The Piper Pawnee was spraying chemical in the local area. The strip being used was 350 m in length, and had several trees at the far end, some 16 m to the left of the departure path. There was a crosswind from the right of about 10 to 12 knots. The strip surface was soft, but the pilot reported he had not experienced any problems during a previous take-off, although the aircraft was unladen.

Prior to the next take-off the aircraft was loaded with chemical. The pilot subsequently reported that late in the take-off run, with the engine operating normally, the aircraft suddenly slowed and slewed left about 20 degrees, before again accelerating normally. The aircraft lifted off at approximately 65 knots, displaced to the left and further along the strip than on the previous take-off. The pilot reported he was unable to prevent the aircraft colliding with the trees located to the left of the normal departure path. This resulted in the aircraft rolling inverted and striking the ground. It is considered the left mainwheel may have struck a soft area of the strip during the take-off run, causing the initial left yaw and slight deceleration.

Pitch Black 96 operating procedures included a general exclusion of military activities in R244 above FL 290 unless acting in accordance with specific air traffic control instructions.  This exclusion was designed, amongst other things, to protect transiting civil air traffic.  DOGSTAR formation had no such air traffic clearance or instruction.

At 1535 CST and when approximately 32 NM south-east of Tindal aerodrome, the crew of the A340 reported a TCAS traffic advisory on unidentified aircraft crossing from left to right about 3 NM ahead and descending from a level approximately 800 ft above them.

Tindal centre were unable to immediately determine the callsign and flight details of the unidentified aircraft and coordinated with the Control and Reporting Unit (CRU) which would have had prior information on exercise aircraft.  The CRU were also unable to immediately identify the aircraft.

The crew of the A340 then saw the other aircraft and reported that they were twin tailed fighters.  They watched as the military aircraft passed in front of their aircraft at approximately the same level. No evasive action was required as they were able to monitor the progress of the formation clear of their projected flight path.  Shortly after, Tindal centre confirmed that the formation had been identified as DOGSTAR and that they were now under Tindal control and clear of the A340.

Radar analysis indicated that DOGSTAR formation passed at a distance of 4.9 NM in front of the A340 and had descended from approximately FL 363 to a level below the A340 during the period of the TCAS alert.  It also established that the occurrence happened in airspace between 25 and 33 NM from Tindal.

The appropriate separation standard in this airspace was either 3 NM horizontally or 2,000 ft vertically. This standard can only be provided when certain pre-conditions are met.  Some of these requirements were that both aircraft are radar identified, and both aircraft shall be on radio frequencies currently in use for radar control. These pre-conditions were not met in this case.  There was also a procedure where the CRU is allowed to provide a separation service in conjunction with the military air traffic controller in military restricted airspace, however, the pre-conditions for this procedure were not met.

Whereas the proximity did not reduce below the 3 NM criteria, a breakdown of separation did occur because the military aircraft were not operating under air traffic control instructions and were not in contact with either air traffic control or the CRU at the time of the occurrence.  Therefore, the terms and conditions set out in the Manual of Air Traffic Services for such a separation standard had not been met.

The crews of the F-15 aircraft had chosen to maintain a higher-than-normal altitude for their initial recovery track because of other exercise traffic involved in air-to-air refuelling in the vicinity of their formation.  They then obtained a radar "lock-on" on the A340 and, believing it to be another military aircraft returning for a recovery, positioned their aircraft to be number one in the recovery sequence.

ANALYSIS

The procedures set down for military exercise "Pitch Black 96" contained restrictions and requirements designed to ensure the protection of transiting civil aircraft. On this occasion, a pair of fighter aircraft contravened the procedures by maintaining an altitude above that approved, without informing either air traffic control or the CRU. This resulted in the aircraft flying in controlled airspace for approximately 60 track miles without an airways clearance and without being subject to a positive separation service.  It also resulted in a civilian aircraft not receiving a guaranteed separation service from the military formation.

SIGNIFICANT FACTOR

The crews of the military formation contravened the published procedures for military exercise "Pitch Black 96".

SAFETY ACTION

The military authorities immediately suspended the exercise and reviewed the safety procedures.  Local amendments were instigated before the exercise was allowed to continue.

