Factual information

The pilot had planned to fly from Moorabbin direct to Ocean Grove, then on to Warrnambool. Prior to departure he was advised that there was 40 litres of fuel in the left main tank and the right main tank was full at 91 litres. Both tip tanks were also full at 63 litres each.  Records held by the operator showed that the aircraft was consuming an average of 61 litres per hour. Accordingly, the pilot was advised to use the right main tank for one hour, then use the tip tanks, and go back to the fullest main tank for the landing.

The pilot loaded his five passengers, selected the right main fuel tank, started the engine, conducted engine runs and taxied for take-off. These actions took approximately 20 minutes. After take-off the pilot flew coastal from Moorabbin to Ocean Grove rather than direct as planned, then tracked direct for Warrnambool. Due to weather constraints, he cruised between 2,000 feet and 2,500 feet above mean sea level and also deviated from his track to avoid rain showers. He used a high-power setting of 24 inches of manifold pressure and 2,400 rpm, and did not lean the fuel mixture. Approximately 65 minutes after take-off, at a position about 15 minutes from Warrnambool, the engine suddenly failed. At low altitude over hilly terrain the pilot said he did not have time to conduct a proper assessment of the cause of the power loss, nor did he have time to carry out a successful restart procedure. The pilot forced landed the aircraft onto a sloping field, colliding with a fence before bringing the aircraft to a stop. The aircraft suffered substantial damage, however the six persons on board were uninjured.

Investigation disclosed that the right main fuel tank contained unusable fuel only, and the fuel feed system to the engine was empty. When the system was supplied with fuel the engine was started and ran satisfactorily. Tests indicated that the fuel quantity measuring system was serviceable.

The pilot advised that during the flight he did not maintain a flight log and did not monitor the right main tank fuel quantity. His planning had indicated that the flight would take about one hour and he had intended to change to the fullest tank prior to landing.

The recommended power charts contained in the pilots operating handbook, which was available to the pilot, did not cover the combination of parameters under which this flight was conducted.

Analysis

While the contents of the right main tank prior to departure could not be definitely established it was most probably full at 91 litres. The coastal track taken by the pilot could have added up to an extra ten minutes flying and his deviations from track to avoid showers would also have added to his flight time. While the flying school's flight sheets indicated that the average fuel usage was 61 litres per hour, this was attained by using recommended power settings and correct leaning procedures. It was calculated that the aircraft could use up to 88 litres of fuel per hour while flying at low altitude with high power and a rich mixture. This, coupled with the taxiing, take-off and climb fuel flows would have depleted the 91 litre contents of the tank after approximately one hour in flight, as occurred.

By operating the aircraft as he did, the pilot chose to fly outside of the recommendations contained in the pilots operating handbook. However, even flying in this manner had the pilot maintained a flight time log and a fuel usage log, and monitored the fuel quantity gauges, he would have become aware of the contents of the right main fuel tank before the fuel was depleted.

Significant factors

1. The pilot did not use effective fuel management techniques.
2. Engine power was lost when the fuel tank in use was allowed to run dry.

VH-OZV departed Moorabbin from runway 35L and after making a left turn, commenced tracking in a southerly direction on climb to 9,000 ft. Three miles south of Moorabbin the pilot called RAS, but the aircraft was not identified because its transponder was not being interrogated. The RAS controller passed traffic information to the pilot of OZV on an aircraft two miles at 12 o'clock, also with no transponder return. The pilot of OZV sighted the other aircraft in his 11 o'clock position, 100 to 200 ft higher. He took evasive action, in the form of a left turn, to avoid a collision.

The conflicting aircraft was later identified as VH-PWQ, whose transponder suddenly started operating after traffic information was passed to OZV. The pilot of PWQ said that he flies from Berwick to Ballarat, as he was on this occasion, once a week, and transits via the coast south of Moorabbin at 2500 ft. He listens out on RAS and the appropriate Moorabbin tower frequency for traffic. However, he did not make a broadcast of his position, altitude and intentions on the Moorabbin tower frequency, as is required by AIP OPS 42.2.1. He heard OZV departing Moorabbin but never saw it, even when they passed in close proximity.

The instructor reported that he and the handling pilot were engaged in introductory ILS training at the time of the accident. An instrument training hood was being used to simulate instrument meteorological conditions. The aircraft had been cleared for an ILS approach to runway 24. As the aircraft approached localiser intercept the pilots were asked to reduce the aircraft's approach speed. The instructor suggested that the handling pilot lower the landing gear and flap earlier than normal. Both believe the gear was selected down at this point.

