Cocking of FPS is one of the means available to provide a reminder for further action by controllers. The supervising controller expected the controller being checked to cock the strip to act as a reminder to transfer the altitude to the appropriate box on the FPS. Controllers "cock" an FPS by placing it half out of the bay. In this way, the out of place FPS acts as a visual cue and requires a physical action for it to be restored to the correct location within a bay. The supervising controller did not notice that the controller had not completed the FPS correctly and that no reminder action had been taken.

The Melbourne controller instructed the crew of the A340 to contact Brisbane centre at PAVKO. The crew acknowledged the instruction but did not contact the Brisbane sector controller when the aircraft reached PAVKO.

The two Brisbane controllers did not notice that the aircraft had not called at PAVKO as co-ordinated. Approximately 15 minutes after the A340 was estimated to have reached PAVKO the controllers handed over responsibility for the sector to a new controller. Traffic was light at the time and the handover/takeover of the sector was completed without any specific mention of the A340.

After the handover/takeover, the on-coming controller expected further co-ordination on the A340 as the "altitude/flight" level box did not have a level. Also, he was only scanning the last two digits of the PAVKO estimate and did not notice that it indicated that the aircraft should have already passed the position. He believed the aircraft had a further 25 minutes to go before reaching PAVKO.

Twenty minutes later the new controller noticed that the level on the FPS for the A340 had been annotated in the "previous position" box but had not been transferred to the "altitude/flight level" box. He commenced checks to establish communications with the aircraft. The controller sought confirmation from Melbourne that the aircraft had passed Alice Springs. He was advised that the A340 had passed Alice Springs an hour ago. The controller then requested the crew of another aircraft in his sector to attempt to contact the crew of the A340. The crew of this other aircraft were able to contact the crew of the A340 by radio and, shortly after, normal air-ground-air communications were restored. There was no conflicting traffic while the aircraft was out of communication with ATC.

ANALYSIS

The supervising controller expected the controller being checked to perform to a high degree of efficiency because of the latter's long period of ATC experience. Consequently, he did not monitor the controller’s actions as closely as he would have for a less experienced controller.

The two Brisbane controllers were nearing the end of their shift, and this may have caused them to relax their vigilance in completing tasks. Consequently, neither controller completed their respective tasks in a satisfactory manner.

The handover/takeover would appear to have been conducted in a cursory manner due to the low traffic levels and the supervising controller’s expectations of the other controller’s performance. This aspect of expectation carried across to the on-coming controller who did not check the FPS. However, once the new controller recognised the error on the FPS, he was able to quickly recover the situation.

The reason for the crew of the A340 not contacting Brisbane centre at PAVKO as instructed could not be ascertained.

SIGNIFICANT FACTORS

1. The controller being checked did not annotate the FPS correctly.
2. The controller being checked did not ensure that all aspects relating to the sector were covered in the handover/takeover.
3. The supervising controller did not adequately monitor the actions of the controller being checked.
4. The crew of the A340 did not transfer to the Brisbane centre frequency at PAVKO as instructed.
5. The on-coming controller did not adequately check the flight progress strips after taking over responsibility for the sector.

Prior to the arrival of the aircraft to conduct spraying operations, the loader driver inspected the grass strip surface and informed the pilot that its condition was satisfactory for take-off and landing. The pilot landed the aircraft and subsequently inspected the condition of the strip himself, before taxiing along the centre of the strip to its western end in order to load the aircraft. He then taxied to the eastern end and commenced to take off towards the west.

The aircraft remained slightly left of the centreline of the strip during the ground roll and encountered an area of soft ground. The pilot lost directional control of the aircraft, which resulted in the left wingtip striking the ground, and the right main landing gear collapsing.

A treeline running north-south was located to the west of the strip. A gap in the treeline, slightly left of the strip centreline, was used by pilots during take-off to ensure obstacle clearance. The pilot reported that he may have been concentrating on the gap during the take-off ground roll and allowed the aircraft to veer to the left of the intended take-off path.

