The pilot reported that while cruising at 1,000 ft the engine started to make unusual noises. He decided to make a precautionary landing on a beach. During the landing roll the aircraft entered soft sand. The nose gear broke off and the propeller was bent.

An inspection after the accident found one fuel tank was empty. No fault was found with the engine. A new nose gear and propeller was fitted, the engine was run, and the aircraft was flown off the beach and returned to its base.

The pilot reported that the landing gear was down, and lights were correct in the circuit prior to landing. After the initial touchdown there was a "thump", the landing gear warning horn operated, and the indicating lights went out.

The initial post flight examination found that both the main landing gear drag braces had broken, allowing the main gear legs to collapse outwards. This prevented the aircraft from resting fully on the runway. Later a more detailed heavy landing inspection revealed minor rib damage in the area of the landing gear attach points, on the left side.

The pilot had recently purchased the aircraft. He reported that he was carrying out taxiing trials and simulated take-off runs because he had not previously flown an aircraft of this size and power. During a simulated take-off run the aircraft became airborne and climbed to approximately 30 feet above ground level. When the pilot closed the throttle, the aircraft stalled. It impacted the ground with a high rate of descent and turned over. The pilot sustained minor injuries.

The pilot had accumulated 174 hours total time only 20 of which were on tail wheel aircraft. He had only flown one hour in a biplane during the previous 12 months. At the time of the accident, he had not obtained instruction on the type.

The pilot had planned to visit a friend's property and made arrangements to land at the nearby Collinsville property airstrip. Before departing he contacted the Collinsville manager to ask permission to use the airstrip and obtain information concerning its location and condition.

On arrival in the area the pilot was able to locate his friend's property from the air, then using directions he had been given he tracked to a property which he believed was Collinsville. He was unable to locate the prominent airstrip of which he had been advised but found an airstrip behind an orchard with the runway directions, and similar physical features to that of Collinsville. He noted that the area had been recently cleared and mowed, and a fence removed to increase its length.

The pilot overflew the airstrip to check its condition and reported that he thought its length maybe a little short but believed he would be able to depart again if he used all the airstrip length from the tree line adjacent to the threshold.

The pilot ascertained that a slight south-easterly breeze was blowing and made an approach for landing towards the south.

The aircraft touched down well into the airstrip, and as it was slowing down the left wheel entered a hole which had been left in the ground after the fence removal. This caused the aircraft to veer left and follow a slope towards the airstrip boundary fence. The pilot was unable to regain directional control of the aircraft before the left wing impacted with a concrete fence post causing substantial damage.

The manager of this property arrived soon after the accident and advised the pilot that Collinsville was the neighbouring property.

The pilot carried out an inspection of a paddock and its surrounds prior to commencing the aerial application of insecticide. Three powerlines were identified, two within the paddock and another just outside a nearby fence line. The pilot reported that all three powerlines were checked for spur lines and T-junctions, as well as for aircraft clearance during the spray runs. The area in which the spray runs were being carried out was described as undulating, with a line of trees to the east, parallel to the flight path of the aircraft.

Five spray runs were subsequently carried out in a north-south direction at a height of about six feet. This required the aircraft to be flown beneath the powerlines, the first of which lay in an east-west direction. On the sixth run, as the aircraft approached the first powerline, the pilot reported that he encountered some turbulence. The aircraft struck the powerline, but the pilot was able to maintain control and land on the property.

A damage inspection by the pilot revealed that the right-wing tip leading edge had been slightly bent, the windscreen was broken, and the propeller had sustained minor damage. He assessed that the aircraft was able to be flown to another location, where repairs were carried out. The weather was described by the pilot as fine, with a light south-easterly wind at approximately 8 kts, and scattered cloud.

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.