FACTUAL INFORMATION

An international B747 flight was proceeding at flight level (FL) 350 from Melbourne to Singapore via Curtin and air route A576, exiting the Australian Flight Information Region (FIR) at ATMAP. Prior to reaching Curtin, the crew were advised by Brisbane air traffic control (ATC) that, due to another aircraft on the same route and level three minutes ahead, FL 350 would not be available. The pilot in command was absent from the flight deck on an authorised rest break leaving the first and second officers controlling the aircraft.  The crew's intention was to eventually cruise at FL 390 but the operational performance of the aircraft at this stage of the flight precluded such climb. Several alternatives were discussed with ATC and eventually an option to climb to a non-standard level (FL 370) was accepted, with an understanding that the aircraft would have to climb to FL 390 by the FIR boundary.  At this point ATC issued a climb instruction to FL 370 only, thus ensuring separation with the preceding B747. The aircraft climbed to, and maintained, FL 370 prior to Curtin.

Approaching Curtin, the crew rotated positions as the pilot in command returned from a rest period and the first officer vacated the flight deck. The second officer remained on the flight deck and continued to operate the radios while the pilot in command assumed the duties of the flying pilot. The crew carried out an information brief at the changeover but could not remember the exact details regarding the level change proposals.

Shortly after the crew had reported the Curtin position with an estimate for ATMAP, the Brisbane sector controller notified the position report and estimate to the Perth flight service operator on international HF radio and coordinated a change of level to FL 390 with Bali Control. The controller then issued a clearance to the crew, advising: "When ready climb to FL 390, requirement reach FL 390 by ATMAP". The second officer correctly read back the level and requirement.

On transfer from Brisbane Control to the Perth HF operator, the crew reiterated the requirement to be at FL 390 by ATMAP. However, the aircraft maintained the current level of FL 370 and subsequently entered the Indonesian FIR at the wrong level. The crew reported maintaining FL 370 at ATMAP to Bali HF and again on first contact with Bali Control on VHF (approximately 15 minutes later).  It was at this point, when the aircraft was identified on radar, that the level was first queried by ATC.  The Bali controller then requested confirmation of the original coordination message from the Australian controller, who confirmed that the aircraft had been required to reach FL 390 by ATMAP.

ANALYSIS

The crew remarked that there was nothing exceptional with respect to the conduct of the flight apart from some problems experienced maintaining situational awareness.  The crew thought the traffic with which they were conflicting at FL 350 was a British Airways aircraft when in fact it was Thai International.  The British Airways aircraft was on a parallel route which would eventually converge with A576 but, at this stage, was well clear of the incident aircraft. The Thai aircraft had reported at Curtin three minutes earlier than the Qantas B747, but this report was not remembered by the crew.  This aspect was not considered to be a significant factor in the incident. 

However, during the investigation it became evident that a lack of situational awareness could ultimately affect pilot actions and that in the future, the introduction of new technology such as automatic dependent surveillance (ADS) might further reduce the ability of aircrew to develop and maintain an air picture. Should separation break down under such circumstances, one of the secondary methods of minimising the likelihood of a collision or near miss would be removed.

The second officer believed he noted the level requirement in the aircraft deck log, but he did not remember referring to the log to confirm the requirement. As a result of his understanding of ATC requirements given at the crew information brief following his return to the flight deck, the pilot in command believed the requirement was to reach FL 390 by ILDAM (a position reporting point in Indonesian airspace) and was thus unconcerned that the aircraft was maintaining FL 370 on entering the adjacent FIR. However, he was the flying pilot at the time that the ATC clearance requiring climb to FL 390 by ATMAP was issued.

The pilot in command and the second officer agreed that the clearance had been correctly issued and read back. They could offer no explanation for their failure to comply with the conditions of the clearance.

Currently, there is no specific company procedure, other than good crew resource management practices, for flight crews to record and action amended clearances or those containing a future requirement. However, the crew members believe there are a number of means available to aircrew to record clearances. Generally, these are used at the discretion of the individuals concerned.

Indonesia had issued NOTAM A 0008/96 on 3 January 1996 which required crews to report their boundary position for the Bali FIR to Control on VHF radio.  However, this NOTAM had not been received in Australia by the date of the occurrence.  Therefore, the crew (and Perth HF) had no reason to change previous standing instructions to contact Bali on HF at the boundary.  This factor had the potential to remove a safety net in that the Bali controller had a delay in receiving the ATMAP position report which required relaying through the Bali HF operator. The investigation was unable to determine why the NOTAM was not received in Australia.

