The pilot reported that he commenced take-off into the east with a three knot tailwind. The strip was approximately one mile long with a powerline at the eastern end which could be flown under if necessary. The aircraft was loaded with 600 lts of water and 80 lts of fuel. Halfway through the take-off the pilot decided to go under the powerline.

After lift off the pilot allowed the aircraft to climb slightly instead of keeping it low enough to pass under the powerline. He said that despite lowering the nose, the aircraft got too high to safely pass under the wire. The top wing of the aircraft hit the powerline resulting in the aircraft becoming uncontrollable. It stalled and hit the ground in a steep nose down attitude, banked to the left.

The pilot reported that while spraying a crop in a scrubby paddock, the engine lost power during a pull-up manoeuvre over a scrub line. There was no suitable landing area ahead, so the pilot turned left through 100 deg in an attempt to reach a suitable clear area. He dumped the load to clear a fence but the angle of approach into the clearing was encroaching on another fence line running in approximately the same direction as the intended landing direction. This required a shallow right turn which was still being completed at touchdown. This resulted in the right-wing spray boom catching in the crop which in turn resulted in a ground loop and left main landing gear collapse.

The maintenance engineer who recovered the aircraft, advised that the engine operated normally when test run. The aircraft is fitted with two fuel tanks, one in each wing. The tanks feed into a common sump and the fuel selector only has two positions - ON or OFF. One tank contained 28 lts of fuel and the other one was empty. The tank vent line for the tank containing fuel was found to be blocked by a wasp's nest. Normally the two tanks would feed evenly to the common sump, but the blocked vent line probably prevented this from occurring and in turn starved the engine of fuel.

The pilot was trying to muster a herd of about 12 head of cattle away from a bore to yards a couple of miles away. The cattle persisted in trying to return to the bore for water. The pilot hoped to overcome the cattle's reluctance to move by flaring the helicopter low and close to the herd. He flared down to about 5 ft and 5 kts across the herd's direction of movement and about 5 metres from the lead animal. During the flare, one bullock darted from the herd towards the right rear of the helicopter. The pilot felt a slight thump through the airframe.

He immediately increased power to move on, but the helicopter yawed right rapidly. By the time the pilot managed to close the throttle, the helicopter had turned through 360 degrees. Once the throttle was closed the rate of yaw diminished and the helicopter rapidly settled to the ground; it contacted first with the right skid which broke. Then, as the helicopter rolled onto its right side, the main rotors were destroyed by ground impact.

When the bullock darted towards the rear of the helicopter, it impacted the spinning tail rotor with its back and broke off both of the tail rotor blades.

FACTUAL INFORMATION

History of the flight

An Airbus A320 was inbound to Melbourne aerodrome and the crew had been cleared to track via an ARBEY four standard arrival route (STAR) on descent to 4,000 ft. The A320 was the third aircraft to track via the ARBEY four STAR in the arrival sequence for runway 27, under the control of the approach controller.

The ARBEY four STAR was being used to facilitate the arrival of aircraft primarily from the west and north of Melbourne to runway 27. Flight crews cleared via the STAR were required to initially track in a southerly direction to the Fentons Hill very high frequency omni-directional radio range (VOR) navigation aid and then turn left to track 106 degrees to a position on right base for runway 27 at 9 NM from the aerodrome. From this position, aircraft were to turn right to intercept final for runway 27.

For sequencing with other aircraft, the approach controller had cancelled the tracking via the ARBEY four STAR for two previous aircraft, and he intended to do the same for the A320. He planned to issue a heading to the crew of the A320 which would continue the aircraft in an easterly direction. The approach controller had limited the descent of the A320 to 4,000 ft to ensure that the aircraft remained in controlled airspace when it was on the easterly heading. His intention was to maintain the A320 north of the extended centreline of runway 27, for separation and sequencing, and to eventually radar vector the aircraft onto final.