The helicopter was being ground run after two of the three rotor blades had been refitted. The aircraft apparently experienced ground resonance and the main rotor struck the ground. The aircraft rolled over and came to rest against a tree. The sole male occupant was admitted to hospital.

Enquiries revealed the person operating the helicopter did not hold a pilots or engineers licence. The helicopter had apparently been purchased on behalf of another person with the intention of shipping it out of the country.

Since the person who was running the helicopter was released from hospital he has been pursued by the CASA for questioning but has disappeared.

Ground running of helicopters must be performed by a licenced helicopter pilot, and if the helicopter is tied down, may be performed by a licenced engineer.

During climb, passing 5,300 ft, a loud bang was heard. The pilot initially thought the noise to be a birdstrike, however it was noticed that the inner cowl on the left engine had fallen from the aircraft. The pilot elected to return to Brisbane. Post flight inspection revealed that the cowl had torn off along the hinge line and had struck the fuselage forward of the entry door causing denting and scoring of the fuselage skin.

The aircraft had undergone maintenance on the previous day, but no work had been done on the left engine, and there was no known reason for the left engine cowl to be unfastened. The copilot, who performed the daily inspection in the early hours of the morning (it was still dark) had not noticed the cowl was not properly fastened. The cause of the cowl being unfastened could not be determined.

The incident occurred on the first day of a two-day pageant to celebrate the 75th anniversary of Essendon airport. A flying display was programmed to commence at 1300 eastern standard time, the first event being a multiple parachute drop from VH-KTD. Air traffic services planned to give priority to programmed pageant events. Before and between events, several local operators took the opportunity to conduct joy flights. Joy flight traffic was heavier than anticipated by air traffic services.

Because the wind was a moderate south westerly, air traffic services established a left-hand racetrack pattern using runway 17 for most departures and runway 26 for arrivals.

Shortly before the incident, joy flight aircraft were being recovered to clear the airspace for the paradrop aircraft awaiting clearance for take-off from runway 17. The aerodrome controller decided to require the pilot of VH-NAY, a joy flight aircraft on approach to runway 26, to hold short of the runway 17 strip after landing so he could expedite the take-off of the paradrop aircraft. As NAY was already on final for runway 26 when the controller made this decision, he decided to wait until NAY had landed and slowed to taxying speed before issuing the hold short instruction. However, in the busy traffic situation the controller forgot to issue the hold short instruction to NAY and cleared the paradrop aircraft for take-off. NAY entered the runway 17 strip (gable marker line) as KTD became airborne north of the runway 17/26 intersection.

The incident would not have occurred if operations had been confined to a single runway. However, the use of runway 17 for departures and 26 for arrivals was a standard operating procedure in suitable weather conditions. The procedure increases traffic throughput and reduces aerodrome controller loads. Use of the "hold short" requirement, once the landing aircraft has reduced to taxying speed, was common.

The Essendon tower team leader was rostered on as an extra staff member in view of the expected heavy traffic. However, because he had attended the briefing for participating pilots, and was still relaying the details of the briefing to other tower staff, he had not taken up the position of assisting the aerodrome controller before the incident occurred.

Significant factors

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

1. Joy flight traffic was heavier than anticipated.

2. The extra tower controller was still briefing other tower staff and was not assisting the aerodrome controller when the incident occurred.

3. There was a degree of pressure on the aerodrome controller to ensure that joy flight aircraft were on the ground prior to the pageant commencing.

FACTUAL INFORMATION

An Australian registered B747 aircraft had departed Tokyo on a flight to Sydney. The crew had been radar-vectored by air traffic control around an active military restricted area (R116) and were commencing a left turn to intercept their planned route in accordance with the instructions received. As the aircraft climbed through flight level (FL) 220, the crew received a traffic alerting and collision avoidance system (TCAS) traffic advisory warning of unidentified aircraft crossing from right to left and climbing from a level beneath that of the B747.

