The pilot was hand starting the engine of the unoccupied Tiger Moth. After start the power increased unexpectedly. Although tethered, the aircraft broke free and ran about 20 metres before overturning.

The pilot reported that he had failed to ensure the throttle friction nut had been adequately tightened before attempting the hand start.

After take-off at approximately 150 ft above ground level, smoke began to enter the cabin. This was immediately followed by a popping sound and the right engine failed. The pilot shut down the engine, made a Mayday call, and landed the aircraft safely on the departure runway.

Later examination of the engine found that the compressor section had moved rearward and seized. Initial inspection suggests a failure of a compressor bearing support. The engine was later removed and forwarded to the manufacturers overhaul facility in the United States of America.

CIRCUMSTANCES

At the time of the incident, control tower staff comprised an aerodrome controller, a surface movement controller and a coordinator. Aircraft traffic was a Cessna 172 engaged in circuit training, a helicopter operating close to the airport boundary, two other aircraft inbound to the circuit and a Piper PA 28 taxying for take-off. In addition, a maintenance vehicle was working in the vicinity of the runway.

The pilot of the PA 28 requested and was given a clearance, by the aerodrome controller, to line up on runway 32. The aircraft was lined up adjacent to taxiway F which is 430 m from the runway threshold. The PA 28 was held on the runway whilst the controller coordinated requirements for some of the other traffic. Shortly after the PA 28 lined up the pilot of the Cessna 172 requested a clearance to land on runway 32. The controller checked that the runway appeared to be unoccupied and cleared the pilot of the Cessna 172 to land. Shortly before the Cessna 172 touched down, the controller noticed that the PA 28 was still on the runway. He did not give any instructions to the pilot of either aircraft. The Cessna 172 landed on the threshold and turned off the runway at taxiway D, 390 m further on. The controller then cleared the pilot of the PA 28 to take-off.

The Manual of Air Traffic Services indicates that a controller should not clear an aircraft to land unless he or she is assured that the landing area will be available. Similar rules are set out in the Aeronautical Information Publications for pilots. Experience suggests that controllers normally use a combination of situational awareness and visual cues to help meet their runway requirements. The aerodrome controller reported his situational awareness was reduced by the distraction caused by the coordination requirements for other traffic and the maintenance vehicle. As a result, he forgot about the PA 28 after he had cleared it to line up. When the controller checked the runway for obstructions, after the pilot of the Cessna 172 had requested a landing clearance, his vision was partly obstructed by a visual display unit located on the console in front of him. As a result, he did not see the PA 28 until he stood up from his normal operating position. This did not occur until after he had given the clearance to land. At that point the Cessna 172 was about to touch down. The controller considered that any instructions from him might make the situation worse and he decided to say nothing. He knew the pilot of the Cessna 172 was very experienced and would avoid any conflict, if possible.

The other tower staff reported they were busy with their own tasks and were not aware of the impending conflict.

The pilot of the PA 28 was inexperienced and reported that he had not fully assimilated the other circuit traffic when he lined up on the runway. As a result, he did not recognise that the Cessna 172's clearance to land would place that aircraft in conflict with his.

The pilot of the Cessna 172 reported that he was concentrating on his student's performance and was not paying attention to other traffic. Therefore, he was not aware the PA 28 had not been cleared for take-off. He observed that the PA 28 was still on the runway as his aircraft approached touchdown. Assuming it had been given a clearance to take-off, he initially thought the PA 28 would get airborne before his aircraft landed. When the PA 28 did not move he reassessed the situation and decided it was safer to continue with the landing than to attempt a go-around. His student had to apply power to roll through to taxiway D, after landing.

Although the visual display unit obstructed the controller's vision of the runway from his normal operating position (seated), it is not unusual for similar obstructions to exist, particularly in older control towers where roof support-posts are used. Consequently, it is accepted practice for controllers to move their position when checking that a runway is not occupied. In this incident the controller did not do this before he cleared the Cessna 172 to land. It is probably that, in the pressure of the moment, he did not recognise that his vision was obstructed.

SIGNIFICANT FACTORS

The following significant factors were identified as contributing to the incident.

1. The aerodrome controller's situational awareness was reduced, by distraction, to a point where he forgot about the position of an aircraft that was critical to his clearance decision.
2. The aerodrome controllers scan of the active runway was obstructed by a part of the tower equipment, and, in the pressure of the moment, he did not recognise the obstruction. Consequently, the controller did not move to check the complete runway, and he did not observe the runway was still occupied, when he cleared the Cessna 172 to land.
3. The inexperience of the PA 28 pilot was a factor in his not recognising that the Cessna 172's clearance could place that aircraft in conflict with his.
4. The pilot of the Cessna 172 was distracted by his instructional activities and did not recognise that the PA 28 had not been cleared for take-off. Consequently, he allowed the student to continue the approach in anticipation the landing area would be clear before the aircraft touched down.
5. When the pilot of the Cessna 172 realised the landing area would not be clear, he assessed that the safest alternative was to continue to a landing rather than attempt a go-around. As a result, the Cessna 172 landed on an occupied runway.

