Wheels up landing involving a Beech Aircraft Corp 76, VH-JWX, Bankstown, New South Wales, on 19 April 1995

Summary

On return from the training area the pilot advised that he had an unsafe indication from the nose landing gear. The tower confirmed that the nose gear was in the retracted position, so the pilot elected to return to the training area to attempt to rectify the problem. All attempts to lower the nose gear using normal and emergency systems were unsuccessful. Emergency services were placed on standby, and the aircraft subsequently landed with the nose gear retracted.

Investigation revealed that the nose gear door actuating system was worn excessively and out of rigging tolerance. This allowed the system to go to an over centre position and hold the doors in the closed position, thus preventing the nose gear from extending. The door actuating rods were incorrectly attached to the rear side of the door brackets, and the door hinges were stiff from lack of lubrication.

Occurrence summary

Investigation number 199501150
Occurrence date 19/04/1995
Location Bankstown
State New South Wales
Report release date 15/06/1995
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 Beech Aircraft Corp
Model 76
Registration VH-JWX
Sector Piston
Operation type Flying Training
Departure point Camden NSW
Destination Bankstown NSW
Damage Substantial

Airframe event involving a Piper PA-34-200, VH-SVS, Parafield, South Australia, on 17 April 1995

Summary

The pilot made a slightly heavier than normal landing. During the landing roll the nose gear down light extinguished, and the nose gear collapsed.

An investigation revealed the nose gear retraction ram mounting bracket had failed, allowing the nose gear to fold rearwards.

The aircraft had been involved in a similar occurrence 70 hours previously when the original factory installed aluminium mounting bracket failed. The bracket used to effect the repair was made from the same type of material, and had failed in a similar manner

Later models of this type of aircraft are fitted with a steel bracket.

Research of the Bureau's occurrences database, and contact with the manufacturer did not indicate this type of aluminium bracket was unduly prone to failure. Because the new stronger steel bracket is now available from the manufacturer no further safety action is considered necessary.

Occurrence summary

Investigation number 199501143
Occurrence date 17/04/1995
Location Parafield
State South Australia
Report release date 08/11/1996
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Accident

Aircraft details

Manufacturer Piper Aircraft Corp
Model PA-34-200
Registration VH-SVS
Sector Piston
Operation type Flying Training
Departure point Parafield SA
Destination Parafield SA
Damage Substantial

Total power loss involving an Amateur Built Kitfox IV, VH-MKF, 9 km south of Mangalore, Victoria, on 14 April 1995

Summary

Approaching the Mangalore area the pilot commenced descent and had reached a height of about 1000 feet when the engine suddenly started to vibrate severely. When the throttle was closed the engine stopped completely. The pilot selected a nearby paddock and landed with a slight tailwind. During the ground roll the right wheel entered a rut, which dislodged the right main gear leg and caused the right wing and the propeller to contact the ground.

The reason for the engine vibration and failure has not been determined.

Significant Factors

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

1. Engine power loss, reason undetermined.

2. Forced landing on unsuitable terrain.

Occurrence summary

Investigation number 199501117
Occurrence date 14/04/1995
Location 9 km south of Mangalore
State Victoria
Report release date 16/05/1995
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Accident

Aircraft details

Manufacturer Amateur Built Aircraft
Model Kitfox IV
Registration VH-MKF
Sector Piston
Operation type Private
Departure point Essendon VIC
Destination Mangalore VIC
Damage Substantial

Collision on ground involving a Thunder & Colt Balloons 69A, VH-HGB, Coomera Golf Course, Queensland, on 18 April 1995

Summary

The pilot intended to fly the balloon to Jacobs Well, due east of his take-off point at the Coomera Golf course. When the balloon rose to about 100 ft above ground level, he saw that extensive areas of fog covered the ground in the vicinity of Jacobs Well. He rejected the flight and landed back on the golf course in the middle of a fairway, only 70 m from his take-off point.

He called his ground crew assistant over to tow the balloon by a trailing rope to the edge of the fairway as he did not want to bring the recovery vehicle onto the fairway. His passenger had left the basket, but the ground crew member had difficulty moving the balloon. The pilot decided to swap places with her. The ground crew member operated the balloon's burners as required and the pilot towed the balloon to the side of the fairway. When the balloon touched trees, the gas was turned off at the tanks and the envelope deflated. As it did so, the basket rolled onto one side on sloping ground. The ground crew member struck her head on the burner controls lighting both burners for several seconds as the gas burnt out of the supply lines.

