FACTUAL INFORMATION

The training pilot was conducting training for a pilot in command who was new to the Boeing 767 aircraft and its electronic cockpit concept. Under instructions from the training pilot, the trainee inserted the expected approach and landing information into the flight management computer (FMC), whilst the aircraft was maintaining cruise altitude. This expectation was based on the training pilot's previous experience, where a RIVET 4 STAR with a CULLERIN transition for a landing on runway 34R was normally applied to aircraft arriving from Melbourne.

There were no runway allocations issued to the crew until approximately seven minutes after commencing the descent. At this time, they were first given the information that they were being vectored to left base for a runway 34L independent visual approach. This was acknowledged by the crew. They were advised again during the descent sequence that they would be landing on runway 34L. The crew acknowledged this instruction as well.

After the crew was instructed to continue for a visual approach to runway 34L, the aircraft was observed to track to intercept the runway 34R extended centreline. Eventually, the crew was advised that they appeared, on radar, to be tracking for the incorrect runway. They adjusted the flight path to intercept the extended centreline for runway 34L and completed an uneventful landing.

The Bureau of Air Safety Investigation has previously recommended to Airservices Australia and the Civil Aviation Safety Authority in interim recommendation IR950213 of 2 January 1996, that aircrew read back runway assignments, especially in parallel runway operations. The responses (July 1996) to this recommendation advised that a complete review of phraseology was underway to bring Australian phraseology into line with ICAO, as far as practicable. Both organisations expected that the results from this review would address BASI concerns regarding runway readback. This review was not complete at the time of the occurrence.

ANALYSIS

The training pilot was concentrating on instructing the new pilot in the duties associated with operating the Boeing 767 and did not become alerted to the assignment of a runway that was different to his expectation. Had he been required to read back the runway allocation, it is probable that he would have recognised the unexpected runway and the need to update the data in the aircraft's FMC.

The balloon with 1 pilot and 10 passengers on board departed at about 0650 from Royal Park for a flight over Melbourne city. The pilot intended to land at Port Melbourne, a distance of approximately 7 kilometres. The pilot said that he was advised that at Essendon, 4 kilometres to the northwest the weather was overcast with a 1 knot northerly wind at 1000 feet and the surface wind was calm. After take-off the balloon climbed to 900 feet and the pilot estimated that he was drifting south at 2 knots. As the flight proceeded across the docks he noticed significant ripples on the water surface and significant movement of trees. He estimated that a surface wind of 10 knots had developed in his planned landing area. Because of the wind speed the pilot was forced to make a rapid descent and land before reaching the shore of Port Philip Bay. He force landed the balloon onto the third floor of a building under construction adjacent to the shoreline of the Bay. Although the balloon dragged across the concrete construction and skidded into a safety railing there was no injuries to the persons on board. The pilot disembarked 6 passengers and attempted to lift off and descend to ground level alongside the building.

During this manoeuvre the vent line snagged and the canopy started to deflate. As the canopy deflated it was ripped by construction materials resulting in the basket having to be manhandled to the ground. Weather station readings taken at 0300 indicated that the wind at 1,000 feet was from the northwest at 10 knots. Actual weather readings taken from automatic weather stations around Melbourne approximately 45 minutes prior to departure of the balloon showed the surface winds were generally from the north to northeast averaging 5 knots. By 0900 the surface winds had increased to 10 knots The pilot considered that the incident occurred because of an extremely rapid and localised katabatic wind had developed in the landing area. He plans to increase the volume of his balloon and to increase his fuel capacity to allow him to overfly Port Philip Bay should he experience increasing winds again. The police advised that this is not the first time that this operator has had problems landing in Port Melbourne. The balloon had landed on the same building site some weeks prior to this event, and in a previous event the balloon with passengers on board had overshot the landing area, flown out over the Bay, and was subsequently towed back to shore by a police vessel.