SIGNIFICANT FACTORS

1. Crew resource management proved to be ineffective in that the crew did not climb the aircraft to FL 390 by ATMAP.
2. The lack of a standard operating procedure to record and act on clearances did not provide a means of alerting the crew when a future action was required.

SAFETY ACTION

As a result of the investigation the company has:

1. Implemented a flight standing order (FSO) which will:

• initiate the use of the flight management computer as a reminder tool for clearances;
• highlight the requirement for flight crew personnel to ensure conditional clearances are brought to the attention of other crew members; and
• instruct crew members to notate all enroute clearances.

2. Initiated an educational program, via the check-and-training system, highlighting aspects outlined in the FSO.

3. Proposed the publishing of a safety magazine article detailing the crew's perspective of the incident.

As an additional result of the investigation, the safety deficiencies in regard to crew situational awareness and the potential problems of introducing Automatic Dependent Surveillance have been referred to the Bureau's Safety Deficiency Section for further analysis. Any resulting safety output made by the Bureau will be published in the Quarterly Safety Deficiency Report.

The pilot, accompanied by a passenger, was departing from an airstrip which had a dry short grass surface, aligned in an east west direction, and located on the top of a lightly timbered hill. The weather was reported as being fine, with a gusty 10 - 15kt wind blowing from the south-west.

The pilot stated that he had ascertained the crosswind component was within the limits for the aircraft before commencing a take-off towards the west. He reported that the engine power and acceleration were normal, but after becoming airborne he noticed the aircraft appeared to be sluggish, and slow to climb. The automatic wing slats had deployed indicating the aircraft was at, or near its stall speed. He had difficulty maintaining directional control, and the aircraft veered to the right.

He considered rejecting the take off, but as the aircraft was moving with a sideways motion, he decided to allow it to accelerate in ground effect rather than chance a landing which may have impose a side load to the landing gear, and the possibility for it to collapse.

The pilot believed the wind gusts increased and changed to a tailwind component, further reducing the aircraft's climb performance. As the aircraft departed from the airstrip area the pilot was unable to arrest the sideways drift before colliding with a tree.

The aircraft was extensively damaged, and the pilot was unable to turn the fuel off as the selector was inaccessible due to airframe distortion. He evacuated himself from the rear cockpit, then assisted the passenger to exit from the front cockpit. During the evacuation smoke was observed around the front cockpit floor area, which originated from fuel contacting the hot engine and exhaust. The aircraft then became engulfed in flames, resulting in an extensive grass/bushfire.

It is possible that the pilot raised the aircrafts tail too soon at the commencement of the take-off run before effective rudder control could be established. The propeller slipstream direction allows the wash to contact the right side of the rudder imposing a tendency for the aircraft to swing right. This would have been aggravated by the aircrafts slow forward speed, and the crosswind from the left.

The slow airspeed, crosswind, and/or the reported wind changes would have caused difficulties for the pilot to maintain and/or recover directional control.

The instructor pilot reported that IFR recency training was being conducted with an experienced airline pilot. During a circling approach in the Caloundra circling area following an instrument approach at Maroochydore, the heavy workload generated by the procedures and additional IFR traffic in the area distracted both pilots and resulted in failure to lower the gear before landing.

The PA-28 had departed Moorabbin at 1734 ESuT and was on climb to 9,000 ft tracking via Melbourne, Fentons Hill and Mangalore to Tocumwal.  The pilot had initially been in Instrument Meteorological Conditions but broke out of cloud just prior to passing over Fentons Hill.

The B737 had departed Melbourne for Brisbane at 1747 ESuT and was tracking via a Runway 27 DOSEL 3 standard instrument departure (SID).  The crew requested, and were given, a climb at 300 kts in lieu of the compulsory 250 kts below 10,000 ft, and the aircraft passed close to Fentons Hill while tracking on the SID.  The crew reported that they were in cloud initially and broke out just past Fentons Hill.

The air traffic controller had both aircraft on his frequency and attempted to coordinate a shortened track for the PA-28.  This request was denied due to the volume of traffic. Consequently, the controller had to radar monitor the climb of three previously departed aircraft past the PA-28. Track shortening on this particular route is normally available.  Additionally, the controller had two aircraft arriving from Adelaide which required a combination of radar vectoring and vertical separation to ensure their safe and timely arrival. The arrival track from the west crosses over the departure track from runway 27.

The traffic volume and complexity required significant concentration by the controller who did not notice that the B737 and the PA-28 were on converging tracks. Radar analysis indicates that the two aircraft came within 1.3 NM whilst at the same altitude with the B737 passing in front of the PA-28.

Neither crew saw the other aircraft and were not aware of the conflict.

