Loss of control involving a Grumman G-164B, VH-HCR, 50 km south-west of Hay, New South Wales, on 26 September 1995

Summary

The pilot was tasked with spreading urea on dry rice crops.

He took off to the south in calm conditions. At an altitude of about 30 ft in the initial climb, he commenced a left procedural turn while continuing to climb at 70 kts to approximately 100 to 150 ft. The pilot then noticed that the airspeed had decayed to about 60 kts so he lowered the nose. Airspeed continued to decay so he stopped the turn while heading northwest and lowered the nose to increase airspeed. The aircraft continued to sink and touched down in a ploughed paddock. The pilot maintained climb power during the ground roll, hoping that the aircraft would take-off again. After a ground roll of 300 to 400 metres through the ploughed paddock, the aircraft collided with a low earthen embankment and overturned.

No fault with the engine or airframe has been reported to have contributed to the accident. The pilot admitted that the inflight turns were somewhat tight. It is probable that the aircraft stalled causing it to mush to the ground. It is also probable that the drag effects of the ploughed soil prevented the aircraft from accelerating enough to become airborne.

Significant Factors

The following factors are considered relevant to the development of the accident:

1. The pilot probably allowed the airspeed to decay during a tight procedural turn.

2. The pilot did not attempt to stop the aircraft in the ploughed paddock.

3. The pilot did not select full power for the attempted take-off from the ploughed paddock.

Occurrence summary

Investigation number 199503214
Occurrence date 26/09/1995
Location 50 km south-west of Hay
State New South Wales
Report release date 14/03/1996
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 Grumman American Aviation Corp
Model G-164B
Registration VH-HCR
Sector Turboprop
Operation type Aerial Work
Departure point 50 km SW Hay NSW
Destination 50 km SW Hay NSW
Damage Substantial

Wirestrike involving a Weatherly Aviation 620A, VH-NZG, 111 km south of Kojonup (ALA), Western Australia, on 29 September 1995

Summary

The pilot was conducting spray runs parallel to an electrical power transmission line. During one run the aircraft collided with a feeder line at 900 to its track. The collision damaged the rudder and vertical stabiliser and although the aircraft remained airborne the pilot had difficulty with directional control. He did not attempt to jettison the load. The pilot continued to fly the aircraft straight ahead until it approached a field that was suitable for a forced landing. During the attempted landing the aircraft was affected by a strong crosswind and the pilot was unable to prevent it from weathercocking into wind and colliding with some trees.

The pilot had been made aware of the main but not the feeder line. He had not noted the feeder line during his pre-application inspection, probably because the line was not visible against the dark background created by the crop. The pilot later indicated that, after the collision, he was reluctant to jettison the load as he was uncertain what effect the sudden loss of weight would have on aircraft stability. When the aircraft weathercocked into wind the damage to the rudder prevented him from being able to exercise sufficient directional control.

Occurrence summary

Investigation number 199503208
Occurrence date 29/09/1995
Location 111 km south of Kojonup (ALA)
State Western Australia
Report release date 12/12/1995
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Wirestrike
Occurrence class Accident
Highest injury level Minor

Aircraft details

Model 620A
Registration VH-NZG
Sector Piston
Operation type Aerial Work
Departure point Bokerup WA
Destination Bokerup WA
Damage Substantial

Runway incursion involving an Airbus A300-B4-203, VH-TAC, Brisbane Aerodrome, Queensland, on 28 September 1995

Summary

A utility vehicle was instructed by the surface movement controller to hold at taxiway A4 holding point which is clear of runway 01. At the same time an A300 was landing on runway 01 and was expected to exit the runway via taxiway A4S, a high-speed exit. However, the aircraft continued past this exit, and as it became obvious that it would now exit at taxiway A4 where the vehicle was stopped, the vehicle driver was instructed to vacate the taxiway. The driver reacted by driving across the runway, passing beneath the wing of the aircraft as it entered the taxiway. The driver misunderstood the instruction and was under the impression that he was cleared to cross the runway. The company has undertaken to re-brief all drivers with reference to clearance requirements.