The pilot had underestimated the wind speed that he would encounter on this flight. Even though the surface winds were calm at Essendon and Royal Park, the actual wind at 1,000 feet was ten knots (as reported at 0300), and this, coupled with a surface wind of 5 knots increasing to 10 knots as the morning progressed, was not the ideal conditions to undertake a flight into an area characterised by very little open landing spaces adjacent to a large expanse of water. The operator's intention is to increase the flight endurance of the balloon and fly across the Bay. This would need careful consideration as some of the land areas at the south end of the Bay are narrow, and the flight path may put the balloon into the mouth of the Bay. It may be that a take-off more to the north of the city would preclude the need to consider an overwater flight.

The pilot reported that the aircraft departed with eight imperial gallons (36 litres) of fuel indicated on the fuel gauge for a one hour aerobatic training flight. The aircraft had just been refuelled, with 20 litres being added to a calculated 25 litres remaining. The flight was authorised for one hour on a planned fuel burn of 24 litres/hour and a calculated quantity of 45 litres useable.

The aircraft departed the training area 55 minutes after engine start with the fuel gauge (believed to be inaccurate/completely unreliable below 5 imperial gallons) flickering around the empty position. The pilot rejoined the circuit on the upwind leg for runway 09. During the descent prior to turning crosswind, at about 1,200 ft above the ground, the engine failed. The pilot elected to land straight ahead on the runway remaining. During the descent the engine regained power momentarily, which resulted in a potential overshoot of the runway. The pilot commenced a series of 'S' turns to lose height in an attempt to touch down prior to the upwind threshold.

As he flared, the engine again regained power momentarily. The aircraft finally touched down in the grass overrun area where it ran through a ditch and then into a fence.

The pilot had planned to conduct a series of tourist flights from the helipad at the rear of the Lodge. A 20 m diameter pad had recently been cleared for the operation. The pad was covered with short grass however, it was surrounded by grass up to 0.5 m high. A shrub-like weed was also woven into the tall grass. Only one passenger was carried on the first of the tourist flights and the helicopter performed as expected. On the second tourist flight, this time with two passengers on board, the pilot flew the helicopter to a 1 m hover and then departed towards the east. As it moved through translational-lift the helicopter descended and the right skid entered the 0.5 m-high grass around the helipad. The grass retarded the helicopter, and the leading edge of the skid made contact with the ground. The helicopter started to roll to the right. The pilot attempted to stop the roll by reducing power. When this was unsuccessful, he increased power to the maximum and attempted to fly out of the roll. This was also unsuccessful, and the helicopter ended up rolling onto its right side.

The helicopter was loaded to just under its maximum weight. The pilot misjudged the amount of excess power that would be available under the prevailing conditions, and he was unable to keep the helicopter clear of the grass during the departure. The scrub-like weed provided sufficient retardation for the right skid to dig into the ground starting a roll to the right. The pilot's description indicates the helicopter had probably entered a condition known as dynamic rollover (Aviation Safety Digest No. 95, 1975, pg. 25) before he started recovery action. As a result, his actions did not work.

The pilot was conducting a routine food and medical supply flight to several outstation settlements. Visual meteorological condition (VMC) existed when he departed, but with storm activity observed along the route, and a cyclone in the area. Approximately 1.5 minutes from the destination a rapid deterioration in the weather conditions to below VMC prevented the pilot from landing so he decided to divert to Oenpelli.

He was again confronted by deteriorating weather conditions making further diversions necessary. He notified Adelaide Flight Service of the diversions and then attempted to return to his departure aerodrome, which also proved impossible.

After spending sometime dodging around storms and heavy rain in an attempt to find a suitable airstrip, then faced with the approach of evening and fading daylight, he decided his safest action would be to find a suitable area for a precautionary landing. He was unable to re-establish contact with Adelaide Flight Service to advise his intentions.