There was a breakdown of separation standards.

Findings

1. The crews of both aircraft were operating in accordance with air traffic control instructions.
2. The traffic volume and complexity were such as to result in a high workload situation.
3. The air traffic controller did not notice that the two aircraft were converging into conflict.
4. The two aircraft came within 1.3 NM with no vertical separation.

Safety Action

Airservices Australia have initiated changes to the Melbourne terminal area airspace that will remove the area of conflict involving the inbound tracks from the west. These changes will come into effect on 20 June 1996 and will significantly reduce the workload on approach/departures control.

The Cessna "Dragonfly" returned for a landing after a brief practice session in the training area. However, during that period the weather in the control zone had deteriorated, with visibility reduced in heavy rain associated with a passing thunderstorm. The aircraft was subsequently cleared to land on runway 29C. Although the touchdown was normal the aircraft failed to stop and overran the runway end, before colliding with the perimeter fence.

The pilot reported there had been a large quantity of standing water on the runway at the time of the occurrence. The loss of braking efficiency was consistent with aquaplaning. In addition, the pilot believed there had been a slight downwind component on the landing runway.

Factual Information

GIA829 was maintaining flight level (FL) 350 on air route G326 and was estimating the flight information region boundary at ONOXA at 0330 UTC.  This information was correctly coordinated by Brisbane sector control to Bali control.

GIA899 was maintaining FL 330 on air route A576 and had passed CURTIN at 0245 with an estimate for the boundary at ATMAP of 0347.  This information was also correctly coordinated with Bali control and included the specific indication of a non-standard flight level.

During the coordination process, Bali control advised that they could not accept GIA899 at the non-standard level (FL 330) and required that aircraft at FL 350.  Brisbane sector accepted this requirement and after checking his flight progress strips, the controller calculated that there would be 13 minutes between the two aircraft at Bali (Den Pasar).  As the required standard is 10 minutes, he then instructed the crew of GIA899 to climb to FL 350.

At 0329 the Brisbane controller was checking his flight strips and realised that the flight plan time interval for GIA899 between ATMAP and Bali was approximately 10 minutes in error and the separation between the two aircraft was in fact only 2-3 minutes at Bali.

When the flight times were corrected, it was realised that GIA899 and GIA829 were already within the zone of conflict and that a breakdown in separation standards had occurred.

The Brisbane controller immediately initiated coordination with Bali control, but it was some minutes before contact was made.  When coordination was completed the Bali controller accepted responsibility for re-establishing separation and commenced distance checks from the two aircraft.

It is not known exactly which separation standard was affected by Bali control.

Analysis

When Bali control made the request for both aircraft to be at FL 350 it was based on the previous reported positions of the aircraft and the flight planned times from those positions to Bali.  In the case of GIA899 this time interval was incorrect and contained an approximate 10 minute error.

As both Brisbane and Bali control were using the same flight plan details, it is likely that both controllers considered that a 10 minute separation standard existed.  It was only when the Brisbane controller checked his time intervals against those being commonly used by other aircraft during the period, that the error was noticed.

The computer aided strip printing system only provided a proportional breakdown of the block times notified on the flight plan.  In this case, the first block times were correct and there was no trend to alert control to any time interval error.

There was also a table of estimated time intervals provided on the control console for controller reference.  This table had several erroneous time intervals included in its data and was commonly not used by controllers.

Findings

1. The flight plan for GIA899 contained an erroneous time interval.
2. The table of estimated time intervals held at the Brisbane control console contained several errors.
3. Bali control was unable to accept GIA899 at a non-standard level (FL 330).
4. Both the Brisbane and Bali controllers had information that indicated that a 10 minute separation standard existed.
5. All coordination between Brisbane and Bali was carried out in accordance with the Letter of Agreement.
6. Brisbane control issued a clearance for GIA899 to climb to FL 350 in accordance with Balis requirements.
7. The actual separation was approximately 2- 3 minutes.
8. A breakdown in separation standards occurred.

Significant Factor

The flight plan details for GIA899 were errant, in that they contained an incorrect time interval between ATMAP and Bali.

Safety Action

As a result of the investigation, Brisbane ATS management have removed the erroneous time interval table from the console.  It has been replaced with a table of average times for each type of aircraft using particular air routes.

Report not released due to no IP comment from the Indonesian agency on this joint investigation report.

ASOR hard copy held on occurrence file.

Report not to be released without the approval of the Director or a DD.