A pair of U.S. military FA-18 aircraft had departed from the Atsugi Naval Air Facility to operate in R116, which was located just east of the air route which the B747 was intercepting. Initially, the formation was proceeding under instrument flight rules but changed to visual flight rules on passing 9,000 ft, and tracked visually to the exercise area. Their rate of climb at this time was approximately 6,000 ft/min.

After receiving the TCAS traffic advisory, the crew of the B747 saw the military formation and, as the formation had changed course to be in conflict with the predicted track of the B747, they elected to increase the rate of climb and continue the left turn, to ensure separation from the FA-18s. During this manoeuvre, the rate of climb of the B747 reached 5,000 ft/min, higher than normal for this stage of flight. No traffic information was given by air traffic control in relation to the FA-18 aircraft.

While the crew of the B747 were carrying out their evasive action, the crews of the FA-18s had sighted the B747 and commenced a level-off manoeuvre to maintain FL 225. They calculated that their track to R116 would have conflicted with that of the B747, and assessed that as that aircraft had left FL 225, vertical separation would be achieved by the time horizontal separation was lost.

Radar analysis indicates that the aircraft passed with a minimum of 1,200 ft vertical difference while there was no horizontal separation. Because the appropriate standard is a minimum of 1,000 ft, no breakdown of separation occurred.

ANALYSIS

The FA-18 pilots were operating in accordance with the "see and avoid" principle of visual flight. They acted in accordance with the rules for aircraft transiting to or from the restricted area and maintained a level beneath that already vacated by the B747.

The crew of the B747 reacted to the visual sighting of military aircraft closing rapidly on their aircraft and on a track that was in conflict with their intended flight path. The TCAS equipment confirmed that the rate of closure and track change of the FA-18 formation would place the aircraft in imminent conflict. Even though there was no resolution advisory, the B747 crew elected to commence an evasive manoeuvre based on their observations. They had no information on the intent of the military crews and did not know of the decision of those pilots to level off below their aircraft.

The air traffic controllers were aware of the visual flight procedures used by the military formation and only had a requirement to pass traffic information on such flights if their other duties allowed. In this case, the controller was too busy to pass traffic to the Australian crew. This crossing point is a particularly busy section of airspace and it is normal for traffic information not to be given as military crews are required to remain clear of civil aircraft.

SAFETY ACTION

The Japanese Civil Aviation Bureau advised the military authorities to remind pilots of the airspace structure and of their requirement to remain well clear of civil traffic.

The Bureau requested that the operator fully brief crews on airspace requirements and military crossing points, and how TCAS advisories can be expected in this environment.

A group of pilots were undertaking endorsement training on the aircraft. They had been briefed on ground handling and starting procedures for the aircraft. The starting procedure involved turning the propeller through with full throttle and ignition off, in order to pass fuel mixture to the cylinders. After that process the throttle was set to be set to 1/4 inch open and the ignition switches turned on for hand starting.

On this occasion the instructor was outside the aircraft to hand swing the propeller and the pilot undergoing the endorsement was in the cockpit. The throttle had been set full open for the priming procedure and the instructor had asked for it to be set to 1/4 inch open. At this time the throttle was moved to a position which the trainee assumed was the appropriate setting. When the engine started it went quickly to a high rpm condition, the tail rose, and the propeller was destroyed by contact with the ground.

The trainee had not closed the throttle initially in order to obtain the correct datum from which to set the throttle for start. He later found that the throttle control movement was much greater than had been expected. In his previous experience, with nose-wheeled aircraft, a high rpm after start was of no concern from an aircraft attitude aspect, however with a tail-wheeled aircraft the tail can rise unexpectedly.

