The glider was being test flown after major maintenance had been completed. During lift off the pilot lost control and the aircraft cartwheeled. The pilot received minor injuries, and the glider was substantially damaged.

Investigation found that the ailerons had been connected in the reverse sense. During the maintenance, reassembly, rigging and preflight the glider had passed through four stages of inspection, all of which failed to detect the incorrect rigging of the ailerons.

It was found that 10 types of glider operated in Australia are fitted with common aileron drive gimbals that can be physically fitted to the incorrect side of the aircraft, thereby reversing the sense of the control.

Immediately after the accident the Gliding Federation of Australia issued an Operations Advice Notice advising details of the accident. The notice made the point that crossed controls had occurred before and that an Airworthiness Advice Notice had been issued in 1980 covering the subject. This notice stated, 'this incident emphasises the dangers of complacency; we have come to expect things to operate correctly and therefore assume that if something is working, it is working correctly'.

The Operations Advice Notice made three recommendations relating to the principles of assuring correct sense and the avoidance of external distraction during preflight inspections.

The Gliding Federation also issued an Airworthiness Directive requiring, on the subject gliders, gimbals for the left wing to be painted bright red and for the gimbals for the right wing to be paint bright green. This action is to be performed at the next annual inspection.

The flight was the first leg of a ferry flight from Australia to the United Kingdom. After passing Adelaide the crew were advised of a change in the weather, because of a cyclone, which meant that their planned destination required an alternate. They elected to change their destination to Broome and re-planned the flight to track via overhead Ayres Rock. Navigation for the flight was being conducted by reference to a global navigation system (GNS).

The crew did not attempt to confirm their Ayres Rock position by checking the Alice Springs navigation aids. Instead, they relied solely on the GNS readout. The GNS positions were not checked on the Ayres Rock - Broome leg because of a lack of ground-based navigation aids. Approaching Broome, as indicated by the GNS, the crew attempted to obtain a cross-check from the navigation aids at Curtin but were unable to obtain any useful information. The crew were also unable to obtain any information from the Broome navigation aids.

The pilot-in-command commenced an instrument descent into Broome using GNS information only. He became concerned after the aircraft had descended to 2,400 ft above mean sea level and the crew could not see the ground, the radio altimeter was indicating the aircraft was only 600 ft above ground level and they were unable to contact anyone using the VHF radio. The pilot-in-command declared an emergency, indicating that he was unsure of his position and that he had 30 min fuel remaining, before climbing the aircraft to 6,000 ft. During the next 45 min the crew, with the assistance of air traffic services and another aircraft, attempted to establish the aircraft's position without success. Eventually a passenger, using a portable global position system receiver which was held against a cabin window, was able to establish that the aircraft was 79 NM north of Telfer. Air traffic services activated the lights at Telfer aerodrome and the aircraft landed there with limited fuel remaining 65 min after the aircraft's original estimate for Broome.

An investigation determined that the planning and conduct of the flight was deficient in a number of areas and that these contributed to the occurrence. Some of the more significant areas were crew compliment, approval and use of global navigation systems and the continued operation of a jet aircraft at low level in a critical fuel situation.

The aircraft was certified for two pilot operation with both pilots endorsed on type. The co-pilot was not endorsed on type, he was not familiar with the aircraft's GNS equipment and had not been trained in its use.

It was considered likely that inaccurate information was inadvertently entered into the GNS after the decision to change the route and destination was made. As the pilot-in-command did not have a standard checking procedure for changes to GNS information, and the co-pilot was unfamiliar with the system, the errors went undetected.

The pilot-in-command's acceptance of GNS information only for route tracking and descent, when some ground aids were available to cross check the information, indicated a lack of understanding of the use of defences to improve the level of aviation safety and of Australian requirements for the use of GNS as the sole means of navigation.