The crew of a Cessna 550 aircraft had planned for a flight from Essendon, Vic to Bankstown, NSW at flight level (FL) 370. The aircraft departed and was given an initial altitude restriction of FL 200 by air traffic control (ATC). The crew were transferred to Melbourne Inner North control and the controller, having no conflicting traffic in the projected flight path of the C550, issued a climb instruction to FL 370. The pilot thought that the controller had said FL 300 and read back FL 300. This incorrect read back was not detected by the controller, who had indicated a read back of FL 370 on his flight progress strip.

Shortly after, the Inner North controller transferred the crew of the C550 to the en-route sector, Melbourne Sector 2. On first contact with Sector 2, the crew reported that they were on climb to FL 300. The Sector 2 controller considered this to be an unusual level and immediately contacted the Inner North controller to confirm the assigned cruising level. He was told that this was FL 370. The Sector 2 controller then asked the crew of the C550 if they would prefer FL 370 and, on receiving a positive reply, issued a climb instruction for the crew to climb to FL 370. This was correctly read back by the pilot and the flight proceeded to Bankstown without further incident.

It is normal operating practice for Sector 2 control to not have any planned levels on their flight progress strips. All aircraft coming into this sector are already under radar control and this rule reduces co-ordination between sectors and the number of level changes that may need to be recorded on the strip.

SIGNIFICANT FACTOR

The pilot of the C550 and the Inner North controller did not exercise sufficient vigilance in their radio listening techniques.

The pilot reported that he conducted an aerial inspection of the strip prior to landing to ensure the runway was clear. Just after touch down the passenger alerted the pilot to the presence of an animal running towards the aircraft from the right side. The pilot was unable to manoeuvre the aircraft in time to prevent it colliding with a deer. The pilot and both passengers were able to exit the aircraft safely once it came to a halt.

Post flight examination showed substantial damage to the aircraft's propeller, engine mounts and nose landing gear assembly.

The clearance was annotated on the departure flight progress strip and ticked as being read back correctly by the crew. The DEP P controller then passed the flight progress strip to the departure north radar (DEP N) controller in readiness for the departure request from the aerodrome controller (ADC). The clearance issued to the B747 was not notified to the tower controllers. To reduce coordination between the tower and DEP P, the tower controllers assume jet aircraft are issued with an appropriate clearance for the runway and destination. Controllers were aware that occasionally the incorrect SID was issued; however, the error was usually detected by the radar controller or the flight crew, prior to the aircraft departing, when they realised that the assigned departure clearance and runway were incompatible.

The crew requested and was issued with a taxi clearance approximately 15 minutes later. The taxi clearance was for runway 16R. The crew were aware that the issued SID was not applicable for a departure from runway 16R but believed that air traffic control (ATC) would not issue an incorrect SID. The crew did not clarify with ATC the use of the WMD 7 SID with runway 16R.

The crew reported ready for departure to the ADC. In turn, the ADC advised the DEP N controller that the B747 was ready for departure from runway 16R and requested departure instructions. The DEP N controller notified the ADC that the B747 was "Unrestricted". That is, there were no conflictions with other traffic and the aircraft could depart in accordance with the issued SID. The DEP N controller did not detect the incorrect SID annotated on the flight progress strip as he issued departure instructions to the ADC. The DEP N controller did not further annotate the flight progress strip to indicate that the B747 had been issued with an unrestricted departure clearance. This annotation was required by the Manual of Air Traffic Services (MATS).

The ADC then instructed the crew that the B747 was cleared for take-off. The B747 departed from runway 16R and tracked in accordance with the SID, which required the aircraft to turn left. The B747 crossed the departure path of runway 16L. The ADC observed the B747 as it turned left and immediately notified the DEP N controller that the aircraft was turning left across the departure path of runway 16L. At the same time, the crew of the B747 had contacted the DEP N controller, but they did not read back the assigned altitude. As the DEP N controller checked the flight progress strip to confirm the terms of the clearance, he saw that the crew had been issued with the incorrect SID. The DEP N controller confirmed with the crew that they were tracking via the WMD 7 SID. After ensuring there were no conflictions with other traffic, he cancelled the SID and re-cleared the crew to track direct to Coolangatta then Brisbane.

