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

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

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

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

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

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

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

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

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

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

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

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

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

History of the flight

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

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

The engine

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

The pilot

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

Fuel considerations

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

Other evidence

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

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

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

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

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

Analysis

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

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

Conclusions

Findings

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

Significant Factors

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

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

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

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

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

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

The separation standard was compromised between two international flights on crossing air routes. UAL862 was flying north-east along A579 at FL290 when the crew asked for clearance to climb to FL310 to avoid turbulence. This request was granted at 1255 and the aircraft climbed to the new level. Its calculated time at position RUSUM was 1312.

`ANZ39 was flying north-west along A464 at FL310. Its calculated time at RUSUM was 1311. The controller did not realise the confliction until 1309, and she immediately issued a descent to UAL862 which was relayed through the International HF Net manned by Flight Service. The aircraft did not respond to SELCAL. At 1312 an instruction to climb to FL330 was issued to ANZ39 via the HF link. The crew of ANZ39 reported that they had another aircraft displayed on their TCAS 14 to 15 nm south-east and at the same level.

The separation standard of 15 minutes was breached at 1256 when UAL862 climbed to FL310.

The Sector 8 controller had no direct communications with aircraft under her control. All air traffic instructions were relayed through Flight Service International on HF. The controller had approximately 6 to 8 aircraft under control in the sector. For reasons not established, the crew of UAL862 did not answer SELCAL.

The New Zealand Air Traffic Controllers were on strike and international aircraft were directed on nonstandard tracks. This added to the complexity of the operating position where lateral separation points had to be calculated for each situation.

Both aircraft crews were aware of the other aircraft due to the TCAS fitment in each aircraft.

The nose landing gear failed to extend when the gear was selected down for landing at Weipa. Several unsuccessful attempts were then made to extend the gear using the manual emergency extension. Later the nose landing gear collapsed during the landing roll when the pilot was forced to land with the nose gear in the unlocked position. All five persons on board were able to exit the aircraft safely. The aircraft sustained damage to both propellers and the forward underside of the aircraft in the incident.

After departing from Bankstown, the pilot of the Turbo Commander was instructed to climb to 5000 ft. At the same time a Boeing 767 was being vectored for a right downwind for runway 16R, on descent to 6000 ft. As the B767 approached that altitude the Departures (S) controller noticed that the Turbo Commander had climbed above 5000 ft and was approaching 6000 ft. The Turbo Commander was immediately turned right but lateral separation between the aircraft reduced to about 2 NM. The required separation standard was 3 NM lateral or 1000 ft vertical.

The pilot of the Turbo Commander later reported that he thought he had been cleared to 6000 ft, but may have confused the altitude clearance with a heading change to 160 degrees given at the same time.