Signed

Alan L Stray

Deputy Director Investigations

6 July 1998

The aircraft departed Archerfield for Bankstown with 100 L of fuel, measured by dipstick. At Coffs Harbour a further 40 L of fuel was added. The pilot again dipped the tanks and determined there was a total of 100 L (50 L per tank) on board. The aircraft then flew to Scone where the pilot again dipped the tanks and estimated that 60 L (30 L per tank) remained. He assessed this was sufficient for the remaining leg to Bankstown.

After departing Scone, the pilot reported that he had to divert around thunderstorms. Later, he had difficulty communicating with Bankstown at Brooklyn Bridge and carried out three orbits whilst the problem was rectified. By then the fuel contents gauges were indicating very low quantities. The engine subsequently stopped in the Castle Hill area, some 10 km from the planned destination. The pilot contacted Bankstown Tower and reported he had run out of fuel and would carry out a forced landing. Although the aircraft was over a playing field, the pilot assessed it as unsuitable for a landing due to powerlines and elected to land in a residential street, where it collided with a power pole. The right wing was torn off, but both occupants managed to escape without injury.

Emergency rescue staff first at the scene of the accident reported only a small quantity of fuel was lost from the ruptured right-wing tank. Only unusable fuel remained in the undamaged left tank. Both fuel tank caps were locked, and the seals were in good condition. There was no evidence of any pre-existing leaks in the fuel system. Subsequently, the engine performed normally during a ground run, after the aircraft had been removed from the site, and a temporary fuel supply connected.

The pilot reported that the engine was operated for the entire duration of the flight without leaning the mixture. Subsequent fuel consumption calculations were consistent with fuel exhaustion at the time of engine stoppage.

Factual Information

An F27 Mk50 (F50) departed Sydney for Canberra from runway 34L and was being radar vectored by Departures South (DepS) for a left turn to intercept the 207-degree radial from the Sydney VHF omni-range beacon (VOR). The controller had restricted the climb of the F50 so that it was maintaining 5,000 ft.  This restriction was initiated in order to provide vertical separation from an arriving B747 that would be radar vectored from the west to make a left circuit to runway 34L.

The B747 was arriving at Sydney from Kuala Lumpur, Malaysia, and had been assigned 6,000 ft on descent in order to provide vertical separation from the F50. The crew had correctly read back the assigned level to Approach South (AppS) control who subsequently issued instructions for the B747 crew to turn their aircraft onto a downwind leg.

The radar vectors issued by DepS and AppS resulted in the two aircraft following flight paths that would cross each other approximately 10 NM south west of Sydney Airport.  As the aircraft converged, the controllers noticed that the height readouts from the two aircraft became 'garbled' (unreadable) and it was only when the aircraft had passed, and were approximately 2 NM apart, that they became readable again.  The AppS controller then observed that the height readout for the B747 showed 5,500 ft. At the same time the crew of the B747 queried their assigned altitude and were told that it was 6,000 ft.

By the time this conversation was completed, the aircraft were more than 3 NM apart and radar separation standard had been re-established.  The AppS controller then instructed the crew of the B747 to continue descent to 5,000 ft.

The crew of the B747 had been involved in making a public address announcement to the passengers as the aircraft had been passing 7,000 ft.  As a result, the attention of the crew was not totally on the altitude restriction and, as a result of high cockpit workload, the aircraft was allowed to descend below the assigned altitude.

The aircraft passed approximately 700-800 ft vertically apart, with no discernible horizontal displacement.  As the applicable standard is either 1,000 ft vertically or 3 NM horizontally, a breakdown of separation standards occurred.

Analysis

The operator's Standard Operating Procedures specified that the public address system should not normally be used below the transition altitude (10,000 ft in Australia).  The crew had been informed that the film being shown to the passengers was running late and the captain elected to wait until it had finished before making the public address announcements regarding arrival at Sydney.

Findings

1. The crew of the B747 allowed their aircraft to descend below the assigned level.
2. Both air traffic controllers acted in an appropriate manner.
3. The crew of the B747 made a public address announcement at a time that was contrary to company standard procedures.

Safety Action

As a result of the investigation the operating company reinforced its Standard Operating Procedures in respect to public address announcements below the transition altitude.

Upon arrival in the circuit, the pilot found that the windsock was wrapped around the pole. From local knowledge he chose to land on the 525m strip towards the north-west. Following touch down the aircraft did not slow down as rapidly as expected and overran the strip. The aircraft came to rest on a 30 degree slope just past the threshold.

Later the pilot said that the grass was wet, he landed slightly fast at 90 kts, there was a three to five knot tailwind, and he selected reverse thrust too late to avoid the overrun. The Cessna 208 flight manual recommends an approach speed of 78 kts under the prevailing conditions. The chart landing distance required was 397m.