There was no aircraft departing from runway 16L at the time.

ANALYSIS

The DEP P controller problems with the flight plans, his probable failure to amend the clearance labels on the flight progress strip bays, his inability to check clearances on the strips issued to the two departure radar controllers and the towers lack of a request to confirm the clearances for aircraft that had taxied prior to the change in runway, did little to reinforce the change of runways in his mind. It is possible that the culmination of these events was to remove the physical and mental cues that normally assist controllers to remember changes. Consequently, he inadvertently issued a runway 34L SID to the crew of the B747.

The DEP N controller's reading of the flight progress strip should have detected the incorrect SID. The controller may have checked the flight progress strip but misread, or did not appreciate the clearance annotation due to an expectation of another clearance.

The crew of the B747 knew the clearance was not suitable for the assigned runway yet continued the flight without clarifying the situation with ATC. A major safety aspect of the aviation system is the regular communication between flight crew, groundcrew and air traffic services personnel to ensure all parties understand the others intention. In this incident the flight crew, when faced with the incorrect SID, explicitly trusted ATC when they should have sought clarification.

The SIDs can be grouped according to the planned enroute track and there are a number available for aircraft to depart to the north, west and south. Some of these SIDs are common to both runway 16R and 34L. For example, heavy aircraft departing either to the south or to the west can be issued with a SID which is applicable for both runway 16R or 34L. However, for departures to the north there is no similar runway common SID. There is a specific SID for runway 34L but there are no SIDs for runway 16R. Consequently, northbound heavy category aircraft requiring the use of runway 16R/34L must be issued with a new clearance when the runway is changed. Alternatively, the aircraft can be issued with a standard radar departure (SRD) which is applicable for departures from either runway.

Amendment of the SIDs to provide a common clearance for northbound aircraft for use with either runway 16R or 34L would reduce the possibility for error by controllers and flight crew. The use of the common runway 16R/34L SRD for all northbound heavy category aircraft would also reduce the possibility of future errors.

SIGNIFICANT FACTORS

1. The DEP P controller inadvertently issued the incorrect clearance to the crew of the B747.
2. The crew of the B747 did not clarify the issued clearance with air traffic control.
3. The DEP N controller did not notice that the clearance on the departure flight progress strip was incorrect.
4. The was no common SID for use with either runway 16R and 34L for northbound heavy category aircraft departures.

SAFETY ACTION

Local safety action

As a result of problems with SIDs and other departure clearances, Airservices Australia has initiated a review of Sydney departure procedures.

It was reported that the flight had initially been planned as a circuit training exercise. When the wind was reported as a 20 kt crosswind the flight was cancelled. As the aircraft taxied back to the parking area the pilots received a report that the crosswind had dropped to 15 kt. They then decided to take-off and complete some upper air work.

Shortly after the aircraft became airborne, with the pilot-under-instruction at the controls, it encountered a strong wind gust which caused it to roll to the right and descend. The instructor took over control of the aircraft and attempted to correct the situation. Although the aircraft apparently started to respond the instructor assessed that his input was not correcting the situation quickly enough and he closed the throttle, held the control column back and allowed the aircraft to descend to ground level.

The aircraft impacted nose first, to the right of the flight strip, before sliding to a stop and overturning.

The Bureau of Meteorology reported that the wind was gusting between 12 and 21 kt and changing direction from 340 to 010 degrees at the time of the take-off. The pilots were using runway 06L.

The amphibious aircraft had been imported in kit form and assembled by the owner. Several uneventful flights had been conducted in the landplane configuration. The aircraft was then operated from a nearby river for water handling evaluation, and for the owner to obtain a floatplane endorsement. On the fourth take-off, just before the aircraft was about to lift off the water, it rapidly nosed over and sank. The owner managed to escape from the aircraft immediately, but the training pilot was temporarily trapped and had to be cut from his seat belt. Neither of the occupants were injured in the accident.

Inspection of the wreckage revealed that the forward section of the planning hull had failed. The failed section then acted as a water scoop, which resulted in the rapid nose over. A subsequent investigation of the wreckage by the manufacturer confirmed that the fibreglass reinforced plastic hull did not meet design specification. Two of the required three layers of woven glass cloth had been omitted from both sides of the foam core during the manufacture of the hull, greatly reducing its strength.