Occurrence summary

Investigation number 199503192
Occurrence date 28/09/1995
Location Brisbane Aerodrome
State Queensland
Report release date 12/03/1996
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Runway incursion
Occurrence class Incident

Aircraft details

Manufacturer Airbus
Model A300-B4-203
Registration VH-TAC
Sector Jet
Operation type Air Transport High Capacity
Destination Brisbane, QLD
Damage Nil

Ground strike involving a Cessna 172N, VH-SIP, Fraser Island (ALA), Queensland, on 27 September 1995

Summary

The pilot stated that he departed Hervey Bay at 1030 EST, with the intention of positioning the aircraft on the eastern beach of Fraser Island to meet buses from Kingfisher Bay Resort and Village. The buses were due to arrive on the beach at Cornwells Break Road at 1100 EST. The pilot said he arrived at the eastern beach at about 1045 and carried out a precautionary search and inspection of the intended landing area. The chosen landing area had a number of four wheel drive vehicles driving over it, and the pilot noticed that they were not leaving any indentations in the sand thus indicating the suitability of the surface for landing.

The pilot said that after the inspection he climbed to 500 ft and made a left turn to position himself for a final approach towards the south. The touchdown point chosen earlier was achieved, and the mainwheel sand indentations were observed to be suitable for a ground run (as viewed from the left seat through the left window). As the speed reduced the indentations began to deepen. The nosewheel had not yet touched down. At this point a go around was initiated. Full power was applied, and 10 degrees of flap was selected. However, the mainwheels encountered an abnormally soft section of sand causing the speed to deteriorate and the nosewheel touched the sand. The nosewheel became embedded in the sand bringing the aircraft to a halt and causing the right wing to strike the ground.

The pilot stated that a Cessna 205 aircraft landed shortly afterwards in the same position without any problems and taxied over to his aircraft to offer assistance.

Occurrence summary

Investigation number 199503197
Occurrence date 27/09/1995
Location Fraser Island (ALA)
State Queensland
Report release date 08/03/1996
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Ground strike
Occurrence class Accident

Aircraft details

Manufacturer Cessna Aircraft Company
Model 172N
Registration VH-SIP
Sector Piston
Operation type Charter
Departure point Hervey Bay QLD
Destination Fraser Island QLD
Damage Substantial

Airframe event involving a Jabiru ST, VH-SSC, Archerfield Aerodrome, Queensland, on 27 September 1995

Summary

The instructor reported that after conducting a session of circuits, a full stop landing was made. Shortly after the aircraft exited the runway the nose gear collapsed. Examination revealed that the nose strut had separated from the firewall bulkhead. The reason for the failure was not determined.

Occurrence summary

Investigation number 199503190
Occurrence date 27/09/1995
Location Archerfield Aerodrome
State Queensland
Report release date 12/03/1996
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Accident

Aircraft details

Manufacturer Jabiru Aircraft Pty Ltd
Model Jabiru ST
Registration VH-SSC
Sector Piston
Operation type Flying Training
Departure point Archerfield QLD
Destination Archerfield QLD
Damage Substantial

Airframe event involving a Beech Aircraft Corp 70, VH-MWJ, Kununurra Aerodrome, Western Australia on 26 September 1995

Summary

The pilot selected the landing gear down during a normal approach to Kununurra airport. Gear extension appeared to stop about midway through the sequence and the gear-down lights did not illuminate. The pilot also reported an acrid burning smell. As the landing gear circuit breakers appeared normal, he attempted to recycle the landing gear. This had no apparent affect. The pilot checked the light bulbs and recycled again before attempting to extend the gear using the manual system. The manual extension handle was jammed, and the gear position remained unchanged.

