The pilot reported that he had refuelled the aircraft to 80 litres per tank prior to departure. Pre-flight and engine checks were normal. Soon after take-off, as the flaps were retracted at about 120 ft, the fuel pressure dropped to zero and the engine stopped abruptly. The pilot immediately landed on the remaining runway but was unable to stop the aircraft overrunning the runway into rough terrain, collapsing the nose landing gear. He reported that during the shutdown checks the fuel selector was turned from the left tank to the off position.

No defects were found when the engine was stripped after the accident. It was reported that the engine ran normally during a test run after reassembly, using all of the original accessories.

The reason for the sudden engine stoppage was not determined.

The pilot took off to conduct a low-level aerobatic display. Shortly after liftoff, at a very low height, he rolled the aircraft inverted. He applied forward elevator to hold the nose up to avoid a descent.

At that point a blanking nut came off the top of the canopy and the pilot instinctively reached for it. As he did so, he inadvertently allowed the aircraft to descend inverted onto the runway surface. While still inverted the aircraft slid to a stop on the runway.

Significant Factors

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

1. The presence of the loose blanking nut.

2. Low height of the aircraft.

3. The pilot allowed himself to be distracted from his primary task of flying the aircraft, at a crucial stage of the flight.

The aircraft was being flown on a freight charter between Canberra and Goulburn, with a company approved check pilot occupying the right control seat. He had earlier conducted a route check on the left seat (handling) pilot who had been acting as pilot in command under supervision (ICUS).

At about 10 NM from Goulburn, the crew heard a radio transmission from an aircraft at Goulburn reporting a flock of birds on the approach to runway 04. The check pilot stated that as the aircraft joined the circuit, his attention was primarily focussed on searching for the reported birds.  As the aircraft entered the downwind leg of the circuit the check pilot advised the handling pilot to tighten the approach and look for the birds.

The handling pilot did not lower the landing gear prior to landing, although both pilots reported having seen the gear down indicators illuminated. They later stated that the indicator lights may have been illuminated by the late afternoon sun. The aircraft subsequently landed with the landing gear retracted, scraping the lower fuselage and damaging both propellors.

Whilst the check pilot had intended to spend the day route checking the handling pilot, he noted that the handling pilot was already qualified on the Canberra to Goulburn route.  The check pilot asked the handling pilot if he was happy to fly the sector to Goulburn, to which the handling pilot replied that he was.  The check pilot assumed that he had passed the pilot in command (PIC) responsibility to the handling pilot and therefore had no formal role in the operation of the aircraft, other than that of cursory supervision.  The PIC name on the flight plan was not amended, and with no formal handover of the PIC responsibility, the handling pilot continued to consider himself ICUS.

Company operations in the aircraft were normally single pilot; however, the conduct of a route check involved two pilots, a PIC and a pilot acting ICUS.  The cockpit during the route check was in effect a multi crew environment, although neither pilot had received any specific training in multi crew operations or crew resource management. The check pilot had not received training in conducting route checks.

The pilots were of similar age and experience, and the check pilot had become confident in the handling pilot's ability during the previous route sectors. This had the effect of him relaxing his supervision of the handling pilot. As the aircraft approached Goulburn the check pilot's attention became focussed on activities outside the cockpit, rather than supervising the performance of the handling pilot prior to landing. The handling pilot normally conducted the prelanding checks on early downwind.  The check pilot's advice to tighten the circuit and look for birds was made early on downwind, probably interrupting the handling pilot's habit pattern, resulting in landing gear extension being omitted from the pre-landing actions.

SAFETY ACTIONS

The Bureau is considering the safety issues revealed in the investigation. Any safety output will be published in the Quarterly Safety Deficiency Report.

ACTUAL INFORMATION

The B747 flight was enroute from Sydney to Kansai, via overhead Cairns then A216. The aircraft had been processed by Sydney and Brisbane ATC sectors and transferred to Cairns area. Cairns area radar position was manned by a trainee controller under supervision. This was the first occasion the trainee had manned the console.

The Cairns planner, who prepares flight strips for use by area radar controllers, did not include coordination annotations on the strip. Prior to handing the flight strip to the radar controller the planner should have annotated the strip with a 'B'. The radar controller places ticks alongside the 'B to indicate completed coordination actions. Later, as the aircraft passed overhead Cairns, the training officer and trainee were so engrossed in training aspects that they failed to update the estimate to the next control agency (Brisbane Sector 10).

