Airspace incursion involving a Cessna 500, VH-ICN and Boeing 747-338, VH-EBX, 13 km south-west of Sydney Aerodrome, New South Wales, on 28 October 1995

Summary

The Sydney Approach (North) (APP(N)) radar controller observed a Cessna Citation infringe the Sydney control zone whilst departing Bankstown. At the same time, a Boeing 747 tracking towards Sydney on the runway 07 localiser had left 2,000 ft on descent. By the time the Citation was noticed by APP(N) the aircraft was approximately 2 NM abeam the 747, some 500 ft below, and travelling in the opposite direction. As APP(N) was about to inform the crew of the 747 of the conflicting traffic, the pilot of the 747 informed the controller that he had a TCAS Traffic Advisory of an aircraft 600 ft below and abeam. APP(N) advised the pilot of the 747 that the other aircraft was now clear of his track.

The pilot of the Citation later commented that, because the passenger charter flight was at night and in poor weather conditions, he was not prepared to undertake a steep turn after taking off in the 11 direction. He also believed his aircraft must have only just infringed the Sydney control zone as the DME indicated the aircraft had remained outside the zone.

A subsequent examination of recorded radar data indicated that the Citation had infringed the Sydney control zone, and that horizontal separation had been reduced to 1.26 NM, with a vertical separation of 800 ft. The required minimum separation standard was 3 NM horizontally or 1,000 ft vertically.

Occurrence summary

Investigation number 199503618
Occurrence date 28/10/1995
Location 13 km south-west of Sydney Aerodrome
State New South Wales
Report release date 02/05/1996
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Incident

Aircraft details

Manufacturer Cessna Aircraft Company
Model 500
Registration VH-ICN
Sector Jet
Operation type Charter
Departure point Bankstown NSW
Destination Cobar NSW
Damage Nil

Aircraft details

Manufacturer The Boeing Company
Model 747-338
Registration VH-EBX
Sector Jet
Operation type Air Transport High Capacity
Departure point Auckland New Zealand
Destination Sydney NSW
Damage Nil

Collision with terrain involving a Piper PA-25-235, VH-FZZ, 17 km north of Camperdown, Victoria, on 31 October 1995

Summary

The pilot reported that he was spraying thistles on the eastern side of Mt Koang. The weather at the time was clear with a moderate easterly breeze blowing. Spray runs were made in a north south direction, starting at the base of the mount and progressing up the slope parallel to a ridge line at the top.

The pilot commenced the last run from the north, flying along the top of the ridge line. Approximately halfway along the ridge line the aircraft hit a wind gust. The pilot was unable to prevent the aircraft from hitting the ridge. The aircraft hit the ground heavily and was destroyed in a post impact fire. The pilot was wearing fire resistant overalls, gloves and a helmet. He received burns to his face which was the only exposed area of skin when the accident occurred.

Occurrence summary

Investigation number 199503631
Occurrence date 31/10/1995
Location 17 km north of Camperdown
State Victoria
Report release date 08/11/1995
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 Minor

Aircraft details

Manufacturer Piper Aircraft Corp
Model PA-25-235
Registration VH-FZZ
Sector Piston
Operation type Aerial Work
Departure point Derrinallum Vic
Destination Derrinallum Vic
Damage Destroyed

Smoke involving a Boeing 737-376, VH-TJD, Canberra Aerodrome, Australian Capital Territory, on 25 October 1995

Summary

While the aircraft was descending to land at Canberra the forward toilet smoke detector activated, the flight deck smoke annunciate light illuminated and a small amount of smoke was visible on the flight deck. The flight attendant confirmed there was no evidence of fire in the toilet. A slight haze was visible in the cabin with wisps emanating from the air-conditioning vents. The crew continued with the landing and a normal disembarkation ensued.

Oil was found to be dripping from the engine which was removed for rectification. The number 1 air/oil seal was found to have delaminated allowing engine oil to permeate into the air-conditioning ducts. The seal had previously been repaired at the manufacturer's facility. After this incident the operator determined to use only newly manufactured seals and introduced an in-situ pressure test of the seal.

