Missed approach involving a Cessna 172RG, VH-KPL, Cairns Aerodrome, Queensland, on 11 February 1997

Summary

The aircraft was forced to go around from short final after three fire tenders were unable to vacate the runway as instructed. Four fire tenders were previously cleared to enter the movement area in order to conduct a response time test to the threshold of runway 33. The controller permitted the exercise after considering the aircraft traffic in the area. His expectation was that the tenders would would be able to clear the runway (to grassed areas outside the flight strip) immediately when requested. When the controller instructed the tenders to vacate the runway he was advised that they were restricted to operations on the sealed areas only. The surrounding ground was too soft.

The aircraft landed safely a short time later, after the fire vehicles had moved to the taxiways.

Notification procedures were then put in place at Cairns, so that air traffic control staff would be made aware of any restrictions to the movement of fire vehicles due to surface conditions.

Occurrence summary

Investigation number 199700376
Occurrence date 11/02/1997
Location Cairns Aerodrome
State Queensland
Report release date 15/07/1997
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Missed approach
Occurrence class Incident

Aircraft details

Manufacturer Cessna Aircraft Company
Model 172RG
Registration VH-KPL
Sector Piston
Operation type Private
Departure point Cairns QLD
Destination Cairns QLD
Damage Nil

Hard landing involving a Cessna 182Q, VH-CJM, Meekatharra Aerodrome, Western Australia, on 10 February 1997

Summary

The pilot reported that he had completed his night rating in January and had decided to practice his night flying techniques. After completing an inspection of a mine site, he returned to the circuit for landing practice. He had completed one satisfactory touch-and-go landing and was on an approach for a full stop landing when the accident occurred. He reported he was unhappy with the approach and decided to complete a go-around from about 30 ft above ground level. Having opened the throttle, the pilot moved his right hand to the trim wheel to remove the significant amount of nose-down trim that was still applied. As he did so the throttle returned to idle and the combination of low power and nose-down trim caused the aircraft to touch down heavily. The nosewheel, firewall and propeller were damaged. The pilot then brought the aircraft to a stop on the runway.

The throttle friction had been set so that it was loose. This contributed to the power reduction when the pilot removed his hand from the throttle. The pilot also reported that he had concentrated his attention on the area of the runway near the expected point of touchdown and not the far end as he had been taught. As a result, he did not recognise the last-minute descent until it was too late to recover.

Occurrence summary

Investigation number 199700382
Occurrence date 10/02/1997
Location Meekatharra Aerodrome
State Western Australia
Report release date 12/02/1997
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 182Q
Registration VH-CJM
Sector Piston
Departure point Meekatharra WA
Destination Meekatharra WA
Damage Substantial

Wheels up landing involving an Amateur Built HH-1, VH-AFW, Serpentine (ALA), Western Australia, on 3 February 1997

Summary

The pilot was familiarising himself with the Sidelinger replica Hurricane before continuing with a flight test program that had already been partly completed by another pilot. He conducted one circuit and landing with the landing gear down. After a short break he took off again and departed the airfield for aerial work. After take-off he retracted the landing gear and noted a normal gear-up cockpit indication.

On return to the airfield, the pilot selected the landing gear down but received an unsafe gear cockpit indication. He checked the landing gear circuit breaker was in and then cycled the selector lever twice more but without success. He then attempted to lower the landing gear using the emergency lowering method. He reported, however, that the emergency lowering system would not operate.

Committed to a gear up landing, the pilot elected to land on the 270 degree grass strip. The pilot said that he approached at minimum speed and touched down tail wheel first with throttle closed and the fuel and electrical systems secured. The aircraft then skimmed along on the underside air scoop before eventually nosing forward and damaging the propeller and air intake. The owner subsequently reported the cause of the landing gear failing to lower via the normal system was a faulty selector switch. The reason why the emergency lowering system would not operate was not determined.

Occurrence summary

Investigation number 199700353
Occurrence date 03/02/1997
Location Serpentine (ALA)
State Western Australia
Report release date 03/04/1997
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 Amateur Built Aircraft
Model HH-1
Registration VH-AFW
Sector Piston
Operation type Private
Departure point Serpentine WA
Destination Serpentine WA
Damage Minor

Ditching involving a Bell 47G-5, VH-JGF, Wiawera Station, South Australia, on 7 February 1997

Summary

The pilot was assisting in flood rescue operations and was directed to a homestead where several people had climbed onto its roof to escape from the fast-flowing flood waters, which had risen to the height of the roof line.

