The pilot reported that the wind direction was varying between 180 and 270 degrees, up to 15 knots. He made an approach for runway 18, maintaining about 60 knots on final and with full flap set. As the throttle was closed for the landing flare the aircraft sank. The pilot applied full power to arrest the sink but said the aircraft did not seem to climb normally.

The aircraft then drifted to the left side of the runway. The pilot said he decided to end the sequence by closing the throttle and landing. The aircraft touched down heavily breaking the nose gear off.

Significant Factors

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

1 The pilot probably mishandled the controls during the initial landing flare.

2 The pilot probably did not apply the appropriate procedures and control inputs during the attempted go around.

During a long final approach to the strip, the engine began to run rough. When the engine power dropped to idle the pilot elected to carry out a forced landing in a paddock. During the landing roll the aircraft ran through a fence and a ditch.

Examination of the engine by an engineering workshop did not find any defects.

The pilot reported that all indications were normal during the pre-landing checks. After landing, the brakes were applied but there was no pressure in the left brake. The pilot then initiated a ground loop to the right as speed and distance remaining were inadequate for a go-around.

During the ground loop as the aircraft was sliding sideways across the grass, the left main wheel entered a depression. The sudden stop caused damage to the left wing and main wheel, as well as the nose gear and propeller. All occupants exited the aircraft safely.

ZK-NBI was inbound to the Plenty locator from Wonthaggi on descent to 5,000 ft. VH-UWW departed Essendon runway 17 with departure instructions to turn left heading 090 deg with an unrestricted climb to 5,500 ft. These instructions were issued by the approach controller who was also controlling ZK-NBI.

Approximately four minutes after VH-UWW departed Essendon, the controller realised that the two aircraft were on conflicting tracks with no vertical separation. Both aircraft were given heading changes, but their tracks closed to approximately two miles at the same altitude before radar separation was re-established.

Investigation revealed that the approach controller failed to ensure maintenance of separation between the two aircraft because he was distracted by separation requirements for other traffic. He had intended to turn VH-UWW to the northeast earlier to maintain separation, but due to the distraction this did not occur.

Two other factors contributed to the failure. The first one was that when the approach controller issued the departure instructions for VH-UWW, ZK-NBI was not displayed on his radar screen. The second was that ZK-NBI maintained an unusually high speed on descent. Even though the aircraft had been issued with no speed restriction below 10000 ft, an unusually high groundspeed was maintained.

It was reported that the pilot made a normal, full flap landing at 70 kt. The aircraft bounced back into the air and touched down three more times before coming to a stop. The propeller struck the ground during the third touchdown. A post-landing inspection disclosed that the engine firewall was bent at the nosewheel leg attachment point. The sequence of events and the damage indicates that the pilot misjudged the landing flare and allowed the aircraft to touchdown, nosewheel first, on at least one occasion.

The student was undergoing a flight check with the Chief Flying Instructor (CFI) and was asked to demonstrate a short field approach and landing onto the grass runway. A speed of 65 kts was maintained until the aircraft approached the runway threshold, at which point the stall warning horn sounded intermittently. The student reported that she closed the throttle at about this time and the aircraft landed heavily. The main landing gear oleo struts were heard to "bottom". A further circuit and landing was carried out without incident.

The CFI carried out a post-flight inspection of the aircraft but did not observe any damage. A subsequent inspection by an engineer revealed that the left forward wing attachment fitting had failed, and the left wing main spar was twisted.

A breakdown in separation occurred between two VFR aircraft, a twin Comanche cleared Station Pier for Essendon at 1,500 ft and a helicopter cleared World Trade Centre for Essendon on climb to not above 1,500 ft. Essendon Tower passed traffic to each aircraft, but the helicopter pilot claimed not to have heard advice on the Comanche.

The Comanche pilot never saw the helicopter whereas the helicopter pilot saw the Comanche pass about 200 ft overhead.

Significant Factors

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

1. Both aircraft were cleared at the same altitude.

2. The two pilots did not take adequate action to ensure separation was maintained.

3. Air traffic control did not provide sufficient information to the two pilots to assist them to sight each other's aircraft.

The pilot was undergoing an instructional flight as part of his training for a commercial pilot licence. When overhead Murray Bridge airfield the instructor simulated an engine power failure for the pilot to practice a forced landing.

Their attention was distracted by an ultralight aircraft operating in the circuit area, and as a result they forget to carry out the final landing checks and landed the aircraft with the landing gear still in the retracted position.

The out-going controller stated that the runway configuration made the management of traffic complex, a situation which required a high level of concentration. She had spent approximately one and half hours on duty and felt ready for a break. Consequently, once the new controller commenced in the approach east position, she relaxed. However, she remained at the console monitoring the audio program for approximately another 10 to 15 minutes but did not maintain a full appreciation of the new traffic sequence. She provided only limited coordination assistance to the new controller.