The crew's inability to establish contact with a ground-based navigation aids and VHF radio stations after the descent was probably a function of the aircraft's altitude and distance from them. In addition, operations at low level in jet aircraft are inefficient as far as fuel usage is concerned. In remaining at low level for over 45 min the pilot-in-command exhibited a lack of understanding of communication and aircraft operational limitations.

Debris was found on the runway shortly after the aircraft had landed. Maintenance investigation found that the number 1 engine thrust reverser was damaged. The number 5, 7 and 8 blocker doors were broken, and the variable guide vane cover panel was missing. The BASI investigation was not able to determine the cause of the failure.

A solo rated pilot was undertaking a check flight with a highly experienced instructor. Operations were from the 01 strip with a 20 to 25 knot wind gusting from the northwest. While the glider was in flight a decision had been made to cease operations due to the inclement weather conditions. During the landing the sols pilot was unable to maintain directional control and the glider weathercocked.

The instructor was not able to take over and recover the situation before the glider collided with a parked glider severing one metre from its right wing.

Two aircraft, at the same level on air route A585, lost separation standards assurance when the controller did not apply the appropriate standard. The lead aircraft was a RAAF VIP Boeing 707 carrying the Australian Prime Minister. The trailing aircraft was a scheduled Qantas passenger service.

The Brisbane Sector 12 controller applied a 10-minute separation standard instead of a 15-minute Oceanic standard when he allowed the lead aircraft to climb to the same level as the trailing aircraft. Later, the controller assured Perth Sector 1 controller that the 10-minute separation standard would be monitored and a distance standard established if necessary.

The separation was reduced to eight minutes at Port Hedland when the lead aircraft, Aussy 360 arrived one minute later than ETA and QFA10 arrived one minute earlier than ETA. The controller did not establish a distance standard (20 NM on DME or 30 NM RNAV) when the aircraft entered the CTA, 120 NM north-west of Port Hedland.

The controller applied an incorrect separation standard of 10 minutes to the aircraft at DOMOM whereas the oceanic standard was 15 minutes. He also did not establish a distance standard between the two aircraft as agreed with the Perth Sector 1. The controller could not explain the omissions. However, he was on a late-night shift with little traffic under his control. He may have been in a state of low arousal and was unaware of the errors.

At the conclusion of an 8 hour, 500 km flight the visiting foreign glider pilot was forced to outland 1.5 km short of the airfield. The glider suffered extensive damage consistent with having been landed in a stalled condition with a high rate of descent.

The pilot advised that he was in a lethargic state of mind having mentally relaxed once the airfield was in sight. The operator is looking into visiting pilot dehydration, coupled with fatigue, as a factor in this type of accident.

The crew of VH-OLM reported a near miss with a Cessna 172 approximately 17 DME south of Albury while passing 8500 feet on descent into Albury. The Cessna was tracking to the southwest. There was no reported traffic in the area at the time and no traffic was painting on Melbourne radar. The Cessna crossed the track of VH-OLM from right to left at the same altitude between half a mile and one mile in front. The incident occurred in very close proximity to the southern boundary of the Albury Control Zone.

It was the pilot's first flight to the destination and on arrival he overflew the landing area to ascertain the landing direction from the windsock. He then continued in a left turn carrying out a circling approach onto final.

The grassy landing area was located in an area of low scrub. It had gable markers in the form of an "L" situated in the corners at each end of the airstrip to identify the thresholds. Four rows of cone markers along the length of the airstrip were used to indicate the extremities of the flight strips, and the runway's location in the centre.

When the pilot overflew the airstrip, he noticed the row of cone markers along the left (eastern) side of the flight strip, and the two rows marking the runway. Because of low bushes and long grass, he did not see the cone markers along the right (western) side of the flight strip, although the "L" threshold marker was visible. This gave him the impression that the row of cone markers along the eastern side of the runway was the runway centreline, and not verify the situation, flew the circuit to land to the left of the perceived centreline, on the flight strip.