He approached the homestead at a height of about 2m above the water level, then hovered the helicopter alongside the roof to allow an elderly person to board. This person had had a safety rope attached to him to prevent him from slipping off the steeply pitched roof. As he climbed onto the skids his weight moved the helicopter slightly sideways, and the rope snagged on the roof causing the helicopter to descend. The pilot was unable to arrest the downward movement in the height available before the helicopter struck the water and sank.

All occupants escaped, the pilot recovered the ELT and activated it.

Occurrence summary

Investigation number 199700355
Occurrence date 07/02/1997
Location Wiawera Station
State South Australia
Report release date 28/02/1997
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Ditching
Occurrence class Accident
Highest injury level Minor

Aircraft details

Manufacturer Bell Helicopter Co
Model 47G-5
Registration VH-JGF
Sector Helicopter
Operation type Aerial Work
Departure point Tikalina Station SA
Destination Wiawera Station SA
Damage Substantial

Loss of separation involving a Boeing 747-338, VH-EBT and Boeing 727-277, VH-ANA, 37 km west of Melbourne Aerodrome, Victoria, on 3 February 1997

Summary

FACTUAL INFORMATION

A Boeing 747 (B747) aircraft departed from runway 16 at Melbourne for Bangkok on climb to 3,000 ft. Runway 27 was the nominated departure runway but the aircraft required a departure from runway 16 for operational reasons. Additionally, the crew advised that they could not comply with the requirement to not exceed 250 kts below 10,000 ft. The crew of the B747 tracked the aircraft via a standard instrument departure (SID) that required them to turn right and intercept the outbound track, to the northwest of the aerodrome.

Shortly after the B747 became airborne the aerodrome controller (ADC) requested departure instructions, from the DEP N controller, for a pending Boeing 727 (B727) aircraft departure to Adelaide from runway 27. The B747 was climbing slowly and would cross the intended track of the B727. The ADC suggested to the DEP N controller that the B727 be maintained at 3,000 ft, on departure, after the crew of the B747 had been approved to, and had climbed that aircraft above 4,000 ft. However, the DEP N controller believed that the B727 would climb faster than the B747 and he intended to radar vector that aircraft behind the B727. The DEP N controller approved the departure of the B727 on the planned track. He then approved the crew of the B747 to climb to FL200 and cancelled the speed restriction. He also instructed the crew to cancel the SID and to turn left onto a heading of 270 degrees.

The DEP N controller had been operating at the console for approximately three hours. A busy traffic period had just finished, and traffic numbers were reducing. Traffic levels were moderate when the B727 departed.

After the B727 departed the DEP N controller cancelled the speed restriction below 10,000 ft and approved the crew to track direct to Bordertown on climb to FL200. These measures were meant to assist in increasing the horizontal distance between the two aircraft which were on near parallel westerly tracks with the B747 to the south of the B727.

When both aircraft were approximately 20 NM to the west of Melbourne and at similar levels, the DEP N controller assessed that he could radar vector the B747 behind the B727. He instructed the crew of the B747 to turn right onto a heading of 340 degrees. As the crew was turning the aircraft, the DEP N controller observed that the separation standard of 3 NM was going to be infringed. He instructed the crew of the B747 to turn left onto a heading of 240 degrees. Both crews reported sighting the other aircraft. Separation reduced to 1.5 NM horizontally and 700 ft vertically before radar separation was re-established. There was a breakdown of separation.

ANALYSIS

The DEP N controller did not establish vertical separation between the two aircraft before attempting to radar vector the B747 behind the B727. An instruction to the crew of the B747 to maintain a level 1,000 ft below the level of the B727 would have caused a minor delay to the climb of the B747 but would have ensured that separation was maintained.