Overhead Cairns the aircraft was approximately ten minutes earlier than estimated. Consequently, the aircraft transferred to Brisbane sector earlier than expected. Brisbane sector was unable to provide Port Moresby air traffic service with the 30 minutes notice required by international agreement.

There was no breakdown in separation.

ANALYSIS

Brisbane Sector 10 uses procedural control methods and does not have access to radar information. Consequently, if estimates for aircraft transiting the sector are not notified or amended by adjacent sectors, there is no other means for air traffic controllers to maintain the disposition of air traffic.

Aircraft overflying Cairns northbound have approximately 35 minutes flying time before they enter the Papua New Guinea flight information region. The need to provide 30 minutes notice to the PNG air traffic service allows only a short period for coordination to be implemented. In turn, this limits opportunities to alleviate errors should coordination be delayed or fail to be implemented.

The Cairns planner controller was required to annotate each flight strip with a 'B' to indicate a requirement to coordinate with Brisbane Control. Normally, the 'B' would have reminded the radar controller (and trainee) to notify the estimate to Brisbane sector. However, on this occasion the lack of a visual cue and the controller’s pre-occupation with training reduced the possibility of successful point to point coordination to such a degree that the system failed.

Point to point coordination is a logical process for transfer of flight information through an air traffic system. However, the lack of redundancy in the process means that the system fails if voice coordination is not implemented. Overall, the lack of a safety net for point-to-point voice coordination leaves little room for error.

FINDINGS

1. The B747 crew planned and operated the flight as scheduled.
2. The aircraft was accepted by and handed off to Cairns area control.
3. The Cairns planner did not place coordination annotations on the flight strip.
4. Cairns area control failed to update the pilots estimate to Brisbane Sector 10.
5. The aircraft was transferred to Brisbane Sector 10 approximately ten minutes earlier than expected.
6. Brisbane Sector 10 was unable to provide 30 minutes notice to Port Moresby air traffic service.

SIGNIFICANT FACTOR

1. There was a breakdown in point-to-point coordination.

SAFETY ACTION

As a result of the investigation Airservices Australia Northern District has implemented a local instruction for sector controllers. Brisbane controllers are to check with the Cairns planner if an updated estimate for northbound aircraft is not received by an aircraft's Cairns estimate.

FACTUAL INFORMATION

History of the flight

The aircraft was engaged on a charter flight for the BHP Cannington mine, and departed from Townsville at 0630 EST. The flight was uneventful, and the aircraft landed at Cannington at 0840. The aircraft was refuelled and at about 0945 seven passengers and baggage were loaded. The aircraft was started and taxied for runway 36. During this time, the necessary checks were completed. The take-off was commenced, and after the aircraft became airborne and was accelerating with a positive rate of climb, the landing gear was selected up.

While the gear was still in transit, there was a sudden power loss from the left engine. The pilot described a simultaneous height loss, roll, pitch, and yaw accompanied by a sound similar to a buzz saw from the left engine. The pilot immediately recognised that the left engine had failed and attempted to maintain speed and directional control. Power was reduced on the right engine to maintain directional control, and it was the pilot's intention to land the aircraft with gear retracted beyond the end of the runway. However, the left wingtip struck a steel fence post, and this spun the aircraft to the left. The aircraft struck a low earth bank while travelling sideways and rearwards. When the aircraft came to rest, all windows were obscured, and the pilot believed the aircraft was on fire. The pilot tried unsuccessfully to open the main cabin door, and the passengers were then evacuated through the emergency exit.

Wreckage examination

The fuselage was structurally intact, but both wings were distorted at the attachment points. Both engines were ripped from their mounts, and both main wing fuel tanks were ruptured. All passenger seats failed inside load, which was the basic cause of most injuries sustained by the occupants. On-site examination of the left engine revealed that both spark plugs in number four cylinder had been damaged. The damage was indicative of a foreign object being present in the cylinder during engine operation. Visual inspection of the piston and bore also revealed extensive damage. No foreign object was recovered from the cylinder during this inspection.

Strip examination of the left engine revealed that:

1. The propeller was physically disconnected from the engine. Examination of the propeller reduction gearbox revealed that all four attachment bolts of the stationary gear assembly had failed.
2. The stationary gear assembly appeared to have excessive backlash between the plate and gear. Disassembly of this item revealed excessive wear on the mating spline teeth of the two components.
3. There was significant fretting present on the mating surfaces of the stationary plate and reduction gearbox housing.
4. Number 4 cylinder was extensively damaged. A foreign object had entered the cylinder and severely peened the piston. The spark plug points were peened over, effectively closing the gap to zero.
5. The supercharger impeller was severely damaged, with the intake section of the vanes being machined off by an unknown object. Additionally, a segment of an impeller vane had been broken off. No foreign objects or remains of the supercharger impeller were found in the intake system.