Because of long grass, and the high nose attitude of the aircraft, the pilot failed to see piles of stones and areas of soft sand on the flight strip. After touchdown the aircraft rolled about 300 m then collided with a pile of stones and entered an area of soft sand, resulting in the separation of the nose gear leg.

History of the flight

The pilot conducted a scenic flight of approximately one hour duration from Stawell around the Grampians with three passengers on board.  At the end of the flight, the pilot approached Stawell from the west and joined the circuit via an upwind leg to the south, then a right circuit for a landing on runway 18.  In the area of late downwind/early base the engine stopped.  The pilot continued turning right towards the aerodrome, but it became obvious that the aircraft was not going to reach the aerodrome without engine power.  He performed some checks but was unable to restore engine power.

There was no area suitable for a forced landing between the aircraft and the aerodrome because the area had moderate tree cover.  The pilot positioned the aircraft towards a clump of small trees and warned his passengers of the impending impact.  The aircraft stalled into the trees and ignited on impact with the ground. All occupants escaped, but three received serious burns.  The aircraft was destroyed by impact forces and fire.

The engine

Although most of the fuselage and right-wing area were consumed by fire, the engine was not fire damaged.  The firewall was intact and the engine cowl, although heat affected, was not burnt. The engine was recovered and subjected to a thorough examination which was unable to determine any reason for the engine failure or why the engine was not capable of producing full power.

The pilot

The pilot was checked in this aircraft by an instructor two weeks prior to the accident. The check involved a check on the aircraft type, a constant speed propeller endorsement and a retractable landing gear endorsement.  Prior to this check the pilot had flown the aircraft once with the owner occupying the right seat as pilot in command.  The instructor who conducted the check flight reported that the pilot handled the aircraft well and was knowledgeable on its systems. After the check flight, the pilot did not fly the aircraft again until the day of the accident.

Fuel considerations

Calculations were made of estimated fuel usage against time flown since the aircraft was last known to have had full tanks.  The result was that at most there was a total of 45 litres remaining in the tanks when the engine failed.  The distribution of the fuel remaining could not be determined.  If evenly distributed, there would have been 22.5 litres per tank.  The pilot said he had the selector on the left tank which by gauge indication had the higher quantity of fuel.  Fire damage at the scene indicated that the right tank probably contained more fuel than the left.

Other evidence

The pilot's operating handbook for the aircraft type warns about taking off with less than 13 US gallons (49 litres) in each main fuel tank.  If a main fuel tank contains less than 49 litres, there is a possibility that a tank outlet will be uncovered (i.e. no fuel available at the outlets and air will be sucked into the fuel lines) during a tight turn while taxiing.  If such a turn is executed immediately prior to take-off, it is possible for the engine to fail during take-off.  It is also possible for a tank outlet to be uncovered during unbalanced flight and accordingly the pilot's operating handbook contains time limits for "maximum slip duration" consisting of 20 seconds for aircraft fitted with unbaffled fuel tanks and 30 seconds for aircraft fitted with baffled tanks.

The pilot advised that when he made the right turn to join the downwind leg of the circuit, he and his passengers were watching a preceding aircraft land.  To facilitate this, he kept the bank angle low and applied right rudder to complete the turn.  This would have resulted in an unbalanced turn.

If the engine stops due to fuel starvation, the procedure for restarting involves selecting the tank which contains the most fuel, retarding the throttle and turning the boost pump on.  Even with these actions correctly taken, it can take a considerable time to restart the engine.  In a recent case involving a similar aircraft, the pilot of that aircraft reported that it took 20-25 seconds to restart the engine with the boost pump set in the on position.  In the present case the pilot completed a series of checks to determine the cause of the engine failure but did not turn the boost pump on. He believed he positioned the throttle to one quarter open because that was what he had been trained to do.  When the wreckage was examined, the throttle was found in the fully open position. The propeller and mixture controls were also in the full forward position.

The severity of the post-impact fire was discussed with an experienced fire investigator. His advice was that a fire of the intensity that had occurred could have been fuelled with less than 45 litres of aviation gasoline.