FACTUAL INFORMATION

Sequence of events

An Aerospatiale AS350B (AS50) helicopter had been hired by the Civil Aviation Safety Authority (CASA) to perform a flight test of a recently installed precision approach path indicators (PAPI) system. The airport owners, the Cairns Port Authority, had asked CASA to conduct the tests as part of the acceptance procedure prior to the commissioning of the pilot-interpreted approach aid. The PAPI site was located clear of the sealed runway surface but within the runway strip.

A CASA pilot had submitted the flight plan to air traffic control (ATC) via a phone call direct to the Cairns ATC Centre using a number that was provided for the notification of local flights. This procedure did not require flight planning via the regional briefing office in Brisbane.

The helicopter had been hired on the morning of the occurrence and there was insufficient time for the CASA pilot to be rated for solo flight in accordance with company procedures. Therefore the helicopter was operated by a company pilot as pilot in command with the CASA pilot as co-pilot. The CASA pilot briefed the company pilot as to the requirements as each test run transpired.

Runway 15 was the duty runway, and the crew of the helicopter commenced operations by testing the runway 15 PAPI system, conducting several runs to the runway centreline. On each occasion the helicopter landed on the runway, even though some parts of the approach were conducted off the centreline. After landing, the crew air-taxied the helicopter to a position near the PAPI site and conducted briefings with the ground party to ascertain their requirements for future runs. These manoeuvres sometimes resulted in the helicopter being held clear of the runway strip, but on occasions it remained within the strip boundaries. Other runway movements took place during this time, including periods when the AS50 was within the runway strip.

After completing the runway 15 tests, the crew were asked to hold away from the aerodrome while a B727 departed. They were then cleared by ATC to land on runway 33 to initialise the global positioning system (GPS) equipment with the ground party prior to commencing the runway-33 PAPI flight tests. The brief to ATC had indicated that the crew would require an approach to the centreline and then position the helicopter abeam the PAPI site, but remaining on the centreline, for initialisation. The crew entered a hover in this position, approximately 2 ft above the runway.

A Cessna 182 (C182) had just completed a parachute drop and the pilot had been instructed to make a visual approach to runway 15. He had continued this approach until over the runway threshold when, as no landing clearance had been issued by ATC, he reported short final. The aerodrome controller (ADC) then gave a landing clearance. The pilot then requested permission to "land long" to facilitate taxi to his company apron. This request was approved by the ADC. The crew of the helicopter heard these transmissions but elected not to question the ADC as they were unsure of the runway being used by the C182.

As the pilot of the C182 was about 20 ft above the runway surface and about to flare, he noticed the helicopter approximately 100 - 150 ft in front of him and commenced a go-around. The C182 passed immediately above the AS35 and came within 15 ft of that helicopter.

Both aircraft subsequently completed their operations without further incident.

Flight test requirements

The Cairns Port Authority had conducted several meetings with CASA's Cairns District Office in the months preceding the test flight regarding the requirements for a flight test of the PAPI systems. On 21 June 1996, the Cairns Port Authority had written to the Cairns District Office requesting the flight test be conducted on Monday 22 July 1996 and specified the personnel and equipment that they would provide. This date was agreed by the Cairns District Office.

At 1000 EST on the morning of the flight, the Cairns Port Authority contacted the Cairns District Office to inquire about the final arrangements. None had been made. A Canberra based CASA pilot was in Cairns on unrelated CASA business and, at approximately 1130, was asked to conduct the test flight. Shortly after, arrangements were made for the CASA pilot and a member of the CASA ground party to provide a general briefing prior to a scheduled departure of 1500. No ATC representatives were asked to attend this briefing.

Flight planning

The team briefing was given at about 1500, after which the CASA pilot phoned Cairns ATC and submitted a verbal flight plan for a local flight. This included information of a generally non-precise nature such as the requirement to make several runs from 2,000 ft and approximately 4 NM, and the need to initialise the GPS while hovering on the runway next to the PAPI sites. The pilot stated that he informed ATC of the need to make each approach to the runway centreline and of the possible requirement to use the runway strip after landing. Although all parties agreed that such a conversation did take place, the investigation was unable to obtain evidence of the exact details contained in the flight plan notification.