After glideslope intercept the handling pilot had to be prompted several times to reduce power to keep the aircraft's speed below the maximum. The instructor was not concerned with this as he had expected there would be a tailwind on final approach. Final's checks were completed prior to reaching decision height and both pilots reported that they thought they saw the green lights which indicated the gear was down. During the approach both pilots reported hearing the outer and middle marker identification signals over the aircraft's speaker but neither reported hearing the landing gear warning horn. The hood was removed at decision height and the handling pilot continued flying to a landing.

The handling pilot reduced power steadily to idle as he flew the aircraft into the landing flare. As the aircraft settled towards the runway the instructor realised the gear was still up and he reached for the selector handle to confirm it was in the down position. He did not recall moving the lever. The aircraft settled onto its lower fuselage and slid to a stop. Neither pilot reported hearing the landing gear warning horn during the flare.

Post-accident inspection of the landing gear did not disclose any faults. The gear selector handle was found in the down position and the main gear had been released from its uplocks. When the aircraft was lifted from the runway, and power applied, the gear extended, and the landing gear warning horn sounded until the gear was locked down. The fact that the main gear had been released from its uplocks is an indication, from past experience, that the gear had been selected down after the aircraft had settled onto the runway.

The instructor reported that he was acting as safety pilot, searching for other traffic and maintaining a visual watch until the landing. As a result, he did not closely monitor the handling pilot's actions in the cockpit. Therefore, he could not be sure the handling pilot actually moved any of the selectors in the direction which he had indicated.

The surface wind was reported as blowing from 030 degrees at around 5 knots. With this wind it is unlikely there was a tailwind on final and the problem with speed control was probably an indication that the gear was still up. It could not be determined why the warning horn did not sound, or if it did, why the pilots didn't hear it.

It is evident that the landing gear was either not selected down, when speed was being reduced, or it was selected up again during the approach. Past investigation indicate that it is possible for a pilot working under stress, as can be evident during a practice precision instrument approach early in their training, to reverse a selection thinking they had selected it correctly. This error is more likely if the system had previously been selected out of sequence, as it was in this case. Consequently, the gear may have been selected up just before glideslope intercept rather than down, as would have been the normal action.

Previous investigations also indicate that pilots sometimes see what they expect to see (a mindset) rather than the actual indication. This may explain their observation of the green landing gear lights when there probably weren't any.

FACTUAL INFORMATION

The aircraft had been flown from Archerfield to Port Macquarie for an air display and, on this flight the radar transponder had failed. At the completion of the display, the pilot departed Port Macquarie a few minutes after another similar type of aircraft which was also returning to Queensland. The transponder was unserviceable for this flight. Prior to commencing the flight from Port Macquarie the pilot arranged for the pilot of the other aircraft to make the appropriate radio transmissions for both aircraft, and inform air traffic services (ATS) of their intentions. Those transmissions were not monitored by the incident pilot.

No taxi calls or preliminary information that the aircraft had an unserviceable transponder were received and understood by ATS staff. The first communication with ATS was a call on departure from Port Macquarie, at 1430ESuT. In this series of transmissions the pilot indicated that he was climbing to flight level 260 (FL260) and that he had submitted a flight plan with a departure time of 1630. His estimated time time over Kempsey was 1438. The pilot was instructed to remain outside controlled airspace (OCTA) as he was not yet identified on radar, and to confirm that he would be tracking clear of the Coffs Harbour controlled airspace steps. After some delay the pilot reported that he might need a clearance through the steps. He was again instructed to remain OCTA.

When asked to squawk ident, the pilot used a military term to report that his transponder was not working. The controller asked him to confirm that the aircraft was not transponder equipped. Upon confirmation, the controller informed the pilot that a clearance into controlled airspace was not available without a transponder, considering that they had been given no taxi details in advance of departure from Port Macquarie. The pilot informed the controller that the taxi calls had been made by the other aircraft which had departed a few minutes ahead of him. However, the controller did not have this information.