Factors

1. The trainee pilot was unfamiliar with the engine control movement;

2. The starting throttle position was not set from the closed throttle position;

3. The throttle was set too far open for start;

4. The flight controls were not set to help keep the tail low;

5. Timely action to reduce engine rpm was not taken;

6. The instructor did not check that the throttle and flight controls were properly set for start.

The pilot was conducting a flight to land three passengers onto the top of Mount Sonder. Prior to making an approach to the cleared area he carried out an engine power check which confirmed that the engine was developing sufficient power to accomplish a landing at the high altitude. The pilot then carried out an inspection of the landing area and completed all four legs of the circuit. While turning onto final approach for landing he noticed a rapid reduction of the manifold pressure indication from 26"hg to 20"hg, accompanied by a loss of engine power.

The pilot was unable to continue to the intended landing area, and was committed to a landing on the sloping, rocky mountain side.

As the pilot reduced the helicopter's forward speed prior to landing the tail rotor struck a rock, causing a yaw. The pilot immediately closed the throttle, and the helicopter came to a stop facing up the slope suffering substantial damage to the landing skids, and separation of the tail rotor blades.

No faults or malfunctions were found with the engine which may have contributed to the loss of power.

An inspection of the turbocharger revealed slight scuffing of the turbine wheel, but the assembly spun freely. The density controller and wastegate were removed for overhaul, obvious problems with these units being difficult to detect.

The reason for the loss of engine power could not be determined.

The trainee pilot was conducting circuits on Runway 29R at Bankstown in a Cessna 152. Late on final approach, she judged the airspeed as being too fast and selected full flap to slow the aircraft. She then saw that the aircraft was descending below the desired approach path and added power to correct. As the aircraft crossed the threshold, the pilot reduced power to idle and lowered the nose but then decided to execute a go around.

However, before power could be re-applied, the main landing gear struck the runway heavily and the aircraft bounced. The aircraft then pitched nose down, landing on the nosewheel, before bouncing once again. The pilot later reported that the force of the bounce had caused her right hand to rapidly increase the throttle setting just as the aircraft began to pitch nose down, accelerating the descent and causing the aircraft to land heavily on the nose wheel. The pilot closed the throttle, but the aircraft continued to oscillate in pitch, bouncing alternately on the main landing and nose gears. The propellor struck the runway numerous times before the nose gear partially collapsed. The aircraft came to rest approximately 150 m after the initial touchdown, after crossing the left edge of the runway.

The Boeing 737 was being radar vectored to a right base position for a runway 35 Instrument Landing System (ILS) approach. The aircraft was in instrument meteorological conditions and had been cleared to descend to 6,000 ft on a heading of 220 degrees, with an expectation of a right turn to intercept the localiser. When no response was heard from the crew of the B737, following an instruction to turn further right onto the base leg for runway 35, the controller repeated the instruction several times on backup radio equipment. Another aircraft in the area confirmed that all the radio transmissions had been clearly received. During this time, the B737 tracked outside controlled airspace below the minimum radar vectoring altitude. When communications were re-established some two minutes later, the controller issued the crew with an altitude alert and instructed them to climb the aircraft to 7,000 ft. The ILS was re-intercepted from the left, after which an approach and landing was carried out without further incident.

It was later determined that the co-pilot had inadvertently preselected the Canberra ground frequency instead of the relevant tower frequency whilst preparing for the arrival to Canberra. When nothing was heard on the radio for a period longer than expected, and cockpit instruments indicated that the aircraft was approaching the localiser track, the pilot in command became concerned about the position of the aircraft in relation to the surrounding terrain and instructed the co-pilot to transmit, "maintaining six thousand". The reply to this transmission was for the crew to contact Canberra Approach. At this time, it became apparent to the crew that the active frequency being monitored was Canberra Ground. Whilst there was no radar altimeter indication or ground proximity warning system alert, the crew commenced terrain avoidance procedures in conjunction with the altitude alert issued by the controller.

As a result of this occurrence the company has produced an article in its flight safety journal to emphasise the ongoing need for situational awareness at all times, and the requirement to pre-brief aspects of the approach, including safety heights and contingency plans, in the event of loss of communications.