Wheels up landing involving a Cessna 172RG, VH-IVE, Ballarat Aerodrome, Victoria, on 9 May 1996

Summary

The flying instructor was conducting dual training for the issue of a retractable undercarriage endorsement. During a touch and go, before take-off power was reapplied, the student momentarily selected the landing gear up while the aircraft was rolling at about 30 knots on the runway. The nosewheel managed to retract, the propeller struck the runway, and the nose landing gear doors were damaged. The aircraft came to rest on the runway.

During the landing roll the instructor retracted the flaps and opened the engine cowl flaps. He saw the student move to select the gear up but before being able to prevent it, the student had moved the selector to 'up', realised his mistake and immediately selected 'down' again.

Occurrence summary

Investigation number 199601597
Occurrence date 09/05/1996
Location Ballarat Aerodrome
State Victoria
Report release date 21/05/1996
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Wheels up landing
Occurrence class Accident

Aircraft details

Manufacturer Cessna Aircraft Company
Model 172RG
Registration VH-IVE
Sector Piston
Operation type Flying Training
Departure point Ballarat Vic
Destination Ballarat Vic
Damage Substantial

Electrical systems involving a Boeing 737-476, VH-TJG, 160 km west of Melbourne Airport, Victoria, on 14 May 1996

Summary

The aircraft departed Melbourne with an unserviceable auxiliary power unit (APU). During climb the left engine driven generator also failed. As the aircraft was left with only one serviceable generator, (the right engine driven generator) the flight returned to Melbourne.

These problems had been intermittently occurring for a couple of days. After extensive investigation maintenance found that the APU start switch was unserviceable. After the switch was replaced, the APU operated satisfactorily. The left engine driven generator and electrical contractor were subsequently confirmed to be unserviceable and were replaced. Subsequent operations have been satisfactory.

Occurrence summary

Investigation number 199601559
Occurrence date 14/05/1996
Location 160 km west of Melbourne Airport
State Victoria
Report release date 29/08/1996
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Incident

Aircraft details

Manufacturer The Boeing Company
Model 737-476
Registration VH-TJG
Sector Jet
Operation type Air Transport High Capacity
Departure point Melbourne Vic
Destination Adelaide SA
Damage Nil

Loss of separation involving a Boeing 737-476, VH-TJM and Beech Aircraft Corp 1900D, VH-MML, 56 km north of Canberra Aerodrome, New South Wales, on 12 May 1996

Summary

FACTUAL INFORMATION

A Boeing 737 was maintaining FL200 while enroute from Sydney to Canberra via Wollongong and a Beech 1900 was maintaining FL190 while enroute from Cooma to Sydney via Shelleys and Bindook. A Saab 340 was enroute from Sydney to Canberra at FL200 tracking via PAGER and Shelleys. The crews of all three aircraft were operating on the same air traffic control frequency when the crew of the Beech 1900 requested climb to FL200 due to turbulence.

The air traffic controller had previously assessed that the Beech 1900 would be a possible restriction for the descent of the Boeing 737 into Canberra. However, when the pilot of the Beech 1900 requested climb to avoid the turbulence, the controller forgot this potential conflict.

There was a route limitation of not above FL190 without prior coordination with the northern adjacent sector. The controller subsequently assessed that there were no restrictions for the climb and that the Beech 1900 would pass safely in front of the Saab 340. Consequently, the controller coordinated a clearance for the Beech 1900 to climb to FL200 and instructed the pilot to climb to that level. As the pilot of the Beech 1900 commenced climb to FL200 the horizontal distance between that aircraft and the Boeing 737 was approximately 6 NM. The controller then recognised the potential conflict between the Boeing 737 and the Beech 1900 and immediately instructed the pilot of the latter aircraft to maintain FL190. However, the pilot of the Beech 1900 had already left FL190 on climb and was unable to descend back to the original level before the aircraft reached FL195. The horizontal distance between the Beech 1900 and the Boeing 737 at the time was 3 NM. The required separation was 5 NM horizontally or 1000 ft vertically.