He found a relatively flat area on top of an escarpment, but during the landing roll the aircraft struck light timber causing the right wing to detach and the aircraft to roll onto its right side. The pilot and passenger evacuated the aircraft, then activated the ELT which was monitored by Airservices Australia SAR via satellite, and their location known. Because of the cyclone and adverse weather conditions a search could not be initiated until the next morning.

They spent the night in the aircraft to shelter from continuous heavy rain, then rescued next morning by helicopter.

After take-off the flight attendants seated at the rear of the aircraft reported a bang followed by abnormal noises from the area of the rear airstairs. Shortly afterwards the flight crew observed that the lower aft body overheat light had illuminated. The appropriate drills were carried out, and the warning light extinguished when all bleeds were closed. The aircraft returned for an immediate landing.

Maintenance investigation found that a titanium duct flange had ruptured upstream of the right-wing anti ice valve. Failure of the flange is a known problem. A special inspection for cracks in the weld zone had been introduced many years ago and, in 1990, after an evaluation of service history, the inspection period was increased from 1,000 cycles to 2,000 cycles. The failed flange was nearly at the 2,000-cycle threshold and had failed approximately 60 cycles and just 12 days before the inspection was scheduled.

The operator is continuing checks to confirm the mode of failure of the flange and is reassessing the compliance period.

VH-BWC departed from runway 17R and at 500 ft turned right to intercept the 195-degree track to King Island. The pilot elected to maintain an altitude of 700 ft until clear of the downwind leg of the runway 17R circuit and of any possible light aircraft traffic along the coast. Crossing the coast at 700 ft, VH-SGE passed in front of BWC from left to right approximately 200 metres distant and 100 ft higher than VH-BWC. The crew of BWC had not been given traffic advice on SGE and had not heard any inbound call from the aircraft. SGE was joining downwind for runway 17R.

The pilot of SGE said that he was unaware of BWC until he saw the aircraft when it was about 400 ft away. At the time of sighting, he said that he was at 1,000 ft and the other aircraft was about 200 ft lower and appeared to be climbing. Although close, there was no need for avoiding action as it was obvious BWC would pass behind SGE.

Recorded communications showed that the pilot of SGE made a standard inbound call at Carrum and then called again joining downwind. The pilot of BWC reported ready for take-off 25 seconds after SGE's inbound call so was most probably still on ground frequency at the time of that call and therefore did not monitor the call. The aerodrome controller did not pass traffic to BWC on SGE. Timings of calls recorded on tape would suggest there was a potential traffic conflict. The frequency was not busy during the period immediately leading up to the incident. The pilot of SGE did not recall hearing BWC reporting ready and being cleared for take-off.

The aircraft departed Parkes on a VFR flight to Coffs Harbour, tracking via Scone, Mount Seaview and Kempsey. The pilot reported that the weather enroute to Scone had been fine with clear skies and winds from the south at 10 kts, however, active storms were observed developing to the south of the intended track.

Shortly after the aircraft passed over Mount Seaview, the pilot assessed that the weather was unsuitable to continue flight on his planned track. He decided to follow the Macleay River valley to Kempsey, then continue coastal to Coffs Harbour.  However, about 5 NM before Kempsey the weather deteriorated rapidly, forcing the pilot to divert in order to remain in visual meteorological conditions.

An area of high ground, which he had overflown some minutes earlier, was chosen for a landing. The pilot made two precautionary passes over the area and believed that the surface was approximately level. He then approached to land toward the south but discovered upon landing that the surface had a considerable downslope. While attempting to stop the aircraft the wheels locked under braking and skidded on wet ground. The right main landing gear collided with a creek bank, slewing the aircraft at right angles to the landing direction, and resulting in substantial damage.

The pilot reported that after landing on runway 27, he turned off onto the gravel taxiway. As he did so a strong wind gust hit the aircraft from the right rear quarter. The aircraft went over initially onto its left wing and nose where it stayed for a few seconds before being hit by another gust which tipped the aircraft onto its back.

The wind was reported by a local operator to have been from the west-north-west, gusting from 20 to 45 knots.