A Boeing 747 was being radar vectored for Melbourne runway 34 when radar controllers noticed an unidentified aircraft at 2,400 ft in controlled airspace (CTA) where it should not have been above 1,500 ft outside controlled airspace. The departures south controller immediately instructed the Boeing 747 pilot to turn right 60 degrees due to conflicting traffic. Melbourne radar advisory service (RAS) gave a general broadcast to any aircraft heading up the western lane to descend immediately to 1,500 ft, but there was no response. Both aircraft passed within approximately 1 mile and 700 ft.

With advice from Essendon Tower, RAS identified the offending aircraft near Brooklyn as VH-LOR and instructed the pilot to descend to 1,500 ft. About 5 minutes later, 2 miles west of Mount Cottrell, LOR climbed above 2,500 ft into CTA without a clearance and was again corrected by RAS.

A student pilot was flying LOR on his second solo navigational exercise. He subsequently advised that he must have made errors in navigation because each time he inadvertently penetrated CTA he thought he was much further west where the base of the CTA was higher.

The student pilot was required to undergo more dual instruction before the next solo navigational flight.

The pilot reported that he had been concerned about the performance of the aircraft's brakes and, following the first flight for the day, he had checked the pads for wear. They appeared to be serviceable with as much as 10 mm of pad material remaining. During the landing roll following the second flight, the aircraft yawed to the left. Corrective action using rudder and brake had no affect and aircraft continued to yaw to the left until it departed the 15 m-wide flight strip and collided with a fence and tree.

A technical investigation disclosed that the brake system was fitted with spacing washers designed to prevent the brake pads being worn down to their backing plates. This prevented damage to the brake discs. The spacing washers were set so that around 10 mm of the pads remained when the brakes reached their maximum wear limit. The operator and pilot were not aware of this limitation and assumed from the amount of pad material remaining that the brakes were still serviceable. When the pilot applied the brakes to prevent the aircraft yaw, movement was restricted by the spacing washers, and he was unable to obtain effective braking.

A Boeing 737, enroute to Brisbane and an A300 enroute to Sydney, both departed from RWY 27 at Tullamarine via a DOSEL 4 standard instrument departure (SID) with a requirement to maintain 5,000 ft.  This was to accommodate an AC50 which had departed Essendon on track to Horsham via overhead Melbourne.  After vertical separation was achieved between the AC50 and the two jets, the pilot of the AC50 was instructed to turn onto a heading of 280 degrees and the crew of the Boeing 737 instructed to initially climb to 6,000 ft and then 7,000 ft as the levels became available.  When these two aircraft were laterally clear of one another, the Boeing 737 was cleared to climb to FL200. The A300 was maintained at 6,000 ft.

Shortly after, the controller’s attention was drawn to a potential conflict between the Boeing 737 and an inbound SA227 from Mildura.  The trainee turned his attention to an inbound A320 tracking via a 27 ARBEY STAR assigned 6,000 ft.  This aircraft was now in conflict with the A300 which was maintaining 6,000 ft and was turning right in compliance with the DOSEL 4 SID.   The training officer recognised the conflict and told the trainee to instruct the crew of the A300 to climb.  For reasons unknown, the trainee did not instruct the A300 to climb - nor did the training officer choose to use the 'B' System handset, which would have enabled him to override the trainee's communications and climb the A300.

The trainee then instructed the A300 to turn left onto 340 degrees.  Both the trainee and the training officer agreed that the aircraft seemed to be slow in commencing the turn.  Because of this, the crew was further instructed to turn immediately onto a heading of 310 degrees and the crew of the A320 to turn left immediately heading 090 degrees. The pilot of the A320 reported sighting the A300 and the two aircraft passed within 2 NM at the same level.  There was a breakdown of separation.

ANALYSIS

The 27 DOSEL 4 SID does not provide separation assurance with the 27 ARBEY STAR once the departing aircraft climbs above 5,000 ft.  In such instances, controllers are required to ensure that the vertical separation is maintained until lateral separation is established.

Neither the trainee nor the training officer applied separation assurance techniques.  The controllers relied upon the performance of the A300 to climb above incoming aircraft.  However, because of the AC50 from Essendon, which was tracking overhead Melbourne, the A300 was held at 6,000 ft, resulting in a lower altitude than normal at the position at which the DOSEL 4 SID requires a turn.   In resolving the conflict between the AC50 and the A300, the controllers failed to recognise in time the conflict between the A300 and the A320.