The controller instructed the crew of the Boeing 737 to turn left onto a heading of 180 degrees to maintain horizontal separation. However, before turning the aircraft, the crew reported that they had the Beech 1900 in sight. The controller provided an update of the position of the Beech 1900 as the aircraft passed 4 NM abeam. The pilot of the Beech 1900 reported at FL190, and the crew of the Boeing 737 reported turning left onto the radar heading. There was a breakdown in separation.

ANALYSIS

The controller could offer no reason for not including the Boeing 737 in his considerations. Possibly, he became focused on providing relief from the turbulence for the Beech 1900 to the detriment of his overall control. Also, the need to ensure that coordination with the adjacent sector was completed prior to approving the climb for the Beech 1900 may have diverted his attention.

SIGNIFICANT FACTORS

The controller forgot the relative positions of the aircraft when he approved the pilot of the Beech 1900 to climb to FL200.

Occurrence summary

Investigation number 199601509
Occurrence date 12/05/1996
Location 56 km north of Canberra Aerodrome
State New South Wales
Report release date 14/11/1996
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Loss of separation
Occurrence class Incident

Aircraft details

Manufacturer Beech Aircraft Corp
Model 1900D
Registration VH-MML
Sector Turboprop
Operation type Air Transport Low Capacity
Departure point Unknown
Destination Unknown
Damage Nil

Aircraft details

Manufacturer The Boeing Company
Model 737-476
Registration VH-TJM
Sector Jet
Operation type Air Transport High Capacity
Departure point Sydney NSW
Destination Canberra ACT
Damage Nil

Loss of separation involving an Airbus A320-211, VH-HYH and Boeing 737-476, VH-TJM, 130 km north of Melbourne Aerodrome, Victoria, on 11 May 1996

Summary

FACTUAL INFORMATION

An Airbus A320 and a B737 departed from Melbourne enroute to Sydney approximately two minutes apart. The A320 departed first and the crew had planned to cruise at FL370, while the crew of the B737 had planned at FL330. Both crews were cleared by air traffic control to climb to their respective levels. Airspace procedures for Instrument Flight Rules (IFR) flights operating in Class C airspace below 10,000 ft require aircraft to operate not above 250 kts indicated airspeed (IAS). Air traffic control may amend or cancel the speed restriction if the reduced speed is not required.

After the two aircraft were airborne, the Departures North (DEPN) radar controller cancelled the speed restriction by instructing both crews to climb at their desired speed. The DEPN controller did not notify any other air traffic control position that the speed restriction had been cancelled. Both aircraft transferred to the Inner North radar controller and, soon after, the crews were each instructed to reach FL330 by 80 NM Melbourne. Both crews acknowledged and readback the level requirement. The Inner North position had assumed control responsibility for the Inner West radar position due to the low level of traffic. This was normal practice when traffic levels at a position reduced such that the responsibility for the position could be consolidated with another control position. The controller was controlling one additional aircraft that was not normally the responsibility of the Inner North position. Horizontal separation between the aircraft was approximately 12 NM with the ground speed of the A320 approximately 10 kts faster than the groundspeed of the B737.

The air traffic control radar display provides a readout of aircraft ground speed which is used by controllers to assist in separating aircraft. During the next ten minutes the Inner North radar controller became involved in coordinating the separation and sequencing of a number of other aircraft and the horizontal distance between the A320 and the B737 reduced to 8 NM. The groundspeed of the B737 had increased and was approximately 100 kts faster than the groundspeed of the A320. A controller from another radar position contacted the Inner North radar controller and queried him with regard to the high rate of closure between the two aircraft and the potential to lose horizontal separation. The Inner North radar controller instructed the crew of the B737 to turn left 30 degrees and to report the new heading. The B737 crew reported that the heading would be 360 degrees and asked the controller for the type of the aircraft ahead of them and, shortly after, for the level of that aircraft. The horizontal distance between the two aircraft was then 5 NM, with the groundspeed of the B737 just over 100 kts faster than the groundspeed of the A320.

The Inner North radar controller advised the crew the aircraft ahead was an A320 at FL310. The controller was required to acknowledge and transmit instructions to a number of aircraft before being able to return his attention to the A320 and the B737. The horizontal distance between the aircraft had reduced to 4 NM, with vertical separation of 700 ft and the groundspeed of the following B737 approximately 90 kts faster than the groundspeed of the A320. The crew of the B737 reported sighting the A320 and vertical separation of 2,000 ft was achieved after another two minutes. The controller cancelled the radar heading for the crew of the B737 and instructed them to rejoin their planned route. There was a breakdown in separation.

