily inspection in the early hours of the morning (it was still dark) had not noticed the cowl was not properly fastened. The cause of the cowl being unfastened could not be determined.

The incident occurred on the first day of a two-day pageant to celebrate the 75th anniversary of Essendon airport. A flying display was programmed to commence at 1300 eastern standard time, the first event being a multiple parachute drop from VH-KTD. Air traffic services planned to give priority to programmed pageant events. Before and between events, several local operators took the opportunity to conduct joy flights. Joy flight traffic was heavier than anticipated by air traffic services.

Because the wind was a moderate south westerly, air traffic services established a left-hand racetrack pattern using runway 17 for most departures and runway 26 for arrivals.

Shortly before the incident, joy flight aircraft were being recovered to clear the airspace for the paradrop aircraft awaiting clearance for take-off from runway 17. The aerodrome controller decided to require the pilot of VH-NAY, a joy flight aircraft on approach to runway 26, to hold short of the runway 17 strip after landing so he could expedite the take-off of the paradrop aircraft. As NAY was already on final for runway 26 when the controller made this decision, he decided to wait until NAY had landed and slowed to taxying speed before issuing the hold short instruction. However, in the busy traffic situation the controller forgot to issue the hold short instruction to NAY and cleared the paradrop aircraft for take-off. NAY entered the runway 17 strip (gable marker line) as KTD became airborne north of the runway 17/26 intersection.

The incident would not have occurred if operations had been confined to a single runway. However, the use of runway 17 for departures and 26 for arrivals was a standard operating procedure in suitable weather conditions. The procedure increases traffic throughput and reduces aerodrome controller loads. Use of the "hold short" requirement, once the landing aircraft has reduced to taxying speed, was common.

The Essendon tower team leader was rostered on as an extra staff member in view of the expected heavy traffic. However, because he had attended the briefing for participating pilots, and was still relaying the details of the briefing to other tower staff, he had not taken up the position of assisting the aerodrome controller before the incident occurred.

Significant factors

The following factors were considered relevant to the development of the incident:

1. Joy flight traffic was heavier than anticipated.

2. The extra tower controller was still briefing other tower staff and was not assisting the aerodrome controller when the incident occurred.

3. There was a degree of pressure on the aerodrome controller to ensure that joy flight aircraft were on the ground prior to the pageant commencing.

FACTUAL INFORMATION

An Australian registered B747 aircraft had departed Tokyo on a flight to Sydney. The crew had been radar-vectored by air traffic control around an active military restricted area (R116) and were commencing a left turn to intercept their planned route in accordance with the instructions received. As the aircraft climbed through flight level (FL) 220, the crew received a traffic alerting and collision avoidance system (TCAS) traffic advisory warning of unidentified aircraft crossing from right to left and climbing from a level beneath that of the B747.

A pair of U.S. military FA-18 aircraft had departed from the Atsugi Naval Air Facility to operate in R116, which was located just east of the air route which the B747 was intercepting. Initially, the formation was proceeding under instrument flight rules but changed to visual flight rules on passing 9,000 ft, and tracked visually to the exercise area. Their rate of climb at this time was approximately 6,000 ft/min.

After receiving the TCAS traffic advisory, the crew of the B747 saw the military formation and, as the formation had changed course to be in conflict with the predicted track of the B747, they elected to increase the rate of climb and continue the left turn, to ensure separation from the FA-18s. During this manoeuvre, the rate of climb of the B747 reached 5,000 ft/min, higher than normal for this stage of flight. No traffic information was given by air traffic control in relation to the FA-18 aircraft.

While the crew of the B747 were carrying out their evasive action, the crews of the FA-18s had sighted the B747 and commenced a level-off manoeuvre to maintain FL 225. They calculated that their track to R116 would have conflicted with that of the B747, and assessed that as that aircraft had left FL 225, vertical separation would be achieved by the time horizontal separation was lost.

Radar analysis indicates that the aircraft passed with a minimum of 1,200 ft vertical difference while there was no horizontal separation. Because the appropriate standard is a minimum of 1,000 ft, no breakdown of separation occurred.

ANALYSIS

The FA-18 pilots were operating in accordance with the "see and avoid" principle of visual flight. They acted in accordance with the rules for aircraft transiting to or from the restricted area and maintained a level beneath that already vacated by the B747.

The crew of the B747 reacted to the visual sighting of military aircraft closing rapidly on their aircraft and on a track that was in conflict with their intended flight path. The TCAS equipment confirmed that the rate of closure and track change of the FA-18 formation would place the aircraft in imminent conflict. Even though there was no resolution advisory, the B747 crew elected to commence an evasive manoeuvre based on their observations. They had no information on the intent of the military crews and did not know of the decision of those pilots to level off below their aircraft.

The air traffic controllers were aware of the visual flight procedures used by the military formation and only had a requirement to pass traffic information on such flights if their other duties allowed. In this case, the controller was too busy to pass traffic to the Australian crew. This crossing point is a particularly busy section of airspace and it is normal for traffic information not to be given as military crews are required to remain clear of civil aircraft.

SAFETY ACTION

The Japanese Civil Aviation Bureau advised the military authorities to remind pilots of the airspace structure and of their requirement to remain well clear of civil traffic.

The Bureau requested that the operator fully brief crews on airspace requirements and military crossing points, and how TCAS advisories can be expected in this environment.

A group of pilots were undertaking endorsement training on the aircraft. They had been briefed on ground handling and starting procedures for the aircraft. The starting procedure involved turning the propeller through with full throttle and ignition off, in order to pass fuel mixture to the cylinders. After that process the throttle was set to be set to 1/4 inch open and the ignition switches turned on for hand starting.

On this occasion the instructor was outside the aircraft to hand swing the propeller and the pilot undergoing the endorsement was in the cockpit. The throttle had been set full open for the priming procedure and the instructor had asked for it to be set to 1/4 inch open. At this time the throttle was moved to a position which the trainee assumed was the appropriate setting. When the engine started it went quickly to a high rpm condition, the tail rose, and the propeller was destroyed by contact with the ground.

The trainee had not closed the throttle initially in order to obtain the correct datum from which to set the throttle for start. He later found that the throttle control movement was much greater than had been expected. In his previous experience, with nose-wheeled aircraft, a high rpm after start was of no concern from an aircraft attitude aspect, however with a tail-wheeled aircraft the tail can rise unexpectedly.

Factors

1. The trainee pilot was unfamiliar with the engine control movement;

2. The starting throttle position was not set from the closed throttle position;

3. The throttle was set too far open for start;

4. The flight controls were not set to help keep the tail low;

5. Timely action to reduce engine rpm was not taken;

6. The instructor did not check that the throttle and flight controls were properly set for start.

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.