Following a flypast the pilot was advised that the gear appeared to be down. He decided to continue with a landing, after briefing the passengers on the situation. A landing was made on the grass to one side of the sealed strip. This area was chosen in case the gear was not locked down. As the main wheels touched the ground the pilot felt them collapse. He shut the engines down as the aircraft settled on to its lower fuselage and slid to a stop.

An on-scene inspection determined that the landing gear extension cycle had stopped after 60% travel. Landing loads had torn both main landing gear struts from the mounts in their wheel wells. The nose gear, although not locked down, was held in position by the aircraft's weight and its tail-down attitude. The normal and manual systems were jammed by a failure in the right landing gear actuator. Once the actuator was released the rest of the system worked normally. The gear-motor clutch is designed to slip if the load gets too great. This caused the acrid smell reported by the pilot.

Inspection of the right actuator determined that the crests of the teeth on the extension/retraction screw drive gear had been making contact with the pinion gear body at the base of its teeth (the gears are set at 90 degrees). The additional loads resulting from this contact eventually caused one or more of the teeth to fail, jamming the gears and preventing full landing gear extension.

Damage to the actuator and the right landing gear system prevented an assessment of landing gear rigging. The failure sequence supports the theory that the right gear over-centre lock may not have been operating correctly. This would have placed additional loads on the landing gear actuator during ground operations prior to the accident flight. The loads probably forced one gear against the other leading to contact between the crest of the teeth on one gear and the body of the other.

Any incorrect operation was not evident to the pilot as it was reported that the landing gear appeared to have been operating normally up until the accident.

Occurrence summary

Investigation number 199503189
Occurrence date 26/09/1995
Location Kununurra Aerodrome
State Western Australia
Report release date 17/04/1996
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Accident

Aircraft details

Manufacturer Beech Aircraft Corp
Model 70
Registration VH-MWJ
Sector Piston
Operation type Charter
Departure point Kalumburu Mission WA
Destination Kununurra WA
Damage Substantial

Wheels up landing involving a Piper PA-30, VH-ASL, Caloundra (ALA), Queensland, on 27 September 1995

Summary

The pilot reported that he was carrying out touch-and-go landings when the accident occurred. Circuit traffic was heavy with a number of slower Skyfox aircraft. A film shoot was being conducted with three additional aircraft on the duty runway. The pilot said he decided to leave the circuit area. He came back about 10 minutes later to find two Skyfox aircraft still in the circuit also doing touch-and-go landings. He then did three more circuits before another Skyfox gave a taxi call indicating he would be joining the circuits. At that point he decided to make a full stop landing. The pilot said he was doing a wide circuit to avoid the Skyfox aircraft and was higher than normal on base leg. The distraction caused by the traffic, caused him to forget to lower the gear and the aircraft was landed wheels up.

Occurrence summary

Investigation number 199503188
Occurrence date 27/09/1995
Location Caloundra (ALA)
State Queensland
Report release date 12/03/1996
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 Piper Aircraft Corp
Model PA-30
Registration VH-ASL
Sector Piston
Departure point Caloundra
Destination Caloundra
Damage Substantial

Loss of separation involving an Airbus A300-B4-203, VH-TAC and Fokker B.V. F27 MK 50, VH-FNC, Sydney Aerodrome, New South Wales on 15 September 1995

Summary

The Airbus A300 aircraft was intercepting the runway 16R localiser for an ILS approach. During the intercept and while the A300 was on final approach in cloud, ATC requested its pilot to slow his aircraft. On the final request, the pilot was informed that his aircraft had a closure rate of 60 kts on a preceding F50 aircraft. When the A300 broke out of cloud at 1,300 ft, its pilot saw that the F50 aircraft was only about two miles ahead. He suggested to ATC that he sidestep his aircraft to approach for runway 16L but the aerodrome controller directed a go-around.