ANALYSIS

The cancellation of the speed restriction for aircraft below 10,000 ft by the Departures radar controller was not in itself a significant factor in the incident. However, the fact that the Departures radar controller did not advise the next control position that he had cancelled the restriction was significant, as the Inner North radar controller was not alerted to the possibility of a ground speed differential between the two aircraft. Had the Inner North radar controller known of the cancellation of the speed requirement, he may have more closely monitored the progress of the two aircraft.

A significant portion of the inner North radar controller's time was spent co-ordinating with another control position and this would appear to have diverted him from adequately monitoring aircraft separation on the radar display. The inquiry by another controller alerted the Inner North radar controller to the proximity of the two aircraft and the high rate of closure due to the different groundspeeds. The Inner North radar controller became aware that the minimum horizontal and vertical separation was not going to be maintained and instructed the crew of the B737 to turn the aircraft away from the A320.

SIGNIFICANT FACTORS

1. The Departures North radar controller did not advise the Inner North radar controller that the speed restriction on the two aircraft had been cancelled.

2. The Inner North radar controller was distracted by coordination with another control position and did not adequately monitor the progress of the A320 and the B737.

3. Action by another controller alerted the Inner North radar controller to the proximity of the A320 and B737 and the significant difference in the groundspeeds.

SAFETY ACTION

The Bureau of Air Safety Investigation is evaluating aspects of separation assurance techniques within air traffic control. The details of this occurrence will be used to support SADN 960051. Any forthcoming recommendations will be published in the Quarterly Safety Deficiency Report.

Occurrence summary

Investigation number 199601506
Occurrence date 11/05/1996
Location 130 km north of Melbourne Aerodrome
State Victoria
Report release date 30/04/1997
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Loss of separation
Occurrence class Incident

Aircraft details

Manufacturer Airbus
Model A320-211
Registration VH-HYH
Sector Jet
Operation type Air Transport High Capacity
Departure point Melbourne Vic
Destination Sydney NSW
Damage Nil

Aircraft details

Manufacturer The Boeing Company
Model 737-476
Registration VH-TJM
Sector Jet
Operation type Air Transport High Capacity
Departure point Melbourne Vic
Destination Sydney NSW
Damage Nil

Involving a Boeing 727-277, VH-ANB and Beech Aircraft Corp 200, Unknown, 45 km south of Gayndah (ALA), Queensland, on 11 May 1996

Summary

FACTUAL INFORMATION

A B200 had departed Amberley, Qld for Rockhampton, Qld and was tracking from Kilcoy to Gayndah on climb to flight level (FL) 200.  This level was an initial air traffic control restriction pending further climb approval from Brisbane Sector 3B.  The pilot contacted sector control prior to Kilcoy and was re-cleared from the aircraft's present position direct to Gayndah.  This instruction had the effect of establishing the aircraft on a track slightly to the west of the Kilcoy direct Gayndah track.

The sector controller had a foreign registered A330 in conflict with the B200 and instigated a step climb procedure until the pilot of the B200 was assigned his preferred level, FL280.

A B727 had departed Brisbane, Qld for Cairns, Qld and was on climb to the standard intermediate level, FL200.  It was on a track that included the leg Kilcoy to Gayndah.  The crew contacted Brisbane Sector 3B and the controller issued a climb instruction to the flight planned level, FL350.  The controller also estimated that the B727 would pass the B200 just prior to Gayndah and, at 1129 EST, asked the crew of the B727 if they could reach FL290 by 80 NM north of Brisbane; a requirement that, if accepted, would have guaranteed separation between the two aircraft.

The B727 crew replied that they could not make the requirement, and the controller acknowledged, informing the crew that a radar vector for separation may become necessary.

Approximately four minutes later, the controller's attention was transferred to the task of processing several aircraft in the Maroochydore area that were in conflict and required separating.

At approximately 1138, as the B727 climbed through FL270, separation with the preceding, slower B200 broke down.  This was not immediately noticed by the controller.  However, when making a subsequent periodic scan of his traffic, he did notice the conflict and initiated a radar vector for the B727. This action re-established radar separation at 1140.