Meteorological information

The weather was fine. The wind was 090 degrees at 15 kts, and the temperature was 30 degrees Celsius.

Weight and balance

The aircraft was loaded within prescribed weight and balance limitations.

Take-off weight (TOW) was 3908 kg. Maximum allowable TOW was 3992 kg.

Aircraft performance

The pilot said that the aircraft had accelerated to 85 kts when he raised the nose to the take-off attitude, and the aircraft became airborne at approximately 88 kts. The take-off weight chart showed that take off safety speed was 86 kts. Take-off safety speed is the speed which ensures that adequate control can be maintained under all conditions, including turbulence and sudden and complete engine failure during the climb after take-off. When the failure occurred, the pilot said he applied full right rudder, right aileron, and lowered the nose attitude. To maintain directional control, he reduced power on the right engine. There was then no alternative but to land straight ahead.

ANALYSIS

There were three distinct failures on the left engine. The stationary gear assembly was disconnected from the propeller reduction gearbox housing. The number 4 cylinder was not producing power as an unknown foreign object had damaged the spark plugs. The supercharger impeller had been severely damaged by the ingestion of an unknown foreign object.

Of these failures, only the failure of the stationary gear assembly would have resulted in the complete loss of power reported by the flight crew.

The disconnection of the stationary gear assembly was attributed to the fatigue failure of its four attaching bolts. In turn, the fatigue failure of these bolts can be attributed to a markedly reduced fatigue life resulting from increased cyclic loading. This loading resulted from excessive backlash between the mating spline between the stationary gear and its attachment plate.

The pilot stated that after the failure he was unable to control the yaw and roll that occurred and elected to land the aircraft wheels up straight ahead. The effect of the sudden and complete loss of power from the left engine above the take-off safety speed should not normally have rendered the aircraft uncontrollable. However, in this case, as distinct from an engine failure, the propeller had disconnected from the engine and was windmilling at high RPM and producing far more drag than it would have done after normal engine failure.

This had the effect of rolling and yawing the aircraft to the left. In addition, there was a 15-kt crosswind from the right, which presented an adverse environment for control inputs required to keep the aircraft straight. The pilot assessed that he may not be able to maintain control in the few seconds available, and he closed the throttles and landed the aircraft.

SIGNIFICANT FACTORS

1. The retaining bolts for the propeller gearbox stationary gear assembly failed when the aircraft had just become airborne.
2. The pilot was unable to maintain directional control and landed the aircraft with landing gear retracted.

SAFETY ACTION

As a result of the investigation into this occurrence, the Bureau of Air Safety Investigation issued Safety Advisory Notice SAN960154 to the Civil Aviation Safety Authority. The notice highlighted deficiencies in the left engine propeller gear box and provided copies of the detailed engineering reports for evaluation.

The pilot had purchased the aircraft earlier in the day and was flying it home to Kingaroy. During the pre-flight inspection he noted that the fuel quantity indication in the sight gauge was 35 litres. This was assessed as adequate for the 20-minute flight, plus reserves.

About 8 km before the destination the pilot again checked the fuel quantity, which was reported to be 10 litres. This was assessed as adequate for the remainder of the flight. Shortly after, the engine failed, and a forced landing was conducted. The paddock chosen appeared to be covered in smooth grass. During the landing roll a wheel struck a clump of the long grass, and the aircraft nosed over, coming to rest inverted.

Examination of the aircraft found that less than three litres of fuel were in the aircraft when the engine failed. The pilot was not aware that the fuel sight gauge was accurate only in flight. There was no mention of this in the aircraft manual.

Factors

1. The pilot had little experience on the aircraft type.

2. The engine failed due to fuel exhaustion.

3. A clump of grass caused the aircraft to nose over.

A video camera was mounted in the cockpit to record the pilot’s actions and comments. This also recorded some of the data presented on the instrument panel and some of the view out of the front windscreen. Most of the record from the video survived the impact and was able to provide a comprehensive record of the flight. Further information was gained from a flight data acquisition unit fitted to the aircraft and from a ground-based video camera which recorded the spin sequence. Later in the investigation the second prototype aircraft was flown and provided additional information.

The aircraft had been spun approximately 60 times prior to this flight. The spins had started with the aircraft set up with low weight and optimal C of G and had progressed to this flight which was conducted at the most critical weight and C of G configuration required for certification.