Occurrence summary

Investigation number 199503176
Occurrence date 15/09/1995
Location Sydney Aerodrome
State New South Wales
Report release date 15/04/1996
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 Airbus
Model A300-B4-203
Registration VH-TAC
Sector Jet
Operation type Air Transport High Capacity
Departure point Coolangatta QLD
Destination Sydney NSW
Damage Nil

Aircraft details

Manufacturer Fokker B.V.
Model F27 MK 50
Registration VH-FNC
Sector Turboprop
Operation type Air Transport High Capacity
Destination Sydney NSW
Damage Nil

Operational non-compliance involving a Boeing 747-438, VH-OJI, Melbourne, Victoria, on 20 September 1995

Summary

The crew was issued with a runway 27 Dosel 2 standard instrument departure (SID) clearance which was acknowledged correctly. This clearance required that the aircraft maintain a track of 263 degrees after take-off and at 5 NM turn right onto 330 degrees.

After becoming airborne the aircraft initially tracked 263 degrees before turning right at 2 NM. An instruction was then issued by air traffic control to turn right onto 330 degrees and to cancel the SID. There was no loss of separation.

The investigation revealed that the crew inadvertently entered the Dosel 1 SID into the flight management computer and then followed that procedure.  The Dosel 1 SID had the same initial track as the Dosel 2 SID but at 2 NM required a right turn onto 010 degrees.

Significant Factors

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

  1. The Dosel 1 and Dosel 2 SIDs had similar sounding names.
  2. The crew selected the wrong SID.

Safety Action

There have been a number of occurrences where pilots have mistakenly flown the incorrect SID, with the same name but different numbers. The Bureau of Air Safety Investigation issued interim recommendation, IR950203, to Airservices Australia on 21 September 1995 which stated in part "It is also recommended that the number and naming of departure procedures should be reviewed to ensure that any likelihood of flight crew selecting the wrong procedure is reduced."

The Civil Aviation Safety Authority has advised that the problems associated with the 'Dosel' SID have been recognised and addressed.

Effective from 7 December 1995, the two 'Dosel' SIDs have been combined and renamed into one procedure.

Occurrence summary

Investigation number 199503110
Occurrence date 20/09/1995
Location Melbourne
State Victoria
Report release date 16/03/1996
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 The Boeing Company
Model 747-438
Registration VH-OJI
Sector Jet
Operation type Air Transport High Capacity
Departure point Melbourne VIC
Destination Sydney NSW
Damage Nil

Fuel starvation involving a Fairchild SA227-DC, VH-KED, Portland Aerodrome, Victoria, on 11 September 1995

Summary

On base leg for runway 26 at Portland the left engine failed without any prior warning. The crew secured the engine, and a successful single engine landing was accomplished.

The engine was removed and transported to the operator's maintenance facility for investigation. During disassembly of the accessory gear drive it was found that the first idler bearing had collapsed. The bearing supported the accessory gear assembly, part number 3103601-6.

When the bearing collapsed the gear moved about the shaft axis and disengaged from the fuel pump spur gear, part number 3102268-2. With the spur gear disengaged, the fuel pump was not able to supply fuel to the engine which shut down without warning, as reported by the crew.

The failed bearing was returned to the manufacturer for investigation, however the factors surrounding the failure have not been advised.

The manufacturer did advise that they have initiated a program to improve the reliability of the first idler bearing by:

- changing from a ball to a roller type bearing,

- changing the idler housing material, and

- improving the retention of the housing thereby improving support and changing the natural frequency.

The program is now at the implementation stage. The operator has determined to retrofit the improved first idler assembly in accordance with the manufacturer's recommendations.

Occurrence summary

Investigation number 199503040
Occurrence date 11/09/1995
Location Portland Aerodrome
State Victoria
Report release date 25/10/1996
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Fuel starvation
Occurrence class Incident

Aircraft details

Manufacturer Fairchild Industries Inc
Model SA227-DC
Registration VH-KED
Sector Turboprop
Operation type Air Transport Low Capacity
Departure point Melbourne VIC
Destination Portland VIC
Damage Nil