The B727 passed 2.3 NM to the east of the B200 while passing through that aircraft's level. The required standard was 5 NM by radar.

ANALYSIS

The controller had recognised the conflict between the two aircraft and had correctly estimated the point at which radar separation would break down. He attempted to establish positive procedural separation but, when the crew of the B727 were unable to meet the proposed requirement, elected to radar monitor the aircraft knowing that both vertical and horizontal separation were likely to be lost eventually.

Alternative procedural standards were available to establish positive separation, but these options were not taken by the controller.  When he became task oriented to the situation developing to the south-east of his area of responsibility, the time available to continue radar monitoring the B727 and B200 in the northern part of his airspace was severely reduced.

Consequently, the controller's traffic scan did not detect the proximity of the two aircraft until a breakdown in separation had occurred.

SIGNIFICANT FACTOR

The sector controller did not apply appropriate separation assurance techniques.

SAFETY ACTION

The Bureau of Air Safety Investigation is evaluating aspects of separation assurance techniques within air traffic control. Any forthcoming recommendations will be published in the Quarterly Safety Deficiency Report.

Occurrence summary

Investigation number 199601504
Occurrence date 11/05/1996
Location 45 km south of Gayndah (ALA)
State Queensland
Report release date 02/10/1996
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Incident

Aircraft details

Manufacturer Beech Aircraft Corp
Model 200
Registration Unknown
Sector Turboprop
Operation type Military
Departure point Amberley Qld
Destination Rockhampton Qld
Damage Nil

Aircraft details

Manufacturer The Boeing Company
Model 727-277
Registration VH-ANB
Sector Jet
Operation type Air Transport High Capacity
Departure point Brisbane Qld
Destination Cairns Qld
Damage Nil

Partial power loss involving a Cessna U206G, VH-AEE, Gove Aerodrome, Northern Territory, on 25 April 1996

Summary

As the engine had missed twice on the previous leg, the pilot carried out an engine check before departure. All indications were normal. About four minutes after departure, the engine became progressively rougher. The aircraft turned back to Gove and landed safely.

The number two piston was severely eroded, possibly due to detonation.

Occurrence summary

Investigation number 199601488
Occurrence date 25/04/1996
Location Gove Aerodrome
State Northern Territory
Report release date 27/05/1996
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Incident

Aircraft details

Manufacturer Cessna Aircraft Company
Model U206G
Registration VH-AEE
Sector Piston
Operation type Charter
Departure point Gove NT
Destination Numbulwar NT
Damage Minor

Loss of control involving a Mooney M20J, VH-KLY, Griffith Aerodrome, New South Wales, on 8 May 1996

Summary

The flight was planned from Maroochydore to Griffith with a refuelling stop at Nyngan. On arrival at Nyngan the refuelling agent could not be contacted so the pilot diverted to Dubbo to refuel. Prior to departure from Dubbo, the pilot estimated that he would arrive at Griffith at last light. He was not night VFR rated. The aircraft ultimately arrived at Griffith at about last light. Conditions were dark and runway lights were required for landing. The pilot made several circuits of the aerodrome while he attempted to turn on the pilot activated aerodrome lighting (PAL) system.

The pilot reported that he made two attempts to turn on the PAL but without success. He then made an attempt to land without the aid of runway lighting. After touchdown he realised he had landed well beyond the threshold and would not be able to stop by the end of the runway. He applied power and attempted to go around but the aircraft stalled and hit the ground in a left wing low attitude after which it cartwheeled to a stop. Although the aircraft was substantially damaged and there was still a significant amount of fuel in the tanks, there was no post impact fire.