The ground crew member received burns to the upper part of her body, including inhalation damage to her oesophagus. The pilot received minor burns.

Occurrence summary

Investigation number 199501095
Occurrence date 18/04/1995
Location Coomera Golf Course
State Queensland
Report release date 13/03/1996
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Accident
Highest injury level Serious

Aircraft details

Model 69A
Registration VH-HGB
Sector Balloon
Operation type Private
Departure point Ormeau QLD
Destination Jacobs Well QLD
Damage Nil

Collision with terrain involving a Stits Playboy, 10-1468, Kooralbyn, Queensland, on 16 April 1995

Summary

A witness reported that, after turning base for runway 12, the aircraft began oscillating in pitch as it continued a shallow descent. The aircraft crossed the extended centreline of the runway and struck a tree at the edge of a public car park. This caused the aircraft to break up, part of it falling on an unoccupied vehicle.

The pilot is reported to have indicated that the aircraft stalled and that he was unable to recover to normal flight before colliding with the tree.

Occurrence summary

Investigation number 199501093
Occurrence date 16/04/1995
Location Kooralbyn
State Queensland
Report release date 17/07/1995
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Collision with terrain
Occurrence class Accident
Highest injury level Serious

Aircraft details

Manufacturer Stits Aircraft
Model Playboy
Registration 10-1468
Sector Piston
Operation type Private
Departure point Kooralbyn QLD
Destination Kooralbyn QLD
Damage Destroyed

Collision with terrain involving an Air Tractor AT-301, VH-FAA, 20 km north-east of Millmerran, Queensland, on 17 April 1995

Summary

The pilot had completed two thirds of the task of spraying a field of cotton which was bounded by a road and powerlines at one end. The pilot had been flying under the wires and had kept a watch for traffic along the road. On what turned out to be his last pass, he again lined up to fly under the wires. As he approached the wires, he saw a truck travelling along the road, on a collision course with his aircraft. Trees had obstructed the truck from view. As the pilot took avoiding action, the right mainwheel of the aircraft struck the road surface. The right main gear was bent backwards. The pilot flew his damaged aircraft to the airstrip and landed. At a slow speed it ground looped and came to rest without any further damage.

Occurrence summary

Investigation number 199501092
Occurrence date 17/04/1995
Location 20 km north-east of Millmerran
State Queensland
Report release date 24/04/1995
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Collision with terrain
Occurrence class Accident

Aircraft details

Manufacturer Air Tractor Inc
Model AT-301
Registration VH-FAA
Sector Piston
Operation type Aerial Work
Departure point Millmerran QLD
Destination Millmerran QLD
Damage Substantial

ANSP info/procedural error involving a Cessna 172N, VH-NIT, Devonport, Tasmania, on 6 April 1995

Summary

The purpose of the flight was to conduct an instrument rating renewal which included an instrument approach to Devonport. As the aircraft broke clear of cloud, the pilots became concerned that the aircraft was considerably lower than expected. Flight instrument indications appeared normal, both during and after the flight. Subsequently, the supervising pilot queried the Melbourne Regional Briefing Office (RBO) regarding the accuracy of the Automatic Terminal Information Service (ATIS) broadcast, on which the instrument approach had been conducted.

The pilot believed that the QNH was in error by approximately 12 hectopascals (hPa), resulting in the aircraft being approximately 360 ft lower than expected, and the wind was from the opposite direction.

Checks by the RBO indicated that the Bureau of Meteorology had not issued a current Devonport aerodrome Meteorological Report (METAR). This was due to the report message generated by the automatic weather station at Devonport being rejected by the Bureau of Meteorology computer.

The relevant air traffic service (ATS) officer had unknowingly broadcast an invalid Devonport METAR stored within ATS computer systems. Internal investigations by ATS revealed that as a result of a software problem, and the absence of a current Devonport METAR, the previous issue (24 hours old) had been retained and broadcast in error. Had a new, valid METAR been received it would have over-written the older, invalid message.

The QNH used for the approach was 1010 hPa in lieu of the actual 996 hPa, placing the aircraft approximately 420 ft lower than expected. The ATS computer system does not provide the origin time of the METAR. This was a fail unsafe deficiency.

The Civil Aviation Authority took immediate actions to prevent a recurrence by implementing revised procedures in the national communications centre.