The approach controller did not instruct the crew of the A320 to cancel the STAR or to adopt an easterly radar heading, and the crew continued tracking via the STAR. The approach controller was under the impression that the crew was maintaining an easterly radar heading. The A320 was heading 106 degrees in accordance with the STAR procedure and was slowly converging on the extended centreline of runway 27 from the north.

As the A320 approached the point at which the aircraft would be turned onto final, the crew reported to the approach controller that they were maintaining 4,000 ft. The approach controller acknowledged the report.

A Saab SF-340, inbound from the southeast, was being radar vectored by the approach controller via a left base for runway 27. The approach controller was using radar to separate a number of aircraft inbound from the east and an aircraft north of Moorabbin (located southeast of Melbourne aerodrome) inbound to that aerodrome. The approach controller vectored the SF-340 through the runway 27 centreline for sequencing with the aircraft ahead on final and instructed the crew to descend to 2,000 ft.

The approach controller meant to instruct the crew of the SF-340 to turn left to intercept final for runway 27, but he actually said turn right. As he corrected the direction of the turn to the crew of the SF-340, he observed that the A320 was turning right onto final and was going to conflict with the SF-340. The approach controller instructed the crew of the A320 to cancel the STAR and to turn left heading 120 degrees. He advised the crew of the A320 of the location of the SF-340 and asked them to report sighting that aircraft. The crew of the A320 reported that they had the SF-340 in sight. The horizontal separation between the two aircraft was 1.5 NM and the SF-340 had descended through the level of the A320. The required separation was 3 NM horizontally or 1,000 ft vertically. There was a breakdown of separation.

The approach controller

The approach controller was a team leader and was undergoing a performance check on the position. The controller operated the position, unobserved by the check controller, for approximatetly 45 minutes while the latter completed some administration. The approach controller was not using flight progress strips for arriving aircraft, although he did have access to the flow controller's strips which indicated the arrival sequence. The use of flight progress strips was not mandatory at the position. During the period at the position the number of aircraft under his control had gradually increased. Analysis of the flow controller's flight progress strips and the radar recording indicated a busy and moderately complex traffic sequence during this period. The check controller returned to the position just prior to the occurrence.

The performance of team leaders was checked in the same manner as other controllers with the exception that the performance and check report was not scored. The check controller was only required to assess the team leader's performance as a pass or fail, and to comment on any shortcomings. The comments provide a history of team leaders' strengths and weaknesses. Other controllers received a score in addition to the comments on their performance and check reports. This provided a history of their performance in addition to the comments on any other aspects of their control. The approach controller maintained his air traffic control skills through regularly exercising his seven ratings. As a team leader this had proven to be difficult to manage at times due to his other administrative and management commitments. Training of other controllers for ratings and consolidation of rated controllers in the various positions reduced the opportunities for him to practice his skills as much as he would have wanted. The approach controller felt that in recent years he had slowed down in his performance of control tasks because of the reduced time at the various radar positions.

ANALYSIS

The approach controller felt that his proficiency at the position had reduced to a level less than he preferred as a result of the limited opportunities to practise his skills. This was mainly due to the team leader duties requiring the majority of his time and an inability to obtain access to radar positions because of the training/consolidation commitments for other controllers. It is possible that a higher level of proficiency would have enabled him to better manage the workload. The degree to which this aspect contributed to the incident could not be ascertained.

Distraction as a result of the problems with traffic in the Moorabbin area and the minor difference between the STAR track and the intended radar heading, probably caused the approach controller to not detect that the A320 was still tracking via the STAR. Once he had accepted this situation, there was nothing to alert or remind him that this was not the case, until the A320 turned right onto final approach for runway 27. The lack of any means to readily display the intended track of an aircraft would appear to indicate that controllers must use their working memory to retain such details. However, the limited capacity of working memory and its limited tolerance to interruptions means that information is often forgotten. Facilities, equipment or procedures that may assist controllers to remember essential details would be beneficial. 