Occurrence summary

Investigation number 199601477
Occurrence date 08/05/1996
Location Griffith Aerodrome
State New South Wales
Report release date 30/05/1996
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Loss of control
Occurrence class Accident

Aircraft details

Manufacturer Mooney Aircraft Corp
Model M20J
Registration VH-KLY
Sector Piston
Operation type Private
Departure point Dubbo NSW
Destination Griffith NSW
Damage Substantial

Airspace incursion involving a Fairchild SA227-DC, VH-WAJ, Perth Aerodrome, Western Australia, on 9 May 1996

Summary

FACTUAL INFORMATION

A Fairchild Metroliner was one of a number of aircraft conducting training in the Perth terminal area. Three air traffic control (ATC) positions were operating in the tower: surface movement, coordination, and aerodrome control. The aerodrome controller was also conducting "on the job training" (OJT) of a trainee controller. The aerodrome controller conducting the training was suitably rated and had completed an OJT instructor course. Runways 21 and 24 were in use for arrivals and departures. Practice instrument approaches were also being conducted by a number of aircraft. The wind was gusty and there were intermittent showers in the area, with a cloud base of approximately 2,500 ft and a visibility in excess of 10 km. Previously within Perth ATC centre, the approach coordination controller had passed aircraft estimates with the assigned runway to the tower coordinator. In an endeavour to reduce voice coordination between tower and approach elements, a procedure utilising the radar display label was in use. This procedure entailed the approach controller including the assigned runway for arriving aircraft on the "Ops Data" line of the radar display label. Thus, any controller with access to a radar display could read the runway assigned to arriving aircraft.

As part of the procedure, the approach coordination controller ceased to provide updated estimated time of arrivals (ETAs) to the tower coordinator. Aerodrome controllers calculated an ETA from the observed position of aircraft on the radar display and updated tower flight progress strips accordingly. This meant the aerodrome controller had to observe the radar display label for each arriving aircraft to obtain the assigned runway and to calculate an ETA. As a consequence, aerodrome controllers generally changed range scales between the 17 NM and 50 NM scales on a regular basis. The procedure was noted as being easily undertaken in low density air traffic situations. However, when traffic conditions were busy, an aerodrome controller's ability to change range scales, calculate an ETA and note the assigned runway was conditional; being subject to the complexity of aircraft operations at the time and the level of experience of individual controllers.

The trainee controller had very little expertise in the procedure and was developing his skills while undertaking OJT in aerodrome control. The aerodrome control position at the console was designed for single-person operation and there was insufficient space for the trainee and the aerodrome controller to occupy the position at the same time. Thus, while the trainee was undertaking OJT he was required to operate and monitor all aerodrome controller facilities on the console. The aerodrome controller's ability to read the tower radar display labels was limited by the physical location of the display and other facilities on the console. This situation was compounded by the use of a glare shield around the radar display, which was used to reduce the effect of extraneous light on the display. Without the shield, sunlight washed the display presentation and made it difficult for controllers to see aircraft symbols and labels. However, when the shield was in use, a controller could not observe the display without standing adjacent to the console and looking directly over the shield onto the radar display. Consequently, the aerodrome controller had to regularly re-position himself to be able to read the radar display while the trainee controller was operating in the aerodrome control position. The aerodrome controller was unable to readily review information on the flight progress strips or on the radar display. As the traffic sequence developed and became more complex, the aerodrome controller assumed control responsibility from the trainee. The trainee stepped back from the console to enable the aerodrome controller to operate facilities, view the flight strips and monitor the radar display.

The correct reading of the label or re-checking of the label information was critical to the aerodrome controller's task as the information was not provided from any other source. However, the trainee controller had not been advised of the potential problems and was endeavouring to learn the procedure while training in the aerodrome control position. After taking over from the trainee the aerodrome controller did not confirm the runway assignment for any aircraft. He only used the information available to him from the flight progress strips on the console. Runway 24 was annotated on the flight strip for a Boeing 737 inbound from the east of Perth. As he subsequently became engrossed in sequencing and separating aircraft, he did not notice that the assigned runway for the Boeing 737, on the radar display label, was actually runway 21.

The crew of the Metroliner had been cleared to operate in the circuit not above 1,500 ft. After completing a number of circuits, the crew were instructed to make a left circuit for runway 21 and to report sighting a Baron aircraft joining an abbreviated instrument landing system final approach at 5 NM. The crew of the Metroliner did not sight the Baron and were instructed to continue downwind, which took them closer to the boundary between Perth and RAAF Base Pearce control zones (CTR). At about the same time, the supervising controller coordinated unrestricted descent for the Boeing 737 arriving from the east for landing on, what he thought, was runway 24. Due to the proximity of the Metroliner to the boundary between Perth and Pearce CTRs to the north of Perth aerodrome, the approach controller queried the aerodrome controller's intentions for the Metroliner. The aerodrome controller intended to instruct the crew of the Metroliner to make a left orbit on base to sequence the aircraft with the Boeing 737, which he believed was to land on runway 24.