The Twin Otter took off from runway 16L, on climb to 3,000 ft. Both pilots reported that shortly after entering cloud at 2,000 ft there was a bright flash from the nose of the aircraft, temporarily blinding them. All electrical services had failed, but there was an electrical burning smell and smoke in the cockpit, which cleared when the electrical fire drills were completed. The on-board Emergency Locator Transmitter had also self-activated. Suspecting a lightning strike, and having lost radio communications, the aircraft was flown back for a landing on runway 25, with the crew broadcasting their intentions blind. The aircraft subsequently landed safely.

The departures controller noticed that the radar return from the Twin Otter had lost its altitude display soon after departure and tried unsuccessfully to contact the pilot. He thought the aircraft had suffered a communications failure and, from its track, assumed it was returning to land on runway 25, and immediately cleared the adjacent airspace. The tower controller also noticed the aircraft was landing on runway 25 without communications and issued a landing clearance by flashing a green light signal.

A subsequent inspection revealed the aircraft had sustained a lightning strike on the nose. The nose cone bonding strip had been destroyed, and the resulting heat damage had ruptured the nose cone structure. The current had taken multiple exit paths throughout the aircraft, rendering most electrical services inoperative, before exiting at various points on the tail surfaces.

The strip was grass covered and wet. When the pilot applied the brakes after touchdown, the wheels locked, providing little retardation. The pilot ground looped the aircraft to avoid running off the end of the strip. During the ground loop, however, the aircraft ran slowly backwards into some bushes, causing damage to the right wing and elevator.

VH-PZN was cleared from Mansfield to Melbourne at 4,500 ft. 30 miles northeast of Melbourne, VH-PZN advised approach radar of sighting an unexpected light aircraft, head-on at the same altitude. To avoid a collision, VH-PZN descended immediately and passed approximately 300 ft below and about 100 metres abeam the other aircraft.

The unidentified aircraft did not show up on radar as a secondary surveillance radar (SSR) return. After the breakdown in separation, its primary return was plotted by the radar controller. All attempts by Air Traffic Services (ATS) to contact the aircraft by radio were unsuccessful until the aircraft subsequently called Melbourne radar advisory service (RAS) landing at Wallan. In the meantime, a Piper PA34 assisted ATS by following the aircraft and identifying it as VH-TOF.

The pilot of VH-TOF subsequently advised that he did not see or hear VH-PZN at any time. He advised that he had been viewing property on the ground from above. He did not believe that he had climbed above 4,000 ft at any stage of his flight.

Both aircraft were flying in accordance with visual flight rules (VFR) in visual meteorological conditions (VMC) with a cloud base of 5,000 ft above mean sea level (AMSL).

Significant Factors

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

1. The pilot of VH-TOF probably inadvertently climbed above 4,000 ft.

2. No SSR transponder returns were received from VH-TOF.

3. VH-TOF was not monitoring Melbourne radar advisory service frequency 135.7 MHZ within 35 miles radius of Melbourne until arrival at Wallan.

The Sector 8 (Oceanic) controllers’ area of responsibility extended from 58 to 320 km east of Sydney. In the period preceding the incident, there was significant military traffic operating in the area above FL300.

VH-TJD was identified on radar 45 km NE of position LOTRA. (LOTRA is a reporting point 071 degrees M, 240 km from Sydney.) VH-TJD was then cleared to track from LOTRA to position CHEZA (084 degrees M, 96 km Sydney) and to descend to 8000 ft.

About 10 minutes later, N188UA departed Sydney. The standard procedure was for this aircraft to intercept the

Sydney-LOTRA track inside 50 km Sydney. On this occasion, however, the Sydney Departures controller asked the Sector 8 (Oceanic) controller if N188UA could track direct to LOTRA. The Sector 8O controller approved the request. As a result, N188UA was in potential conflict with VH-TJD.

At the time of the request from the Sydney Departures controller, the Sector 8 (Oceanic) controller had been distracted by a telephone call concerning a radar technical matter. He checked the radar display for conflicting traffic before agreeing to the request and did not see any confliction. At this time, however, the radar symbol for VH-TJD was amongst the military traffic radar symbols and was not noticed by the controller. The controller approved the request from Sydney Departures on this basis, and without checking the flight progress strips which displayed the flight details of all aircraft under his control at the time, including VH-TJD and the military traffic. In not checking the strips, the controller failed to comply with standard procedures, thus bypassing an element of the safety net which may have alerted him to the conflict.