Occurrence summary

Investigation number 199503616
Occurrence date 25/10/1995
Location Canberra Aerodrome
State Australian Capital Territory
Report release date 22/10/1996
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Smoke
Occurrence class Incident

Aircraft details

Manufacturer The Boeing Company
Model 737-376
Registration VH-TJD
Sector Jet
Operation type Air Transport High Capacity
Departure point Melbourne Vic
Destination Canberra ACT
Damage Nil

Collision with terrain involving a Cessna 210M, VH-STB, Colwell Station, Queensland, on 26 October 1995

Summary

As the aircraft was about to land at the property strip at night a car positioned at the end of the strip with its headlights shining along the strip.

During the landing the aircraft struck the car with the left main gear and crashed onto the runway with the gear collapsed. The pilot was aware that the car was parked near the end of the strip.

Occurrence summary

Investigation number 199503592
Occurrence date 26/10/1995
Location Colwell Station
State Queensland
Report release date 13/03/1996
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 Cessna Aircraft Company
Model 210M
Registration VH-STB
Sector Piston
Operation type Private
Departure point Townsville QLD
Destination Colwell Atation QLD
Damage Substantial

Airframe event involving a Beech Aircraft Corp 58, VH-OKI, Yam Island, Queensland, on 27 October 1995

Summary

The pilot reported that the landing gear collapsed late in the landing roll. An inspection by a Licenced Aircraft Maintenance Engineer failed to find any pre-existing defects.

An accident diagram submitted by the pilot indicated that all the landing gear collapsed at about the same time.

Occurrence summary

Investigation number 199503600
Occurrence date 27/10/1995
Location Yam Island
State Queensland
Report release date 19/07/1996
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Accident

Aircraft details

Manufacturer Beech Aircraft Corp
Model 58
Registration VH-OKI
Sector Piston
Operation type Charter
Departure point Saibai Island QLD
Destination Yam Island QLD
Damage Substantial

ACAS warning involving a Boeing 747-438, VH-OJL, Sydney Aerodrome, New South Wales, on 30 October 1995

Summary

A Boeing 747 aircraft was departing from runway 16R at Sydney whilst a DeHavilland DASH 8 aircraft was departing from runway 16L. As the Boeing 747 reached about 800 ft, the crew received a Traffic Collision and Avoidance System (TCAS) resolution advisory (RA) alert which advised them to monitor the aircraft's vertical speed.

The crew of the Boeing 747 were able to observe the DASH 8, airborne from the parallel runway, and ascertained that there was no danger of confliction. The TCAS alert was of very short duration. The Boeing 747 crew maintained their current rate of climb, monitored the TCAS and did not deviate laterally or vertically from their cleared route. The routes of the two aircraft were divergent and separation increased rapidly as the flight of both aircraft progressed.

A radar plot of the two aircraft confirmed the Boeing 747 crew's perception that there was no confliction with the other aircraft. The plot indicated an initial horizontal separation of 0.6 NM which reduced momentarily and then diverged in accordance with the cleared routes of both aircraft. Vertical separation of over 1,000 ft and lateral separation of 3 NM was achieved when the Boeing 747 was four miles from the aerodrome.

The radar plot showed that the DASH 8 became airborne just prior to the Boeing 747. Because the Boeing 747 was behind and had a significantly higher rate of climb in comparison to the DASH 8, it is likely that the TCAS assessed the DASH 8 as approaching the Boeing 747 and the system generated a preventative RA alert. Subsequently, as the Boeing 747 accelerated and passed abeam whilst climbing through the other aircraft's level, the TCAS reassessed the situation and cancelled the RA. There was no breakdown in separation.

Occurrence summary

Investigation number 199503596
Occurrence date 30/10/1995
Location Sydney Aerodrome
State New South Wales
Report release date 16/09/1996
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category ACAS warning
Occurrence class Incident

Aircraft details

Manufacturer The Boeing Company
Model 747-438
Registration VH-OJL
Sector Jet
Operation type Air Transport High Capacity
Departure point Sydney NSW
Destination Christchurch NZ
Damage Nil

Forced/precautionary landing involving a Hughes Helicopters 269C, VH-LBP, 130 km north-east of Derby Aerodrome, Western Australia, on 25 October 1995

Summary

It was reported that the pilot and passenger were conducting a stock survey at 200 ft above ground level when there was a loud noise and severe vibration from the area of the engine. The pilot immediately entered an autorotation descent and turned the helicopter into wind. A check indicated that no power was available from the engine. The terrain was rocky and covered in trees, so the pilot attempted to cushion the landing as much as possible. On touchdown one skid collided with a large rock causing the helicopter to roll over onto its side. It caught fire immediately and the passenger, who was the first to exit the wreck, assisted the pilot to escape. The helicopter, including the emergency locator beacon, was destroyed by fire.