The aerodrome controller then observed the radar display symbol for the Boeing 737 approaching left base for runway 21 and subsequently requested confirmation of the assigned runway from the approach controller. The approach controller confirmed the Boeing 737 was assigned runway 21. The crew of the Metroliner were aware the aircraft was well north of Perth and close to the airspace boundary, but they expected to turn and return to Perth very shortly and were thus unconcerned. The crew of the Boeing 737 reported sighting the Metroliner and were instructed by the approach controller to maintain 2,500 ft. The aerodrome controller instructed the crew of the Metroliner to orbit right to enable the Boeing 737 to continue descent for landing. Once radar separation was established, the crew of the Boeing 737 were instructed to make a visual approach. As the crew of the Metroliner orbited to the right, the aircraft entered the Pearce CTR and conflicted with a Macchi aircraft.

The pilot of the Macchi was conducting a tactical air navigation (TACAN) approach to runway 36 at Pearce and the last reported level was 2,000 ft. The Macchi and the Metroliner were observed by Pearce air traffic control radar to pass with approximately 1.5 NM horizontal separation. Neither crew observed the other aircraft. The crew of the Metroliner and the Macchi continued their flights and landed at Perth and Pearce respectively. There was a breakdown of separation. ANALYSIS Procedures The procedure for notifying assigned runway and calculating estimates for arriving aircraft for the tower had proven to be an effective alternative to the previous voice coordination. However, controllers needed to ensure that the label information was correctly transposed to the flight progress strips and that the radar display scale was changed regularly to check for arriving aircraft. This entailed a degree of skill which had to be developed with experience. The difficulties in using the radar display and the need to occasionally re-check aircraft label information was appreciated by other rated and more experienced controllers. However, this aspect had not been brought to the attention of the trainee controller prior to undergoing OJT. Consequently, he was unprepared for the switching of range scales on the display and the need to confirm the "Ops data" information, on an opportunity basis, to ensure the integrity of the operational information transposed to the flight progress strips. It is possible that the trainee annotated the incorrect runway on the flight progress strip for the Boeing 737 prior to the aerodrome controller taking over the position.

Additionally, because of the difficulties in observing the radar display while the trainee was operating at the position, it is likely that the aerodrome controller was unable to readily confirm the runway assignment of individual aircraft as the trainee annotated the respective flight progress strips. The procedure relied solely on controller skill; should the controller not perform the procedure correctly there was no back-up to ensure the tower received the necessary information. Training The trainee had not received any preparatory brief or training prior to the conduct of aerodrome control OJT. The trainee was rated at surface movement control but he had been absent from Perth aerodrome for a number of months working as a relief controller at Jandakot aerodrome. The lack of preparatory training was in contrast to terminal area trainees who receive 1 week of classroom training and 2 weeks of simulator training prior to undertaking OJT. The lack of preparatory training meant the trainee had to learn most aspects of the task while actually operating in the control position. This made the training difficult because of the different learning skills involved.

The different learning aspects coupled with his unfamiliarity with operations meant that the trainee was unlikely to be able to perform at the optimum level for OJT. Better preparation of the trainee prior to commencing the OJT would have been a defence against the incident occurring. Airspace Due to the proximity of RAAF Pearce to Perth, similar runway alignment and the location of the CTR boundary midway between the two aerodromes, operations in both CTRs can be constrained at times. This makes management of the airspace difficult and can limit the options available to controllers. It also requires a high level of situation awareness by controllers to ensure aircraft are not instructed or cleared in a manner that would have them infringe the Pearce CTR. In this incident the aerodrome controller was aware of the proximity of the Metroliner to the CTR boundary but was limited in his options to ensure descent was available for the Boeing 737. To achieve this he needed the crew of the Metroliner to orbit right. The subsequent instruction caused the Metroliner to enter the Pearce CTR. The crew of the Metroliner were aware that the aircraft was close to the CTR boundary but they believed the controller would have obtained clearance from Pearce ATC for the aircraft to enter the CTR. Consequently, the crew complied with the controller's instruction. The aircraft entered the adjacent CTR without a clearance and conflicted with the Macchi aircraft.