SIGNIFICANT FACTORS

1. The training officer was inexperienced in the approach departures training role.
2. The training officer chose not to use an override system for radio transmissions.
3. The training officer failed to adequately monitor the trainee and to correct the situation as it developed.
4. Neither controller applied adequate separation assurance techniques.

The pilot elected to go around from final approach for runway 23 when he noticed that the windsock had swung to favour runway 35. He reported that the approach for runway 35 was normal and estimated the wind speed and direction at about 10-15kts from 300 degrees. Soon after the main wheels had contacted the runway the aircraft became airborne again, both throttles were closed at this point. The aircraft dropped back onto the runway and bounced hard. The nosewheel then contacted the runway heavily and the windscreen popped out. The aircraft was taxied clear of the runway and all three persons exited the aircraft without injury.

Post flight examination found there was significant damage to the nosewheel assembly, the windscreen had separated, and the right propeller had contacted the runway.

The pilot advised that he had subsequently obtained a wind trace from the Amberley met office which indicated that winds were gusting from 290 degrees between 5-18 kts, at the time of the accident.

The pilot reported that he had flown a normal circuit and approach to land on runway 30. He did not monitor the airspeed adequately on the approach, with the result that the aircraft began to stall at about 10 feet above the runway. Power was applied to correct the descent, however the aircraft "ballooned" and then landed heavily. When the pilot taxied the aircraft off the runway, he thought the nose wheel tyre was deflated.

Post flight examination found that the tie down ring on the underside of the rear fuselage had broken off. The nose landing gear assembly was badly damaged, with sheared rivets at the top of the leg casting, and the engine firewall was buckled. The right side of the nose wheel fork had spread and was abraded by contact with the runway surface.

In describing the event the pilot insisted that it be called an act of "gross stupidity".

Sequence of events

The aircraft entered the circuit on a left downwind leg for runway 18 from the south. The pilot was aware of another aircraft approaching from the north. The pilot said that the downwind checks were delayed because the speed of the aircraft was too high to lower the landing gear. He became somewhat distracted looking for the other aircraft entering the circuit. The pilot felt sure that he had lowered the landing gear. He said that neither he nor his passenger heard the landing gear warning horn before the propellers struck the bitumen runway surface.

A post-flight inspection of the landing gear did not find any fault in its operation.

Analysis

The pilot probably forgot to lower the landing gear when he became distracted.

Following a short flight in the local area, the pilot joined the circuit for a landing. He noticed that the strip was occupied by 2 large bulls, but he continued with the approach and overflew the animals to chase them off the strip. In this he was successful. He completed another circuit and landed the aircraft with the landing gear retracted.

The pilot later said that he thought he had selected gear down and had seen 3 greens but later conceded that he may have omitted to lower the landing gear.

Post-flight examination confirmed that the landing gear was fully retracted on landing and its operation could not faulted.

When the aircraft arrived in Brisbane, ground engineers noticed that the left number 11 leading edge flap was missing, and that there was slight damage to the number two engine core cowl. No evidence was found to indicate the primary failure point. A new flap was fitted, and the aircraft was dispatched the next day.

The aircraft was engaged in aerial seeding and was being operated from a grass strip. The pilot reported the take-off direction was towards the north-west, to take advantage of a 12-15 kt wind blowing from slightly left of the take-off direction. The aircraft became airborne with about 100 m of the strip remaining but failed to accelerate and climb out of ground effect. Turbulence was encountered about 100 m beyond the end of the strip, which yawed the aircraft to the right, through about 60 degrees.

The pilot selected the hopper dump lever to the fully open position, in order to jettison the load, and attempted to manoeuvre the aircraft to avoid a line of trees. When it became apparent, he would not be able to fly over the trees, he tracked towards the clearest area within the tree line. At a height of about ten feet the wings collided with small trees. The aircraft continued for a short distance before striking the ground and sliding to a halt. The pilot escaped without injury. He was subsequently told, by a person who had been located nearby, there had been a major wind gust/shift in the area at the time of the accident.

After carrying out a damage inspection of the aircraft, the pilot reported that about 90% of the load had remained in the hopper during the accident sequence. Whilst he described the load of seed and superphosphate as dry and free flowing, he considered that the design of the hopper base was not satisfactory, as the gate-like opening inhibited the free flow of solids. Had he been able to jettison a greater portion of the hopper load in the time available, he believed the resulting improved climb performance of the aircraft would have allowed him to avoid the trees.

The hopper base was described as a gate box type, principally designed for use with liquids. The pilot indicated that operators may use this style of hopper base for both liquid and solid applications during those times when the aircraft may be required to frequently change from one medium to the other.