A CASA ground party member had, in the month preceding the flight test, obtained a sample flight plan from the Melbourne-based flying unit. This plan detailed the procedures and requirements to conduct such a flight test.

No written flight plan was submitted.

Air traffic control

There were five controllers in the tower at the time of the occurrence. A rated ADC had controlled the initial runway-15 PAPI checks and had instructed the crew of the helicopter to track towards runway 33 and then handed over to a rated ADC who was undergoing familiarisation following a period of leave. The current ADC remained at the console supervising the familiarising ADC and, although feeling a little tired, considered himself fit to undertake the task.

The familiarising ADC issued a clearance for a B727 to depart and then cleared the helicopter to land. In doing so, he wanted to refer to the PAPI site in his transmissions but became confused as to the name of the PAPI during his instructions to the helicopter crew. Consequently the supervising ADC moved away from the console and picked up the instructional material on the equipment for the familiarising ADC to read. The helicopter then landed on the centreline, next to the runway 33 PAPI site, and commenced initialisation. Both ADCs were then of the opinion that the helicopter had manoeuvred to a position outside the runway strip markers, even though the clearance to land authorised the crew to use the runway and runway strip. No transmission clarifying this situation was made.

As the familiarising ADC was reading the PAPI documentation, the pilot of the C182 reported short final. The ADC looked up, saw the C182 over the threshold, made a quick scan of the runway and, believing the helicopter to be clear of the runway strip, issued a landing clearance. He then approved the long-landing request because there were no other aircraft needing to use the runway.

The pilot of the C182 then reported that he was going around due to a helicopter on the runway.

Neither ADC saw the C182 until the pilot reported short final because its approach had been across the setting sun, which severely restricted their observations in that sector. They had used the radar to monitor its position relative to the aerodrome. All the controllers thought that the helicopter had operated outside the runway strip markers during its work on the runway-15 PAPI site, even though the initial approach was on the centreline.

Although the two ADCs believed that the helicopter was hovering outside the markers, some of the other controllers believed that the helicopter was within the runway strip. They were each attending to their own tasks at the time and did not look specifically at the runway until after the clearance for the C182 to land long was given. Although two of the controllers saw what they considered to be a conflict, they had insufficient time to speak before the pilot of the C182 had commenced his go-around.

The flight progress strip for the helicopter was in the sequence bay at the ADC console, a position that indicated authorisation for the use of the runway.

Meteorological information and tower location

The incident occurred at approximately 1730, when the sun was low on the horizon and the sun shields in the tower were deployed to minimise the effect of the brightness. This situation made it difficult to see the C182 as it made its turn onto final and the controllers did not see the aircraft at all until short final.

There were many areas of shade and sun covering various parts of the runway, but the position of the helicopter was such that it was in one of the better situations for sighting purposes. However, the comparatively low aspect of the control tower cabin, when combined with the hover height of 2 ft, enabled the ADCs to see grass from the far side of the runway strip under the helicopter skids. The controllers stated that this caused a visual perception of the helicopter being beyond the grass and therefore clear of the runway strip.

Helicopter crew

The helicopter was equipped with a communications system that allowed only the pilot in command to use the radio and consequently, all communications with ATC were performed by the company pilot. However, the flight-test requirements were being specified by the CASA pilot who was the flying pilot for the majority of the tasks. This system therefore required a relaying of requests through both pilots with a resultant increase in workload.

Even though a flight plan had been notified, each test run was slightly different, and the company pilot was unaware of the changes until briefed by the CASA pilot immediately before the run commenced. These briefings included requests from the ground party prior to each run.

During the runway-15 PAPI tests, the crew had made their approaches to the runway centreline and had remained on the runway for most of the time between runs. They had received a landing clearance in each case and that entitled them to remain on the runway until commencing the departure phase of each run. They usually hovered over the grass area when co-ordinating with the ground party. During these manoeuvres, the helicopter hovered both inside and outside the runway strip markers while runway operations continued.