SIGNIFICANT FACTORS

1. The trainee controller was inadequately prepared to undertake OJT.

2. The aerodrome controller had difficulties in observing the radar display while the trainee was operating the control position.

3. The aerodrome controller, after taking over control from the trainee, had insufficient time to confirm the runway assignment of arriving aircraft.

4. The proximity of Perth and Pearce aerodromes and the common CTR boundary limited the options available to the aerodrome controller.

SAFETY ACTION

1. Perth ATS management implemented a traffic management plan in December 1996 which should assist controller traffic management.

2. The Bureau of Air Safety Investigation is evaluating aspects of "on the job training" relating to Perth Tower.

Any forthcoming recommendations will be published in the Quarterly Safety Deficiency Report.

Occurrence summary

Investigation number 199601487
Occurrence date 09/05/1996
Location Perth Aerodrome
State Western Australia
Report release date 27/03/1997
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Incident

Aircraft details

Manufacturer Fairchild Industries Inc
Model SA227-DC
Registration VH-WAJ
Sector Turboprop
Operation type Flying Training
Departure point Perth
Destination Perth
Damage Nil

Operational non-compliance involving a Piper PA-31-350, VH-OZP, Launceston Aerodrome, Tasmania, on 3 May 1996

Summary

FACTUAL INFORMATION

A Piper Chieftain aircraft, inbound to Launceston from Moorabbin, had been cleared to track via the Launceston (LT) very high frequency omni-directional radio range (VOR) navigation aid to the Nile non-directional beacon

(NDB). The cloud base was approximately 300 feet with fog and visibility of 4000 metres at the aerodrome. The Chieftain was to conduct an instrument landing system (ILS) approach to runway 32 left (32L) due to the weather conditions.

The tower was manned by a single air traffic controller. Prior to the incident the controller had frequently discussed weather conditions with the Melbourne Centre Coordinator, Sector controller and local meteorological personnel. At the same time, the controller had processed a number of aircraft (inbound and outbound) and was monitoring the operations of two vehicles on the aerodrome. A safety officer in one vehicle was conducting runway 32L lighting checks, which required the controller to adjust runway light switches, while the other officer was inspecting grass runway 18/36.

Due to the inbound track of the aircraft and orientation of runway 32L the pilot of the Chieftain had to make a reversal procedure at the Nile NDB prior to commencing the ILS approach. When the pilot reported over the Nile NDB, after tracking from the VOR and before conducting the reversal procedure, the controller instructed the pilot to report 'Nile outbound'. This was queried by the pilot and confirmed by the controller as 'Nile outbound'. The pilot tracked outbound from the NDB, conducted the reversal procedure and reported 'Nile inbound' which was contrary to the report required by the controller. The controller cleared the pilot to make a 32ILS approach, provided airfield information and instructed the pilot to 'Report on final leaving 3,000'.

As the controller completed flight strips, he became distracted and did not observe the Chieftain as it broke out of cloud and approached the runway. The safety officer on runway 32L observed the aircraft on final in the vehicle's rear vision mirror and immediately vacated the runway. The driver did not notify the controller the vehicle had vacated the runway strip.

The pilot had become visual just before the minima and after visually ascertaining the runway was unobstructed continued with the approach and landed without a landing clearance. There was a breakdown in procedures but no breakdown in separation.

ANALYSIS

The controller assumed the pilot report of 'Nile inbound' was the previously requested 'Nile outbound' report, and that the reversal procedure was still to be completed. Consequently, the controller thought there were a few minutes available to clear the printer and compile flight strips before needing to look for the Chieftain on ILS final and instructing the driver to vacate the runway. However, this was not the case, and the aircraft was closer to the aerodrome than the controller appreciated. The controller would appear to have heard what he expected to hear and not what was actually reported by the pilot. The phenomena of 'hearback' is recognised as a problem in aviation communication. However, it is difficult to guard against, especially when an individual is working alone. Had another controller been present the misunderstanding of the pilot's report may have been detected. Alternatively, if the controller had been able to concentrate on controlling and not been required to prepare flight strips, he may have been able to detect the changed report.