When the Navajo was north-east of Perth, the approach east controller radar vectored the aircraft to separate it from the Baron and to position it for right base runway 03. This was in compliance with a local instruction that required inbound aircraft which would overfly the departure end of a nominated runway to be maintained above 4,000 ft or radar separated from departing traffic. After radar separation was established with the departing Baron, the pilot of the Navajo was instructed to descend to 2,500 ft. When the Navajo was approximately 20 NM east of Perth, the approach east controller elected to track the aircraft for runway 11. The Navajo was radar vectored on a heading of 270 degrees for a left circuit to that runway.

Shortly after, the approach east controller observed the secondary surveillance radar altitude readouts from both aircraft and determined they would pass without adequate vertical or horizontal separation. The pilot of the Navajo was instructed to maintain 3,000 ft, which provided 500 ft vertical separation from the Baron. This was less than the required vertical separation of 1,000 ft. The approach east controller also instructed the pilot of the Baron to turn right onto a south-easterly heading for separation. As the controller further determined that both the horizontal and vertical separation standards were not going to be maintained, he passed traffic information to the pilot of the Baron. The pilot of the Baron subsequently sighted the Navajo and monitored the flightpath of the other aircraft until it was well clear.

The two aircraft passed with less than 3 NM horizontal separation and less than 1,000 ft vertical separation. There was a breakdown in separation.

ANALYSIS

The Navajo was the second of three aircraft being sequenced for runway 03. The controller determined the Navajo might eventually conflict with following traffic and considered changing the aircraft to runway 11. However, a pending Airbus departure to the east from runway 03 would possibly have conflicted with the Navajo as it tracked downwind and thus it remained sequenced for runway 03.

When the Airbus from runway 03 was airborne, the controller reconsidered the earlier option of changing the Navajo to runway 11. Two larger and faster aircraft, following for runway 03, were closing and would require vectoring to maintain separation and spacing for landing. The controller decided to change the Navajo to runway 11. At this stage the Baron and Navajo were radar separated and assigned the same level. However, when the approach east controller turned the Navajo downwind for runway 11, he placed both aircraft on closing reciprocal radar headings without re-establishing vertical separation in accordance with local instructions.

The turn given to the pilot of the Baron was an attempt to maintain 3 NM separation. The controller was also aware that 500 ft was insufficient separation for IFR category aircraft but believed that under the circumstances it was better than having the aircraft at the same altitude. The provision of traffic information was appropriate and enabled the application of visual separation by the crew of one of the aircraft.

The out-going controller could have contributed more to assist the new controller in the period immediately following the handover/takeover. While the new controller would have appreciated the immediate disposition of aircraft on the radar display it takes some time to appreciate the plan for a developing sequence of air traffic. The basis of the handover/takeover and monitoring process is to ensure the out-going controller maintains the full disposition of aircraft and understands what actions are needed to manage and separate, immediate and pending aircraft until the new controller fully appreciates the disposition and sequencing plan of the control position. While the initial reaction of a controller to relax after handing over is understood, for an effective handover/takeover, all controllers at a control position should maintain a state of awareness commensurate with active controlling until the new controller indicates a complete comprehension of the traffic situation.  Perth Approach Control Centre does not have specific handover/takeover instructions for controller guidance.

During the investigation, aspects of the restructure of Perth airspace scheduled for implementation by December 1996 were provided. The restructure will provide track crossover points outside 30 NM and separation assurance procedures. While these measures will not necessarily alleviate similar occurrences, they should provide an airspace environment better able to cope with similar situations.

SIGNIFICANT FACTORS

1. The aircraft were required to pass on approximately reciprocal tracks due to the runway configuration.
2. The approach east controller did not use separation assurance techniques when there was a possibility the aircraft would conflict.
3. The out-going air traffic controller did not fully monitor the new traffic sequence and only provided limited assistance to the new air traffic controller.

SAFETY ACTION

The Bureau of Air Safety Investigation is evaluating controller handover/takeover procedures. Any forthcoming recommendation will be published in the Quarterly Safety Deficiency Report.

The pilot reported that the helicopter was being used to muster cattle. While manoeuvering at about 30 ft AGL and a speed of 10 knots the pilot said he heard a loud bang. He was able to conducted an immediate autorotative landing.

Post flight inspection found that the main rotor drive shaft flex plate had separated at the gearbox end. The flailing end had then cut into the fuel tank, as well as causing other damage in the area.

Specialist examination concluded that the flexplate failure was caused by fatigue crack growth. The fatigue crack initiated at a region of intergranular corrosion at the edge of the plate. The pilot reported that the failure occurred some 40.8 hours after the previous 100 hourly inspection. Because of the type of flexplate in use, a dye penetrant inspection had been conducted on the flexplate during that previous inspection. This was required by an Airworthiness Directive, which subjected all such flexplates to a special inspection every 100 hours until they were replaced by a new version of flexplate. A similar directive issued by the United States FAA required an inspection every 50 hours.