The workload due to the level and complexity of the traffic sequence allowed little time for the approach controller to review his actions. The cancellation of the STAR for the two previous aircraft may have led him to believe that he had also cancelled the STAR for the A320.

The "Maintaining 4,000 ft" report by the crew of the A320 probably alerted the approach controller to the location of the A320. However, he was unaware of the potential conflict until the A320 turned onto final.

SIGNIFICANT FACTORS

1. The approach controller's proficiency was not at an optimum level.

2. The approach controller was unable to adequately review his actions because of the workload associated with the busy traffic sequence.

3. The approach controller did not cancel the STAR with the crew of the A320.

4. There was no segregation between aircraft on the STAR and aircraft on final for RWY 27.

5. The approach controller did not notice that the A320 was continuing to track via the STAR until the aircraft turned base.

SAFETY ACTION

Local safety action

Airservices Australia has amended the STAR to provide horizontal separation between the downwind portion of the procedure and the extended centreline of runway 27.

Bureau of Air Safety Investigation safety action 

The Bureau of Air Safety Investigation is reviewing issues associated with team leaders' maintenance of proficiency and their performance assessment. Any recommendations arising from this investigation will be published in the Quarterly Safety Deficiency Report.

Prior to departure from Ceduna, the pilot refuelled both fuel tanks. This should equate to about two hours endurance per tank. Approximately 55 minutes after departure, while cruising at 7,000 ft, the engine suddenly lost power. The pilot established the best glide speed and performed trouble checks. Engine instruments were all in the green range. The fuller fuel tank was selected and the electric fuel pump switched on but except for an occasional surge, the engine would still not produce power.

The pilot informed Adelaide Flight Service of his situation and then concentrated on a forced landing approach to a wheat paddock, where the aircraft was landed without damage. After landing, the pilot ran the engine, but it would still not produce significant power. Initial engineering investigation indicated a faulty fuel injection system.

Three aircraft were being processed by Brisbane Sector 3B for arrival at Maroochydore. VH-CZB was tracking via position TRIKI (21 NM, 128 degrees from Maroochydore) and was on descent to 6,000 ft. VH-PIE was level at 5,000 ft and also tracking via TRIKI. Another aircraft was on the Brisbane-Maroochydore direct track at 4,500 ft. Seven other aircraft were under the control of Sector 3B at the time. Because of the workload in the sector, PIE had been maintained on Brisbane Approach frequency, although the Sector 3B controller had a flight strip for the aircraft at his control position.

When CZB reported approaching 6,000 ft, it was cleared for further descent to 5,500 ft. This provided vertical separation with the aircraft on the Brisbane- Maroochydore track but not with PIE. About 20 seconds after clearing CZB to 5,500 ft, the controller realised that it would conflict with PIE. He instructed CZB to maintain 6,000 ft but the aircraft was already at 5,500 ft. At the time, CZB was 3.4 NM ahead of PIE. The separation standard required was 5 NM or 1,000 ft.

At the time of the incident, there were 10 aircraft on the control frequency. In this high workload situation, the controller had initially forgotten about PIE. Because PIE was on another radio frequency, the option of descending that aircraft to a lower level when he became aware of the confliction was not available.

FACTUAL INFORMATION

Two aircraft were taxiing at Darwin for departure from runway 11. The crew of VH-EFB, a C210, had received an airways clearance to track via the 184 radial of the Darwin Very High Frequency Omni-directional Beacon (VOR) on climb to 8,500 ft. The crew of VH-HYK, an A320, were cleared via the 163 radial of the Darwin VOR.

The weather was quoted as being 2 oktas at 2,500 ft with visibility in excess of 10 km. Tower controllers considered that the cloud had built up to 3 - 4 oktas at the time of the occurrence and most of that was in the southern sector, where the aircraft were due to transit.