SIGNIFICANT FACTORS

1. The DEP N controller did not use appropriate separation assurance techniques.

Occurrence summary

Investigation number 199700295
Occurrence date 03/02/1997
Location 37 km west of Melbourne Aerodrome
State Victoria
Report release date 05/10/1997
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 The Boeing Company
Model 727-277
Registration VH-ANA
Sector Jet
Operation type Air Transport High Capacity
Departure point Melbourne, VIC
Destination Adelaide, SA
Damage Nil

Aircraft details

Manufacturer The Boeing Company
Model 747-338
Registration VH-EBT
Sector Jet
Operation type Air Transport High Capacity
Departure point Melbourne, VIC
Destination Bangkok, Thailand
Damage Nil

Incorrect configuration involving a Beech Aircraft Corp V35A MK II, VH-FWY, Archerfield Aerodrome, Queensland, on 6 February 1997

Summary

The pilot reported that after a normal landing and landing roll, whilst watching for the next exit from the runway, he accidentally raised the gear switch instead of the flap switch. The gear retracted and the aircraft slid to rest on the runway.

Occurrence summary

Investigation number 199700330
Occurrence date 06/02/1997
Location Archerfield Aerodrome
State Queensland
Report release date 25/03/1997
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Incorrect configuration
Occurrence class Incident

Aircraft details

Manufacturer Beech Aircraft Corp
Model V35A MK II
Registration VH-FWY
Sector Piston
Operation type Private
Departure point Archerfield
Destination Archerfield
Damage Minor

Flight control systems involving a Robinson R44, VH-JFK, Southport Aerodrome, Queensland, on 29 January 1997

Summary

Sequence of Events

Following an extended period of hovering practice and a circuit, the student remarked that the lateral trim was heavy. The instructor flew another circuit. He noticed that increasing left cyclic control pressure was required to prevent the helicopter from rolling right. At about 150 ft AGL a loud metallic "springing" noise was heard and a reaction felt through the controls and airframe. The cyclic pressures returned to normal. The helicopter was landed safely and closed down.

An after-flight inspection found that the lateral trim springs had parted, and right cyclic control was restricted to about 50% of the normal control authority.

Safety Action

Following this incident, the Civil Aviation Safety Authority was notified and made two submissions for the manufacturer to take urgent action. The manufacturer had been aware of a potential problem involving undue wear on a shaft in the trim assembly which could cause binding. A service letter, SL-13, which called for an inspection at each 100-hour inspection and annually was issued prior to this incident. Service Bulletin, SB-19, which called for a mandatory inspection of the trim shaft to determine the minimum diameter of the shaft was issued on 16 April 1997. Time of compliance was within the next 50 flight hours or by 31 May 1997, whichever came first.

Occurrence summary

Investigation number 199700274
Occurrence date 29/01/1997
Location Southport Aerodrome
State Queensland
Report release date 03/04/1997
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Flight control systems
Occurrence class Incident

Aircraft details

Manufacturer Robinson Helicopter Co
Model R44
Registration VH-JFK
Sector Helicopter
Operation type Flying Training
Departure point Southport ALA QLD
Destination Southport ALA QLD
Damage Minor

Ditching involving a Hughes Helicopters 269C, VH-IHV, Geelong Heliport, Helicopter Landing Site, Victoria, on 26 January 1997

Summary

After conducting 15 joy flights from the Geelong helipad from about 1145, the pilot flew two passengers on an advertising project. One of the passengers, a local radio announcer, was tasked to perform a live radio cross from the helicopter.

On the commencement of the last approach to land to the south-east, the pilot estimated the wind to be 15 kts from the north-west. He advised that when on short final, 200 metres from the helipad, he noticed a sudden wind shift and the helicopter experienced loss of lift. He increased throttle and collective in an attempt to maintain height and reach the helipad. However, rotor RPM decayed and the helicopter settled into the sea 60 metres short of the helipad.

Subsequent viewing of amateur video footage showed the latter part of the landing approach to be very shallow, followed by a classic example of overpitching with the main rotor disc coning and the RPM audio decreasing as the helicopter descended into the sea.

No fault was reported with the airframe or engine which may have contributed to the accident.

Occurrence summary

Investigation number 199700230
Occurrence date 26/01/1997
Location Geelong Heliport, Helicopter Landing Site
State Victoria
Report release date 21/04/1997
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Ditching
Occurrence class Accident
Highest injury level Minor

Aircraft details

Manufacturer Hughes Helicopters
Model 269C
Registration VH-IHV
Sector Helicopter
Departure point Geelong HLS, Vic
Destination Geelong HLS, Vic
Damage Destroyed

Runway incursion involving a Boeing 737-377, VH-CZO, Brisbane Aerodrome, Queensland, on 29 January 1997

Summary

Sequence of Events

The aircraft had commenced its take-off run on runway 19 when the driver of an FAC car on the eastern side of the runway radioed the Surface Movement controller (SMC) with a request to cross the runway at taxiway Mike. The SMC who did not hear the transmission properly, assumed that the car was already on the western side of the active runway and approved what he thought was a clearance to enter the taxiway.