The following factors contributed to the development of the occurrence:

  • The Devonport automatic weather station report was rejected by the Bureau of Meteorology computer.
  • ATS officer unknowingly broadcast an invalid METAR.
  • ATS computer error.
  • ATS computer failure to provide message origin time for metar.
  • This resulted in the pilot being provided with an incorrect QNH.

Occurrence summary

Investigation number 199501082
Occurrence date 06/04/1995
Location Devonport
State Tasmania
Report release date 22/12/1995
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category ANSP info/procedural error
Occurrence class Incident

Aircraft details

Manufacturer Cessna Aircraft Company
Model 172N
Registration VH-NIT
Sector Piston
Departure point Devonport TAS
Destination Devonport TAS
Damage Nil

Airframe event involving a Bell 214ST, VH-LAT, 440 km west-north-west of Darwin, Western Australia, on 7 April 1995

Summary

Circumstances

About 20 minutes after take-off, while cruising at 3,000 ft and 128 kts with the autopilot engaged, the pilot in command heard or felt a bang which was immediately followed by a high-frequency, high-amplitude vibration. The vibration was such that the crew were unable to read the outboard instruments, both skid balls were fully deflected towards the centreline of the aircraft, and the horizontal situation indicator slaved some 60 degrees off heading and oscillated through 30-40 degrees. The co-pilot reported that the vibration through the cockpit floor made his feet go numb.

The pilot in command altered heading for a return to the rig. All controls appeared to be operating normally and the only warning light to illuminate was the number one elevator light which went out when the system was reset.

Speed was reduced to 60 kts and the aircraft was descended to 200 ft as a precaution in the event of a failure. The change in airspeed and power and the manipulation of the controls did not alter the frequency or level of the vibration.

About 30 minutes later, the vibration stopped as abruptly as it had started. The aircraft felt completely normal, and all controls worked normally. The pilot in command increased speed to 100 kts. As the aircraft passed another rig, which was considered to be unsuitable for an emergency landing, it was observed by the rig crew, who reported that everything appeared normal.

About 2 minutes after the vibration stopped, it started again at the same frequency, but at a higher amplitude. A very short time later, the aircraft suddenly yawed to the right and tail rotor control was lost. The pilot in command closed the throttles and the yaw stopped. He then placed the aircraft in an autorotational descent, using cyclic control to counter yaw. The pilot in command reported that the tail rotor controls felt as if they were rubbing against something when he operated them following the tail rotor failure.

During the subsequent flare, as the pilot in command was about to lower the nose and cushion the landing, the aircraft commenced an uncommanded pitch nose-down, even though the pilot in command was still holding full back cyclic control. The pilot in command increased the collective pitch and the co-pilot activated the floats. The aircraft was pitching nose-down and rolling to the right as it touched down on the water. It continued to roll to the right until it was upside down. All doors were opened by the impact. Both pilots left the partly submerged, overturned aircraft by their respective doors and surfaced at about the same time.

The pilots observed that the tail boom, held on the surface by a partially inflated flotation bag, was about 40 m from the main fuselage. The left main fuselage flotation bag was fully inflated. The right bag was inflated except for the centre section.

Both the tail and main fuselage sections subsequently sank in 85 m of water.

A search of the seabed failed to locate the tail section. The main fuselage section was located, inspected and videotaped using a remotely piloted underwater vehicle.

Inspection of the video and of photographs taken before the fuselage sank indicated that the tail boom broke off approximately 1.5 m aft of the boom attachment bulkhead. The boom appeared to have fractured upwards and then sideways to the right. One main rotor blade had marks indicating a fuselage strike. The other blade was shattered.

There was no evidence of failure of the longerons adjacent to the boom attachment bulkhead (a known problem).

No photographs of the tail boom were available.

The helicopter was maintained in accordance with requirements in force at the time of the accident.  There was no evidence of pre-existing defects which could have contributed to this occurrence.

Analysis

The vibration was reported by the crew as high frequency and high amplitude indicating that it was most likely associated with tail rotor components rather than engine accessories. Both sets of components rotate at high speed and therefore could induce high frequency vibration. However, it is unlikely that an engine accessory could introduce a high amplitude vibration such as that described by the crew. In addition, the vibration caused the horizontal situation indicator (HSI) to slave off heading. As the compass sensor for the HSI is located in the tail boom this indicates that the vibration was probably centred in that area. The vibration did not vary with power or speed indicating that it was not associated with uneven aerodynamic loading (of the tail rotor). Vibration associated with a previously reported longeron failure was reported as low frequency.