Pilot of the C182

The pilot had received a clearance to make a visual approach and considered it normal to call short final over the threshold and with the speed of the aircraft approximately 130 kts. It was also normal to ask for a long landing in order to minimise taxiing distances to the company dispersal area.

After receiving a clearance to land, he scanned the runway twice but did not see the helicopter. As he was about to touch down, he did see the helicopter and commenced a go-around.

ANALYSIS

Flight planning

Despite agreeing to a date for the flight test a month earlier, the Cairns District Office did not organise the operation until the morning of the test. The CASA pilot just happened to be available at short notice and was not briefed on the requirements until approximately 4-5 hours before the flight.

The verbal pre-brief was not sufficiently adequate for the complexity of the task and did not specify the particular and unusual requirements of the test flight.

The phone facility to ATC was designed for general operations of local flights and not for "one-off" specific tasks of this nature. The complexity of the test was such that it required a specific pre-brief of ATC and a full flight plan, so that all parties were aware of the requirements. The phone plan left the controllers unsure of exactly what was going to happen. This situation resulted in control being based on individual descriptive requests from the helicopter crew as they happened and the belief that the runway was not going to be used after the initial approach.

Aircrew

While both aircrews complied with their respective clearances, each could have been more proactive in putting into place some form of safety net.

The pilot of the C182, by not reporting short final until over the threshold, did not give the ADC time to compensate for any error that may have been made.

The crew of the AS50 heard a landing clearance being given to the C182 but were unsure which runway was being used. They elected not to question the ADC as to the status of the runway.

Aircraft markings

The AS50 helicopter was painted in generally dark colours which made it difficult to see from above, especially above and behind. The lack of contrast between the grey blur effect of rotating rotor blades and the grey of the runway surface gave few visual cues to the pilot of the C182 as he approached to land.

Air traffic control

The controllers believed that the helicopter was operating clear of the runway strip most of the time and considered that the runway-15 PAPI tests were conducted on this basis. While it was unclear how many runs were made to the runway-15 PAPI site, there were in fact, several. However, each one resulted in a landing on the runway centreline and subsequent taxi to the grass areas inside the strip markers. That situation meant that during these runs, ATC were not providing a positive runway separation service between the helicopter and other runway users. However, due to the airborne phase of the test runs involving the centreline, airborne separation was provided at all times. No controller sought clarification of the status of the helicopter following its approach to the runway-33 PAPI site, nor during the previous manoeuvres involving the runway-15 PAPI site.

The belief that the helicopter was operating clear of the runway strip was reinforced by the sighting of grass below the skids and the fact that helicopters rarely use the runways at Cairns. It is normal for helicopters to arrive and depart via a taxiway or helipad and remain clear of the runway at all times.

Because of the late call on final from the pilot of the C182, the ADC had insufficient time to adequately scan the runway for any unexpected obstructions. The fact that he was reading at the time, albeit about the PAPI approach aid, further diminished the amount of time available to perform this duty. It may have also led to a short-term loss of situational awareness.

The supervising ADC had been lulled into a false sense of security by the fact that the familiarising ADC was a rated controller who had been away for only 18 days. He was a bit tired and may have allowed himself to relax more than the circumstances warranted. He had also just left the console momentarily to find the PAPI information, and he thought that this action may have led to some loss of situational awareness.

SIGNIFICANT FACTORS

1. The preparation by the Cairns District Office did not contain an adequate plan for the flight test.

2. The CASA representatives did not adequately brief ATC.

3. Neither ADC maintained an adequate situational awareness.

4. The ADCs did not ensure that the runway was clear prior to issuing a landing clearance; contributing to this situation was the late "short final" call by the pilot of the C182.

SAFETY ACTION

As a result of the investigation:

1. The operator of the AS50 has painted white markings on the rotor blades to improve sighting opportunities from above.

2. The operator of the C182 has issued instructions for pilots to initiate a "final" call at least 300 m prior to the threshold.