The driver of the car did not realise that the clearance did not contain the words "clearance to cross the runway" and subsequently did not question the SMC. He also did not stop the car at the holding point to check for air traffic. He did not see the approaching jet until the car had entered the runway. He attempted to accelerate the car out of the way. The aircraft became airborne about 200 m short of the car and overflew at about 80 ft.

Analysis

The SMC did not follow standard ATS procedures. He did not ask for a repeat of the transmission from the FAC car driver and did not check the physical location of the vehicle before issuing a clearance. The clearance he issued did not comply with local operating instructions. The controller was moderately busy at the time.

The driver of the car did not follow ground safety instructions. He did not receive a correctly phrased clearance, nor did he stop at the holding point to check for any aircraft landing or taking off.

A collision between the aircraft and the car was avoided by good fortune only. The aircraft became airborne before reaching the taxiway.

Occurrence summary

Investigation number 199700267
Occurrence date 29/01/1997
Location Brisbane Aerodrome
State Queensland
Report release date 20/03/1997
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Runway incursion
Occurrence class Incident

Aircraft details

Manufacturer The Boeing Company
Model 737-377
Registration VH-CZO
Sector Jet
Operation type Air Transport High Capacity
Departure point Brisbane QLD
Destination Townsville QLD
Damage Nil

Loss of separation involving a Cessna 550, VH-KTK and Saab SF-340B, VH-EKX, 35 km south-south-west of Canberra, Australian Capital Territory, on 24 January 1997

Summary

FACTUAL INFORMATION

A Cessna 550 aircraft had departed Wagga on a training flight to Canberra and was maintaining flight level (FL) 170.

A Saab SF340B aircraft had departed Sydney on a regular public transport flight to Albury and was maintaining FL 120 on the route section between Canberra and Albury. Both aircraft were under radar control.

At 1218 ESuT, the crew of the C550 requested descent and were cleared to FL 130 by air traffic control. The pilot read back FL 120 but this incorrect level was not detected by the controller. One minute later the controller informed the crew of the C550 that there would be a delay for further descent due to crossing traffic (the SF340B) on the Canberra to Albury track.

At 1222, the controller noticed that the radar return for the C550 was indicating FL 120 and was 3 NM from the SF340B on crossing tracks. There was a breakdown of separation.

Radar analysis indicated that at the time vertical separation broke down, the C550 had passed through the intended track of the SF340B by approximately 1 NM and that the closest point between the aircraft was 3 NM. The required separation standard was 5 NM horizontally or 1,000 ft vertically.

ANALYSIS

Air traffic control

Because the controller believed he had heard the crew of the C550 read back FL 130 he annotated this on the flight progress strip. This meant that, in his mind, he had provided separation for the conflict he was expecting to occur. He then monitored the aircraft as they passed in the belief that vertical separation would be maintained until he could re-establish radar separation. It was only when he observed on radar that the C550 was maintaining FL 120 that he realised that a breakdown in separation had occurred. At that time, the aircraft had already passed each other, and separation was increasing.

Flight crew of the C550

The crew thought they heard FL 120 given as the descent instruction and when this read back was not questioned, they continued a normal descent to FL 120, believing it to be the assigned level. They did not see the other aircraft and considered that, as air traffic control were providing separation, any instructions to the other aircraft would not have been queried, even if they indicated a climb through the level of the C550.

SIGNIFICANT FACTORS

1. The crew of the C550 read back an incorrect assigned flight level.

2. The air traffic controller did not detect the incorrect read back.

Occurrence summary

Investigation number 199700213
Occurrence date 24/01/1997
Location 35 km south-south-west of Canberra
State Australian Capital Territory
Report release date 16/05/1997
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 Cessna Aircraft Company
Model 550
Registration VH-KTK
Sector Jet
Operation type Flying Training
Departure point Wagga, NSW
Destination Canberra, ACT
Damage Nil

Aircraft details

Manufacturer Saab Aircraft Co.
Model SF-340B
Registration VH-EKX
Sector Turboprop
Operation type Air Transport Low Capacity
Departure point Sydney, NSW
Destination Albury, NSW
Damage Nil