The post-accident fire damage to the right wing and fuselage precluded any assessment of loss of fuel in flight via a leak somewhere in the system.  The left wing was largely undamaged by fire and there was no evidence of any fuel leakage from that wing.

Analysis

Examination of the engine found no reason why the engine stopped.  Calculations of time flown against fuel usage showed that at the time the engine failed there was probably a total of no more than 45 litres of fuel in the tanks. Fuel distribution could not be determined. The pilot believed that the left tank contained more fuel than the right tank, but the post-impact fire damage suggested that there was more fuel in the right tank.

Immediately prior to the engine failure, the pilot made an unbalanced turn to the right with the left fuel tank selected.  With the amount of fuel remaining in the tanks, this probably uncovered the outlet in the left tank and starved the engine of fuel.  After the engine failed, the pilot did not turn the boost pump on and may not have correctly positioned the throttle, as recommended in the pilot's operating handbook, in order to restart the engine. However, even if the pilot had performed all actions correctly, it may not have been possible to achieve a restart in the time available.

Conclusions

Findings

1. The pilot was correctly licensed and qualified to fly the aircraft.
2. The pilot had low total flying experience and low experience on type.
3. When the aircraft approached Stawell at the end of the flight, it was calculated that there was no more than 45 litres of fuel remaining in the aircraft fuel tanks.
4. Shortly after completing a 180-degree turn onto the downwind leg of the circuit, the engine stopped.
5. In the limited time available, the pilot was unable to determine the cause of the engine failure or achieve a restart.
6. The aircraft was unable to reach the aerodrome from the position at which the engine failed.
7. The area between where the engine failed and the aerodrome was unsuitable for a forced landing.
8. A thorough examination of the engine found no fault or any reason why the engine was not capable of producing full power.
9. The pilot's operating handbook, in the limitations section relating to fuel management, warns against taking off when the fuel quantity gauges indicate in the yellow band or with less than 13 US gallons (49 litres) of fuel in each main tank.  The same section also specifies maximum slip durations for baffled and unbaffled tanks.

Significant Factors

1. When the aircraft approached its destination, it was calculated that there was no more than 45 litres of fuel remaining in the aircraft fuel tanks.
2. The pilot made a 180-degree unbalanced right turn onto the downwind leg of a circuit. It is probable that the turn resulted in the outlet of the left fuel tank being uncovered.
3. The engine failed over an area that was unsuitable for a forced landing.
4. The pilot was unable to restart the engine.

The purpose of the flight was to assess the student prior to his first solo flight. Preflight fuel contents were 95L, and the pre-take off engine run, which included a carburettor heat check, was reported to have been normal.

The instructor pilot reported that two uneventful circuits were completed. On the third circuit, prior to turning onto the base leg, the student applied full carburettor heat and reduced engine power to 1500 RPM. After turning onto the base leg, the approach appeared too high and engine power was further reduced to 1100/1200 RPM. Turning onto the final leg, the aircraft appeared to be undershooting, and the student was prompted to increase power, but there was no response from the engine. The instructor immediately took control, confirmed that carburettor heat was on, the mixture was rich, and changed the fuel tank selection. However, there was no response from the engine, which continued to rotate at 1100/1200 RPM.

By now, the aircraft was well below the required approach path. The instructor made a brief MAYDAY call and tried to manoeuvre the aircraft to land on a cleared area short of the runway, but the landing gear collided with a 2 m high wire fence. The aircraft cartwheeled sideways before coming to rest. Both occupants were able to escape without injury.

Investigation determined that the engine controls were correctly connected and functioned normally. The carburettor hot air box had been squashed in the accident, and the hot air duct was disconnected. It could not be determined if the duct had detached before, or as a result of, the accident. After removing the hot air box, the engine performed normally during a ground test.

The weather conditions at the time were conducive to severe carburettor icing at descent power. It is likely that carburettor icing occurred during the low power descent and precluded the engine accelerating above idle power on the final approach.