The spinning flight immediately prior to the accident flight was conducted at a slightly lower weight and at a not so critical C of G. The pilot was not able to recover from the spin on this flight until he had dumped the ballast and deployed the anti-spin parachute. The manufacturers investigation determined that the pilot had been slow to apply the correct control inputs, and the elevator control rigging did not allow full down movement of the elevator. The control cables were reset to ensure that the elevators were able to operate to the stops. After the accident there was not sufficient data available to show whether these corrective actions were effective in restoring full elevator control during a spin, although ground checks had shown full and adequate movement was available.

The investigation into the accident determined that inadequacies in the design of the fin and rudder, and in the rudder control system, had combined with the airflow blanking effect of the horizontal stabiliser, the elevators, and the slab sided fuselage, to preclude adequate spin recovery.

The fin and rudder were assessed as having insufficient area outside of the blanking flow when the aircraft was spinning. The manufacturer has since extended the chord and height of the fin to increase the area outside of that which is blanked during a spin.

The rudder has been extended in chord and lowered in position relative to the tailplane. The fin has been increased in height thereby increasing its aspect ratio. A ventral fin has been fitted to the underside of the fuselage. These measures should increase the effectiveness of the empennage.

The second prototype aircraft was initially flown with essentially the same empennage as the accident aircraft. After some flights on the second aircraft the rudder hinge moment was found to be inadequate. This factor had been masked in tests on the accident aircraft by the use of bungies in the nose wheel steering system. Installation of springs in the nose wheel steering system of the second aircraft showed up the hinge moment inadequacy which the manufacturer has corrected in the redesign of the rudder system.

Analysis of the accident data, and of subsequent test flights, has raised some doubts as to the effectiveness of the application of the elevator control during critical spin recovery. Tests are continuing in an endeavour to assess whether or not there is a problem in this area.

After the accident a review of literature concerning the effectiveness of anti-spin parachute installations was undertaken. This disclosed that the use of a parachute on a long lanyard to pitch the aircraft out of a spin has been rejected in favour of stopping the rotation through use of a larger parachute with no lanyard and short risers.

Analysis

This was a prototype aircraft and some deficiencies and/or problems during testing are to be expected.

With this particular aircraft the fact that the inadequate rudder hinge moment was masked throughout flight testing meant that the inadequate rudder performance during critical spin recovery was not clearly detected until it combined with other factors to become critical. These other factors included an ineffective anti-spin parachute, extensive blanking of the fin and rudder, and flight at the extremes of the weight and C of G envelope.

It is not known what, if any, effect the previous rerigging of the elevator controls had on this flight.

Significant factors

1. The rudder and fin effectiveness was inadequate for the spin test being undertaken.
2. The anti-spin protection systems were ineffective.

The aircraft was not able to be recovered from an intentional spin.

The flight was to transport two Telstra employees to a radio transmission tower on Lumley Hill 800 metres west of Cairns Airport. The pilot said he departed Cairns Airport at about 0925 EST and proceeded to the helipad which is about 800 feet above sea level. On arrival in the area, he carried out an inspection of the helipad by making a left-hand circuit. He then commenced a final approach from the north of the helipad from a distance of about 400 metres and on a shallow approach path. During the approach he became aware that there was only one entry and egress, which was in the direction from which he was approaching. The wind was light and variable at the time and he noticed numerous high trees on the southern side of the helipad. At about 100 feet from the pad, he became aware that he was undershooting. However, he felt that he was then committed to land as there was not enough power available to exit at that point. The helicopter was landed on uneven ground, about ten feet short of the helipad, the front of the left skid touching first. It then slid backwards down the hill for about five feet and impacted against a log which damaged the tail boom struts, and the tail boom and tail rotor assembly separated from the aircraft. The pilot and passengers were able to exit the helicopter safely after the engine had been shut down and the main rotor had ceased spinning.

The pilot reported that he was landing on the beach to conduct sight-seeing flights, and did not notice a washout in his landing path. He attempted to raise the nose and fly over it, but the nosewheel struck the far bank and the aircraft nosed over onto its back. The pilot was able to exit the aircraft safely.

Factual Information

The DHC8 aircraft VH-TNG was cleared for take-off from runway 32 and was assigned a heading of 315 degrees, which is the runway direction. After take-off the pilot turned right onto a heading of 315 degrees, and this reduced separation and brought the aircraft into conflict with the Boeing 737 VH-TJD which had become airborne from runway 01 at the same time. The pilot of VH-TJD had been instructed to turn left at 3 NM onto a heading of 350 degrees. The pilot of VH-TNG called Brisbane Approach at about 2 NM established on a heading of 015 degrees. He was instructed to immediately turn left onto a heading of 310 degrees to re-establish separation.