The operator maintained its own search and rescue watch on its aircraft, and a search was commenced as soon as the aircraft was reported as overdue. The pilot and passenger were found the following day by search aircraft attracted by a signal fire lit by them.

Post accident inspection indicated that the engine problem was caused by the failure of a big-end bolt in the conrod of the no.1 cylinder which allowed the conrod to come loose and punch a hole in the crankcase. The engine had been overhauled by the manufacturer 300 hours (operating time in service) prior to the accident. The fire was probably started by oil that had leaked from the hole in the crankcase onto the exhaust system.

Occurrence summary

Investigation number 199503560
Occurrence date 25/10/1995
Location 130 km north-east of Derby Aerodrome
State Western Australia
Report release date 14/12/1995
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Forced/precautionary landing
Occurrence class Accident
Highest injury level Serious

Aircraft details

Manufacturer Hughes Helicopters
Model 269C
Registration VH-LBP
Sector Helicopter
Operation type Aerial Work
Departure point Pantijan WA
Destination Pantijan WA
Damage Substantial

Forced/precautionary landing involving a Piper PA-32-260, VH-PYV, Shute Harbour (ALA), Queensland, on 26 October 1995

Summary

The pilot reported that soon after take-off at a height of 150 to 200ft the engine spluttered and then stopped. The aircraft was landed on the remaining runway. The left main landing gear was torn off and the right wing was damaged during the landing. The cause of the engine stoppage was apparently caused by fuel flow interruption, however extensive post flight examination could find no fault with the engine or fuel system.

Occurrence summary

Investigation number 199503563
Occurrence date 26/10/1995
Location Shute Harbour (ALA)
State Queensland
Report release date 31/01/1996
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Forced/precautionary landing
Occurrence class Accident

Aircraft details

Manufacturer Piper Aircraft Corp
Model PA-32-260
Registration VH-PYV
Sector Piston
Operation type Charter
Departure point Shute Harbour QLD
Destination Linderman Is QLD
Damage Substantial

Loss of separation involving a Boeing 747-438, VH-OJD and Saab SF-340B, VH-OLN, 27 km south-west of Sydney, New South Wales, on 23 October 1995

Summary

VH-OJD was cleared to track inbound via the 229 VOR radial on descent to 6,000 ft. The Approach South radar control sector controller (APP S) was processing the aircraft for landing on runway 16R. Due to operational requirements, the APP S controller delayed turning the aircraft onto a right downwind for that runway.

VH-OLN had departed runway 16R, cleared initially to climb to 5,000 ft. The Departures South radar control sector controller (DEP S) cleared the aircraft for an early right turn and an unrestricted climb to its planned cruising level.

The APP S controller was about to instruct the crew of VH-OJD to turn onto right downwind for runway 16R when he recognised that VH-OLN was climbing through 5,000 ft. In an attempt to maintain lateral separation, he instructed the crew of VH-OJD to turn left immediately and advised them of the traffic ahead to their right. At this time, the crew of VH-OJD advised that they were complying with a TCAS Resolution Advisory and climbing to 7,000 ft.

Recorded radar information indicated that the aircraft had closed to approximately 2.1 NM, with 400 ft vertical separation when the minimum separation should have been 3 NM or 1,000 ft vertically. Each had penetrated their respective airspace boundary buffer.

The runway 16 airspace agreement has a narrow corridor in the APP S airspace to the west of the airport. This airspace design limits the flexibility available to APP S when vectoring aircraft to downwind for runway 16. The latitude that DEP S may apply when vectoring departing aircraft onto south-westerly headings, and providing climb, is also restricted.

Separation was not ensured before VH-OLN was cleared for an unrestricted climb. The situation was worsened by the high rate of climb achieved by VH-OLN.

Findings

  1. The unrestricted climb instruction provided to VH-OLN by the DEP S controller was premature.
  2. The vectoring of VH-OJD onto right downwind for runway 16R by the APP S controller was initiated late.
  3. The airspace agreement boundary for runway 16 operations restricted flexibility in the processing of both arrival and departure aircraft.

Factors

1. The radar surveillance techniques used by both controllers were inadequate to prevent the loss of the prescribed separation standards.