During the period of the initial vibration, and during the break from it, the aircraft controls appeared to respond normally. The pilot lost tail rotor control shortly after the onset of the second period of vibration. The tail rotor drive rotates at a relatively constant speed and the drive components are located inside the fuselage structure. As a result, it is likely that vibration associated with these components would remain relatively constant at all power settings and speeds. The one unusual aspect of the failure is that all vibration ceased for a period and flight returned to normal. As the tail boom and tail rotor components were not found, the precise nature of the failure could not be determined. Available information indicates that the vibration was possibly associated with a failure of either the tail rotor drive shaft and/or its mountings or one of the two tail rotor drive gearboxes and/or its mountings.

The damage to the main fuselage in the area of the tail boom fracture and to the main rotor blades indicates that the boom probably failed following contact with the water, during the landing flare, and as a result of a main rotor blade strike. The fact that a tail boom flotation bag partially inflated also indicates that the boom was still attached on touchdown.

Occurrence summary

Investigation number 199501030
Occurrence date 07/04/1995
Location 440 km west-north-west of Darwin
State Western Australia
Report release date 25/01/1996
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Accident

Aircraft details

Manufacturer Bell Helicopter Co
Model 214ST
Registration VH-LAT
Sector Helicopter
Operation type Charter
Departure point Rig Ocean General ZOCA
Destination Darwin NT
Damage Substantial

Loss of separation involving a Boeing 737-476, VH-TJP and British Aerospace PLC BAe-125-700B, VH-HSP, 120 km south-west of Sydney, New South Wales, on 7 April 1995

Summary

VH-HSP departed Sydney five minutes before VH-TJP. Both aircraft were tracking via Wollongong and T18 to Eildon Weir. On first contact with sector control, VH-HSP was cleared to climb as planned to flight level (FL) 350. VH-TJP was also planned at this level but on first contact with sector control, VH-TJP was cleared to climb to amended FL 330. At this stage, VH-TJP was closing on VH-HSP at 110 knots and was 13 miles behind.

A very inexperienced trainee was operating the position under the supervision of a rated controller. The controller was distracted from his supervision task for a short period and when he returned his attention to the screen, he noted that VH-TJP was now only five miles behind VH-HSP and 200 feet below.

The controller told the trainee to turn VH-TJP onto 150 degrees. The trainee instructed VH-TJP to turn right onto 150 degrees but immediately corrected this to turn left onto 150 degrees. The crew then queried the direction of turn. The controller took over from the trainee, told the crew to turn left and gave them traffic information on the other aircraft. Separation reduced to a minimum of three miles at the same level.

Both the controller and the trainee indicated they were not very familiar with the performance of VH-HSP and that the climb performance achieved had been less than they anticipated. The controller expected that VH-HSP would reach flight level 350 before longitudinal separation was lost. Separation would then be maintained vertically which was the reason VH-TJP was assigned amended FL 330.

Significant Factors

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

1. Inadequate knowledge of the performance of VH-HSP.

2. The controller did not maintain an adequate monitor of the situation to ensure that the separation strategy devised, actually achieved its aim.

Occurrence summary

Investigation number 199501047
Occurrence date 07/04/1995
Location 120 km south-west of Sydney
State New South Wales
Report release date 16/06/1995
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 British Aerospace
Model BAe-125-700B
Registration VH-HSP
Sector Jet
Operation type Charter
Departure point Sydney NSW
Destination Essendon VIC
Damage Nil

Aircraft details

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

Collision with terrain involving a Eiriavion Oy PIK 20-D, VH-WQQ, 5 km south-west of Warra, Queensland, on 2 March 1995

Summary

The flight was an attempt by the pilot to achieve the 500km Goal Flight. During the flight the pilot was unable to find continuing lift and an outlanding became necessary. During the landing the right wing struck grass at the boundary of a paddock and the glider ground looped.

The pilot had misjudged the approach and overshot his intended touchdown point. He had also forgotten to lower the landing gear.

Occurrence summary

Investigation number 199501053
Occurrence date 02/03/1995
Location 5 km south-west of Warra
State Queensland
Report release date 26/07/1995
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Collision with terrain
Occurrence class Accident

Aircraft details

Manufacturer Eiriavion Oy
Model PIK 20-D
Registration VH-WQQ
Sector Other
Operation type Private
Departure point Dalby QLD
Destination Dalby QLD
Damage Substantial