3. Airservices Australia has replaced the tower blinds with a better quality product that reduces glare effect.

A Boeing 737 (B737) aircraft was being radar vectored onto final approach to runway 16R at Sydney from a right base, whilst another B737 aircraft was already established on a straight-in approach from 4,000 ft to runway 16L. The aircraft being radar vectored was given an initial instruction to turn right onto 060 degrees and descend to 3,000 ft, followed by a further instruction to turn right onto 130 degrees to intercept the 16R localiser.

However, this instruction was given late, resulting in the aircraft passing through the runway 16R extended centreline at 3,500 ft, conflicting with the leading B737, already established on final to runway 16L. The crew of the following aircraft had the other aircraft in sight at all times. At their closest point, separation was reduced to 1.2 NM laterally and 700 ft vertically. Instructions were then issued to both aircraft to resolve the confliction.

Details of the flight were forwarded to Bankstown Tower, and both Sydney and Brisbane Air Traffic Control centres.  As the plan was considered to be for the following day, it was held at the Aviation Data System Operators' desks in the two centres, and flight progress strips were not issued to the appropriate sector controllers. 

Consequently, when the crew requested a clearance there was a delay of about 40 minutes to the planned departure as time was spent locating the plan and flight progress strips.  Due to this delay, the crew elected to depart visually from Bankstown, via the lane of entry at 2,000 ft, outside controlled airspace.

The Bankstown tower coordinator controller notified Sydney Flight Service of the aircraft callsign, time of departure, tracking details and altitude.  As the flight had been originally planned to remain within controlled airspace, this was the first time that the Flight Service officer was provided with information about the Citation. The officer annotated a flight progress strip for the aircraft with the details provided.

The crew of a Twin Otter reported departure from Aeropelican aerodrome and indicated that the aircraft was tracking 215 degrees M, on climb to 6,000 ft. The Flight Service officer did not pass mutual traffic information to the crews of the Citation or Twin Otter, as the nominated altitudes of the aircraft provided vertical separation and ensured the aircraft were not in conflict.  When the Citation was north of the lane of entry, the pilot in command initiated a climb outside controlled airspace, anticipating that a clearance would become available which would allow the aircraft to continue climbing to the planned level of Flight Level 330. Recorded radio communications indicated that the Citation crew did not report climbing above 2,000 ft.

Shortly after the Twin Otter departed Aeropelican, the Flight Service officer handed over duty to another officer, a process which took about two minutes to complete.  The new officer then became engaged in coordinating clearances into controlled airspace for the Citation and another aircraft, and responding to a number of calls from other aircraft in the officer's area of responsibility. The Citation was then instructed to contact Brisbane centre for a clearance. Just after the pilot transferred to the Brisbane frequency, the Flight Service officer was advised by the Sydney Departures radar controller that the aircraft had passed in close proximity to the Twin Otter, while outside controlled airspace. Neither crew were aware of the proximity of the other aircrft.

The Flight Service officer handing over was expecting the pilot of the Citation to receive a clearance with little delay. His impression was that the aircraft would soon enter controlled airspace and would therefore remain in his area of responsibility for only a short period. Consequently, he did not request additional tracking information on the Citation such as the next position and estimated time interval. As a result, the Flight Service officer assuming responsibility for the area had limited information to assist in resolving the conflict. The situation was further compounded by the high speed of the Citation, in comparison to other general aviation aircraft, and the rate of closure with the Twin Otter. As the new officer became distracted by other coordination tasks there was insufficient time to appreciate the lack of positional information on the flight progress strip. Without that information the officer was unable to establish if a traffic conflict was likely to occur.

The Flight Service officer may have been assisted in identifying a conflict if the departure report for the Citation, provided by the Bankstown tower coordinator controller, included details regarding the next reporting point and estimated time interval. Current procedures require Bankstown tower controllers to notify only those details which were provided in this occurrence.

The absence of a report by the crew of the Citation, advising that the aircraft had left 2,000 ft and was climbing, was an important cue not received by the Flight Service officer. Without this cue, the officer continued to assume that the Citation and Twin Otter were vertically separated and not in potential conflict. Consequently, traffic information was not provided to the crews of either aircraft.

Safety Action

The Bureau is researching safety issues highlighted during the course of this investigation concerning aspects of Air Traffic Control coordination.  Any recommendations and responses will be published in the Bureau's Quarterly Safety Deficiency Report.