Safety action

As a result of occurrence 9503423, the Bureau of Air Safety Investigation made interim recommendation IR950212. As the interim recommendation is also applicable to this investigation, it is reproduced below.

IR950212

The Bureau of Air Safety Investigation recommends that Airservices Australia amend the runway 16 airspace agreement boundaries to ensure that arriving and departing aircraft cannot be on, or near, reciprocal tracks. The amendment should address excursions into either buffer area.

Occurrence summary

Investigation number 199503515
Occurrence date 23/10/1995
Location 27 km south-west of Sydney
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 Saab Aircraft Co.
Model SF-340B
Registration VH-OLN
Sector Turboprop
Operation type Air Transport Low Capacity
Departure point Sydney NSW
Destination Orange NSW
Damage Nil

Aircraft details

Manufacturer The Boeing Company
Model 747-438
Registration VH-OJD
Sector Jet
Operation type Air Transport High Capacity
Departure point Bangkok Thailand
Destination Sydney NSW
Damage Nil

Forced/precautionary landing involving a de Havilland Aircraft Pty Ltd DH-82A, VH-HPH, 3 km south of Jandakot Aerodrome, Western Australia, on 20 October 1995

Summary

The pilot reported that shortly after departure from Jandakot the engine lost power and then stopped altogether. He attempted to carry out a forced landing in a grassed paddock, but the aircraft was damaged in the process.

An inspection of the aircraft's fuel system disclosed that the fuel filter, lines and carburettor were contaminated by a significant amount of rust-coloured water. However, no water was evident in fuel obtained from the drain points on either the main or auxiliary fuel tanks. The pilot reported that he had drained a significant amount of water from the main fuel tank prior to departure.

The main fuel tank was constructed of corrugated metal. The longitudinal corrugations were not connected to each other, and most were not connected to the single drain-sump. Water had collected in the corrugations, and some was still evident after the accident. The drain-sump was not located on the lowest part of the tank and undrainable water could accumulate in the tank, aft of the sump, with the aircraft in the ground attitude.

An experienced Tiger Moth engineer reported that inadequate fuel tank drain systems was a known problem, and an Airworthiness Directive (AD) had been issued which required that fuel-drain points, fitted to some aircraft types (including the Tiger Moth), be designed so that water could not be conveyed to the engine in any normal attitude for the aircraft. These drain points were usually fitted to the lowest point on the tank. That is, along the rear edge. The AD was withdrawn when a number of requirements, covered by several ADs, were incorporated into Civil Aviation Orders Part 100. Transfer of the fuel-drain requirements to the CAOs was incomplete because, whilst similar fuel-drain requirements exist for aircraft constructed in accordance with the amateur-built category of aircraft there is no longer any requirement to retrofit similar systems to existing aircraft, such as the Tiger Moth.

Two Tiger Moth fuel tank modifications, designed to meet the requirements of the AD before it was withdrawn, were available to overcome the lack of drainage found in this tank. Both incorporated drain points along the rear edge. Neither of these modifications had been incorporated in VH-HPH's fuel tank. It is probable that in-flight aircraft movement allowed some of the water that had collected in the corrugations, and at the rear of the tank, to make its way into the fuel system and cause the engine stoppage.

An inspection of the ground marks at the accident site indicated that the aircraft touched down whilst it was still in a sideslip to the left. Touchdown was followed by a partial ground-loop as the aircraft tipped up onto its nose and left upper wing. The aircraft was approaching a fence on touchdown. It is possible that the pilot used the sideslip manoeuvre in an attempt to lose height quickly and touchdown earlier but did not stop the sideslip in time for the landing.

An inspection of the lower left wing during the post-accident investigation disclosed that one spar had fractured some time prior to the accident. It was also evident that reconstruction of the wing, also carried out some time prior to the accident, was not in accordance with the manufacturer's specifications.

Occurrence summary

Investigation number 199503537
Occurrence date 20/10/1995
Location 3 km south of Jandakot Aerodrome
State Western Australia
Report release date 22/08/1996
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Forced/precautionary landing
Occurrence class Accident

Aircraft details

Manufacturer de Havilland Aircraft
Model DH-82A
Registration VH-HPH
Sector Piston
Operation type Private
Departure point Jandakot WA
Destination Jandakot WA
Damage Substantial