The pilot had a clearance for final which authorised the aircraft to leave the lowest holding altitude and to make a circling or missed approach as appropriate. A clearance for final is subject to any further air traffic control instructions and a clearance to land. In this situation the pilot had a clearance limit of the runway and should not have continued with the landing without a specific clearance of 'Clear to land'. But the pilot had the impression that he had a clearance to land and that the controller was well aware of the aircraft's location in the approach. Consequently, the pilot considered further reports unnecessary. This aspect is a failed defence as procedural air traffic control relies solely on pilot reports to arrange aircraft separation in instrument meteorological conditions. The lack of reports would have diminished the controller's situational awareness. Provision of the report of 'On final leaving 3,000' may have provided a cue to the controller that the aircraft was closer to the aerodrome than expected. As a consequence, the controller would probably have given greater priority to the approaching aircraft by ensuring runway availability (by instructing the vehicles to vacate) and issuing a landing clearance.

While the safety officers were obliged to notify the controller when a vehicle had vacated the runway, in accordance with airport operating procedures, the lack of notification was not a significant factor in the incident. Whether notification was provided or not, would not alleviate the responsibility of the controller to make a visual check of the runway to ensure the landing path was not obstructed prior to approving the aircraft to land. The action of the safety officer operating on the aerodrome control frequency while on the runway was an active defence in the incident. The officer heard the radio transmissions between the Chieftain pilot and the controller and was aware an aircraft was in the vicinity preparing to land. Consequently, he was prepared and able to vacate the runway in sufficient time for the Chieftain to land after the aircraft was observed on final. The officer's high level of situational awareness was the major factor that ensured the runway was not obstructed when the pilot landed without a clearance. However, the driver could have assisted the controller to maintain situational awareness by notifying that the vehicle was vacating the runway due to an approaching aircraft.

The pilot stated he became visual just before the minima and observed some vehicle activity near the runway edge. After checking the runway was clear he continued with the approach and landed. The controller did observe the flight of the Chieftain just prior to touchdown. However, after visually scanning the runway, observing the vehicles had vacated and believing that a landing was inevitable, he felt there was no need to distract the pilot with a late radio transmission during a critical phase of flight.

FINDINGS

  1. The pilot of the Chieftain did not report at Nile outbound.
  2. The controller incorrectly heard or misinterpreted the pilot's Nile inbound report.
  3. The pilot did not report on final leaving 3,000 feet as instructed.
  4. The safety officer observed the approaching aircraft and vacated the runway strip.
  5. The safety officers did not report vacating the runway strip to the controller.
  6. The controller observed the Chieftain just prior to touchdown.
  7. The pilot of the Chieftain landed without a clearance.

Occurrence summary

Investigation number 199601474
Occurrence date 03/05/1996
Location Launceston Aerodrome
State Tasmania
Report release date 01/08/1996
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Operational non-compliance
Occurrence class Incident

Aircraft details

Manufacturer Piper Aircraft Corp
Model PA-31-350
Registration VH-OZP
Sector Piston
Operation type Air Transport Low Capacity
Departure point Moorabbin VIC
Destination Launceston TAS
Damage Nil

Abnormal engine indications involving an Embraer EMB-110P1, VH-KHA, Darwin Aerodrome, Northern Territory, on 24 April 1996

Summary

The aircraft had started descent into Darwin when the right engine ITT and torque exceeded their maximum limits. The right power lever was then moved to flight idle but had no effect on the ITT and torque. A precautionary engine shut down was then completed. The flight continued uneventfully, and a landing made at Darwin.

The drive from the fuel pump to the fuel control unit failed.

Occurrence summary

Investigation number 199601454
Occurrence date 24/04/1996
Location Darwin Aerodrome
State Northern Territory
Report release date 27/05/1996
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Abnormal engine indications
Occurrence class Incident

Aircraft details

Manufacturer Embraer-Empresa Brasileira De Aeronautica
Model EMB-110P1
Registration VH-KHA
Sector Turboprop
Operation type Air Transport Low Capacity
Departure point Jabiru NT
Destination Darwin NT
Damage Minor