The tower controller obtained departure clearances from the approach radar controller that would allow him to visually separate the aircraft in their respective right turns from the runway heading to their cleared tracks. Radar separation was not expected to occur during this initial stage of flight.

EFB departed and the crew turned the aircraft in accordance with their instructions to intercept the 184 VOR radial, and changed frequency to contact approach radar. The crew of the A320 then became airborne and were instructed to change frequency to approach radar, which they did. As the A320 approached the 163 VOR radial, it disappeared from the view of the tower controller behind, or into, cloud. At this point visual separation could no longer be provided and the approach radar controller could not guarantee radar separation until both aircraft were established on their departure tracks.

The A320 passed marginally through its assigned track before the crew made a corrective adjustment. This track correction occurred at the same time that the tower controller lost sight of the A320 and at a position approximately 5NM south-east of the aerodrome.

The approach radar controller, realising that he could not expect to obtain radar separation for a further minute or two, maintained EFB at 3,000 ft and co-ordinated with the tower controller to confirm that he was still providing visual separation. When the reply was negative, the radar controller was unable to apply corrective action before a breakdown in separation occurred. The aircraft came within 2 NM horizontally and 600 ft vertically of each other. The appropriate standard is either 3 NM by radar or 1,000 ft vertically.

ANALYSIS

The tower controller was inexperienced in the position having only six months service since obtaining his tower rating. The tower and radar controllers had agreed to a course of action that required the tower controller to provide visual separation until a radar standard could be achieved. Because of the relatively close proximity of the departure tracks, this was not expected to occur until the aircraft were approximately 8 - 10 NM from the aerodrome. As the cloud cover was predominantly in this sector, some doubt should have existed as to the ability of the tower controller to guarantee continuous visual contact with both aircraft until a radar separation standard existed.

The fact that the A320 went marginally through the assigned radial did exacerbate the situation. However, this type of minor adjustment is common with the larger aircraft when given turns of this nature and should be considered in any decision regarding separation.

The tower controller was unsure of his responsibilities with regard to providing visual separation and found that the guidance given in the Australian Manual of Air Traffic Services was insufficient. After asking the opinion of several other tower controllers, the investigation team found a general lack of understanding of the application of visual separation principles.

SIGNIFICANT FACTORS

1. The tower controller did not provide visual separation for the entire period prior to radar separation being achieved.

2. The tower controller was unsure of his full responsibilities in regard to providing visual separation.

SAFETY ACTION

The Bureau of Air Safety Investigation is evaluating aspects of visual separation responsibility and how the subject is addressed in the Manual of Air Traffic Services. Any forthcoming recommendations will be published in the Quarterly Safety Deficiency report.

The pilot departed Essendon and flew to the Bacchus Marsh area to check out his aircraft after extensive maintenance had been carried out. On return to Essendon, he flew a normal full flap approach for a landing on runway 35. At the time the wind was 350 degrees at 10 kts. The pilot inadvertently landed heavily, nosewheel first, and the aircraft bounced. On the next touchdown the nosewheel tyre blew out and the nosewheel forks broke off. The propeller struck the runway surface as the aircraft skidded to rest on the runway. No evidence was found of a previous fault with the aircraft which may have contributed to the accident.

The pilot reported that he had descended with the intention of moving a mob of cattle when some ran under the helicopter. He turned to follow the cattle but then realised that he was travelling downwind. Power to maintain height was not adequate and the main rotor was overpitched. As a result, the helicopter struck the ground hard with a ground speed of about 20 kts. The pilot assessed the wind as south-easterly at 15 to 20 kt.

Prior to recovery of the helicopter, the owner checked the engine and was satisfied that it was capable of normal operation.

The fixed emergency locator transmitter was activated but was not used or required for the rescue. The occupants walked to a nearby hill and used a citizen band radio to contact a truck which took them to a local mine.

The two aircraft met their respective requirements and there was no breakdown in separation. The exact nature of the pilot's query was not able to be determined.