At 1436 the pilot reported his position as five miles south of Kempsey and passing FL160 on climb to FL250. The controller reminded him that he had been instructed to remain OCTA. In the area between Port Macquarie and Kempsey the lower limit of controlled airspace was FL125. The pilot was then instructed to hold over Kempsey and maintain FL160. At 1437 the pilot again reported that he was five miles south of Kempsey at FL160. Upon being informed that he would not be given a clearance to Archerfield, the pilot responded immediately that he would go OCTA. The instruction hold over Kempsey at FL160 was re-affirmed. The pilot suggested that he could go east to Point Lookout, whereupon the controller confirmed with him that Point Lookout was to the northwest of Kempsey. After this the pilot offered to go to the west of the Coffs Harbour steps. The requirement to remain over Kempsey at FL160 was re-stated. 

Subsequently, at 1440 the pilot was cleared to track direct from Kempsey to Grafton and leave controlled airspace on descent to 9,500 ft, with a requirement to reach FL120 by 20 NM south of Coffs Harbour. The pilot then reported leaving FL160 on descent. At 1442 the pilot was transferred to the Coffs Harbour Tower frequency and was asked his distance from Coffs Harbour. The pilot responded that he was at 12,000 ft. No further monitoring of the flight was conducted.

The pilot reported that he conducted the remainder of the flight to Archerfield below 10,000 ft and in areas where high density light aircraft traffic could be expected. Visibility was also reduced due to smoke haze. He considered that he was forced to fly through the Casino - Ballina mandatory broadcast zone and then through the Archerfield training area. In his opinion this was less safe than flying in controlled airspace at a level without much traffic.

The pilot claimed that events which occurred during his earlier southbound flight had affected his actions during the northbound flight. On the flight to Port Macquarie, the pilot had been left with the impression that the Williamtown restricted area between Kempsey and Port Macquarie was active but uncontrolled. He did not appear to be given any descent clearances on that flight, he was simply reporting leaving levels on descent. He had not been instructed to call Williamtown at all. He later departed from Port Macquarie with the consideration that the same situation applied. That led him to believe that he could climb unrestricted within the restricted area, until north of Kempsey.

Recorded communications for the period covering the flight from Coffs Harbour to Port Macquarie indicated that the pilot reported over Coffs Harbour at 1041 ESuT, maintaining FL190 and estimating Port Macquarie at 1053. The pilot was then asked to report at 11 NM south of Coffs Harbour. At 1045 the pilot was issued with a clearance to leave controlled airspace on descent. This was acknowledged with his distance from Coffs Harbour. The acknowledgement was out of context with the clearance just issued. A minute later the pilot reported maintaining FL190 and he was again issued with the clearance to descend. This was then acknowledged correctly. At 1050 the controller asked if the aircraft had left FL190. The pilot subsequently reported having left FL190 at 1051.

Also, prior to departing Archerfield, the pilot had obtained the appropriate Notices to Airmen (NOTAMs), which would inform him of short notice or temporary changes to airspace and facilities enroute. These NOTAMs indicated that the Williamtown restricted areas were not active. The pilot was using the enroute chart which was to become valid on 5 December 1996, some days after these flights. The restricted area identification numbers around Williamtown were altered on these charts from those that were actually current.

ANALYSIS

Prior to his departure from Port Macquarie the pilot made no attempt to make some arrangement for a flight inside controlled airspace without a transponder. He did not update his planned departure time. Although he made an arrangement, with another pilot, to provide taxiing information at Port Macquarie, this was not understood by the flight service officer as a notification of a pending departure and, consequently, the officer did not co-ordinate with air traffic control. As a result, the controller was presented, at no notice, with an aircraft on which no information was held and which could not be monitored on radar. In addition, he soon learned that the aircraft was well inside controlled airspace.

After the pilot arranged a clearance which would allow the aircraft to leave controlled airspace, he then elected to fly below 10,000 ft through airspace likely to contain numerous aircraft. A number of alternatives for routes away from known traffic areas could have been used, as could a higher cruise level. Had advance arrangements been made, it was likely that a flight inside controlled airspace would have been possible

The pilot was using the incorrect enroute charts for the date. As a result, he was not able to correlate the NOTAMs with the restricted areas on the chart, and was not fully aware of the situation concerning the Williamtown restricted areas. His reported concept that the restricted areas were active but not controlled by military controllers should have led him to confirm the actual situation with air traffic services.

The controller for the flight to Port Macquarie had issued a descent clearance which was not initially understood by the pilot. Subsequently, the pilot reported leaving his cruising level, which was the only call required by the controller. This happened some two minutes before his arrival time at Port Macquarie. The controller had queried his level because a descent should normally have been initiated some time earlier.