Recorded Radar Data

Examination of recorded radar data was undertaken to determine the proximity of the aircraft at the time of the incident. VH-TNG was observed to take off on runway 32 and commence a right turn at recorded mode C pressure altitude of 900 ft. At 2000 ft the aircraft had stabilised on a magnetic track of 015 degrees. At 2700 ft VH-TNG turned left and commenced tracking 327 degrees magnetic.

VH-TJD was observed to take off on runway 01 and commence tracking along the extended centreline of the runway. At approximately 3.5 NM DME at a pressure altitude of 2800 ft, VH-TJD turned left and commenced tracking 348 degrees magnetic.

A minimum horizontal separation of 2.2 NM occurred at approximately 0832 UTC and the vertical separation at that time was 700 ft. The minimum separation standard is 3 NM and 1000 ft.

Examination of VH-TNG Crew Actions

The Company inquiry reconstructed the likely sequence of events leading up to the incorrect heading being taken up by the pilot of VH-TNG.

Pre-flight Preparation

The cockpit pre-flight preparation proceeded normally. An airways clearance was obtained, a transponder code was not immediately available but was this was issued later during taxi. The pilot in command (PIC) was the pilot flying for this sector. he conducted the standard turn-around, pre-take-off and departure briefing according to the airways clearance received. This briefing was given relative to an anticipated departure from runway 01. Standard procedure in this circumstance is to set 016 (runway magnetic heading) on both horizontal situation indicators (HSIs) with an allowance for crosswind drift.

Taxi Out

When taxi clearance was obtained, both runways 01 and 32 were available for departure, and runway 32 was assigned. When clear of the inner apron areas the PIC confirmed the instrument serviceability checks, briefed the change of HSI heading setting to 315 degrees (runway 32 magnetic heading) plus 5 degrees for crosswind allowance. The PICs HSI was set to 320 thus acknowledging the change of runway from the runway anticipated in his previous briefing. The PIC could not be certain that the copilot reset his HSI to the appropriate heading. The copilot believes he did reset the HSI, but there was inadequate cross checking at this point, and it is possible that the copilots HSI may have remained set at 016.

The PIC then continued with a revised take-off and emergency return brief for runway 32. No revised brief for the Standard Radar Departure (SRD) relative to the change of runway was made. This was at variance with company standard operating procedures (SOPs) and the brief would have ensured that both HSIs were set correctly to 315 plus wind allowance.

Take-off

When all checklists were completed as far as possible the radio was transferred to tower frequency, and the copilot called ready some distance back from the holding point. The aircraft was cleared to line up on runway 32. As the aircraft rolled onto the runway to lineup the tower advised Tango November Golf assigned heading 315, clear for take-off. No reference was made to turning left or right and as evidenced from a play back of the tower tape, the instruction was clear and concise. The copilot hesitantly acknowledged the clearance with Tango November Golf, right onto 315.  The words right onto were not queried by the tower or the PIC. At this stage the copilot, as non-flying pilot should have set and confirmed his heading on the HSI to be 315. The PIC remembered the copilot reaching for the adjusting knob on the HSI but did not confirm that the HSI was correctly set. This a further breakdown in SOPs.

After take-off, checks were completed and passing 600 feet the PIC asked the copilot to confirm the right turn. The copilot confirmed right onto 015. The copilot the transferred to Brisbane Approach Frequency, and the aircraft was then promptly vectored away from the resulting confliction.

Analysis

Air Traffic Control Phraseology

The instruction was given assigned heading 315, cleared for take-off. The use of the phrase "maintain runway heading" may have prevented this incident. The Civil Aviation Safety Authority Head Office had recently issued an instruction to Air Traffic Services to discontinue the long-established practice of issuing the instruction " maintain runway heading."

Crew

The PIC had only recently gained command status and was relatively inexperienced on the DHC8. The copilot was senior in age and experience on type which may indicate a flat cockpit command gradient.

Relevant Factors

1. The PIC did not adequately re-brief on the standard radar departure or the change of runway to 32.
2. The PIC did not adequately monitor or cross check the copilot’s instrument settings.
3. The PIC did not detect the error in readback of the departure clearance by the copilot and was unclear as to the terms of the departure clearance before take-off.
4. The crew did not comply with Company SOPs and two crew procedures.
5. Inappropriate Air Traffic Control phraseology.