SIGNIFICANT FACTORS

1. The pilot planned the flights using invalid charts.

2. There was a mechanical failure of the aircraft's radar transponder.

3. The pilot did not update his planned departure time prior to departure.

4. The pilot did not make prior alternative arrangements for flight without a transponder.

5. The pilot entered controlled airspace without a clearance. 6. The pilot did not select a route and altitude intended to avoid known areas of light aircraft traffic.

The aircraft was involved in spraying operations. The pilot reported that at the end of the third load for the day, while pulling out of the final spray run and banking to the right, the engine failed suddenly and completely. The pilot rolled the wings level and flew towards a farm track at an oblique angle. While slewing the aircraft around to the left to align it with the track, the left wing hit a wire fence. This slewed the aircraft further to the left where it ran into another fence and nosed forward hitting the propeller on the ground.

When the aircraft was inspected after the accident, there was only half a litre of fuel drained from the entire fuel system. The flight time since the last refuel was consistent with fuel exhaustion. After the accident, the engine was started and ran normally.

The crew reported that, following touchdown from a normal approach, they observed an unidentified object about a third of the way down the runway. As the aircraft approached the object it was identified as an emu which was close to the strip. The beta lights were confirmed, and maximum reverse and braking were applied. At the same time the aircraft was moved to the right of the strip and away from the emu. The emu followed the aircraft and was struck by the left propeller as the aircraft decelerated through about 50 kts. It was thrown into the side of the fuselage. The pilot-in-command secured the left propeller and engine and the landing and taxi in were completed on one engine.

The aerodrome had been inspected by a ground agent about 15 minutes prior to the aircraft's arrival and there was no sign of the emu. The strip is surrounded by an animal-proof fence however the three gates are not self-closing. It was reported that the passenger gate had been left open overnight. It is likely the emu entered the aerodrome during the night and remained hidden until it was disturbed by the aircraft.

SAFETY ACTION

The aerodrome owner advised they are fitting self-closing devices to all the gates.

The pilot reported that the upper half of the aircraft's cabin door separated in flight. The incident occurred when the top front latch came loose, at about 110 kts during the pullout from an aerobatic manoeuvre. The slipstream then pulled the window outwards, and it was torn off. As it departed the Perspex window and top door frame struck the lower surface of the right wing, tearing the fabric and fracturing 5 ribs.

The pilot was able to land the aircraft safely at Archerfield. He said that control of the aircraft was not greatly affected by the damaged wing.

The pilot reported that he selected the landing gear down on the downwind leg. He did not complete his pre-landing checks because he was distracted by his attempt to identify the wind direction from a damaged windsock. He did not realise the landing gear was still retracted until the aircraft had touched down on its lower fuselage. The landing gear warning horn did not activate until it was too late to do anything about it. The aircraft slid to a stop on the runway. A passenger later observed that he did not see the orange unsafe landing gear light at any stage.

Investigation found that the landing gear selector was in the down position, the circuit breaker was popped and the main gear uplocks had been released

During cruise flight at 5,500 ft, about 30 minutes after departure, the engine began to run roughly. The RPM dropped to about 1,700 with full throttle and the pilot was obliged to allow the aircraft to descend at about 400 feet per minute. The pilot was able to select a suitable section of a nearby road and carried out an uneventful landing. Initial investigation found oil leaking from one of the cylinders on the engine.

Later detailed examination found that a valve had failed in the no. 2 cylinder.

The aircraft was not fitted with an ELT.

The pilot reported that when he selected the landing gear up, after departure, he heard a loud clunking noise. The mechanical landing gear indicator showed that the nose gear was not retracted. He also noticed a reduction in airspeed, and a wind noise from the front of the aircraft.

The pilot advised Flight Service of the problem and continued to Bankstown where he extended the landing gear. However, inspection by engineers from the ground revealed that the nose gear was not fully extended. Airport emergency procedures were implemented. The aircraft was landed on the mainwheels, but the nose gear collapsed as it contacted the runway.

An inspection of the aircraft subsequently revealed that an eye-end fitting, at the actuator end of the nose landing gear push-pull rod, had failed. The operator later reported that post accident landing gear rigging checks were normal, and the landing gear had operated normally after installing a replacement eye-end fitting. The reason for the failure was not determined.