As N188UA was climbing through about 15000 ft, the crew advised the Sector 8 (Oceanic) controller that they were deviating left as they had sighted descending traffic ahead. Examination of the recorded radar data showed the two aircraft to have been at the same level at 7nm (12 km) lateral separation.  The minimum separation standard which applied in the circumstances was 1000 ft vertical separation, or 5 nm (8km) lateral separation. The 1000 ft standard was infringed when the aircraft were between 8 km and 6 km apart.

AMENDED TEXT

The Sector 8 (Oceanic) controller's area of responsibility extended from 58 to 320 km east of Sydney. In the period preceding the incident, there was significant military traffic operating in the area above FL300.

The B737 was identified on radar 45 km NE of position LOTRA. (LOTRA is a reporting point 071 degrees M, 240 km from Sydney). It was then cleared to track from LOTRA to position CHEZA (084 degrees M, 96 km from Sydney) and to descend to 8,000 ft.

About 10 minutes later, the B747 departed Sydney. The standard procedure was for this aircraft to intercept the Sydney-LOTRA track inside 50 km Sydney. On this occasion, however, the Sydney Departures controller asked the Sector 8 (Oceanic) controller if the B747 could track direct to LOTRA. The Sector 8 controller approved the request. As a result, the outbound B747 was in potential conflict with the inbound B737.

At the time of the request from the Sydney Departures controller, the Sector 8 (Oceanic) controller had been distracted by a telephone call concerning a radar technical matter. He checked the radar display for conflicting traffic before agreeing to the request and did not see any confliction. At this time, however, the radar symbol for the B737 was amongst the military traffic radar symbols and was not noticed by the controller. The controller approved the request from Sydney Departures on this basis, and without checking the flight progress strips which displayed the flight details of all aircraft under his control at the time, including the B737 and the military traffic. In not checking the strips, the controller failed to comply with standard procedures, thus bypassing an element of the safety net which may have alerted him to the conflict.

As the B747 was climbing through about 15,000 ft, the crew advised the Sector 8 (Oceanic) controller that they were deviating left as they had sighted descending traffic ahead. Examination of the recorded radar data showed the two aircraft to have been at the same level at 7 NM (12 km) lateral separation.  The minimum separation standard which applied in the circumstances was 1,000 ft vertical separation, or 5 NM (8km) lateral separation. The 1,000 ft standard was infringed when the aircraft were between 8 km and 6 km apart.

A passenger on board the aircraft, said that the measured length of the airstrip was 1,000 m, with trees on the left and open grasslands on the right. He said the airstrip surface was rough to the left of the centreline for almost the entire length. The airstrip also had a slight uphill gradient in the take-off direction.

The passenger stated that he had taken a short flight with the pilot earlier the same day. He said that during the accident take-off the aircraft was further to the left of the runway centreline than on the previous occasion, and it appeared to accelerate more slowly. At a height of about 100 to 120 ft above ground level, the stall warning horn sounded, and the aircraft began to descend towards the trees to the left of the strip. The left wing then clipped a tree, and the aircraft descended to impact the ground nose first.

The investigator was unable to obtain details of the accident from the pilot in command.

The pilot, who still had an area restriction annotated on his pilot's licence, planned to ferry the aircraft to Kalgoorlie where he was going to pick up another pilot for the remainder of the flight to Melbourne. Prior to departure from Jandakot he checked the fuel tanks were full. On taxy out, with the left tank selected, the pilot observed fuel venting from the right-wing tank. As a take-off clearance had already been given, he elected to continue with the flight.

Whilst cruising at 2,500 ft the engine lost power. The pilot attempted to correct the situation by changing magneto settings, but this failed to work. He then concentrated on completing a safe forced landing. As the aircraft touched down in a farm paddock two sheep ran towards the aircraft and collided with the landing gear. The pilot lost directional control, and the landing gear collapsed.

The aircraft operations manual indicates that the right-wing fuel tank must be selected for take-off and until the contents reduce to one quarter full. If this is not done it is possible for the excess fuel, which is normally returned to the right tank, to be vented overboard; thus, reducing the range. The pilot had the left tank selected for take-off and he observed fuel venting from the right wing. it is probable that the aircraft ran out of fuel because the pilot did not operate in accordance with the operations manual instructions. The pilot had limited experience on the aircraft type and was not aware of the fuel management requirements.

FACTUAL INFORMATION

History of the flight

The B747 had been cleared to depart from Sydney for Noumea via a Runway 16 Right Jet Three departure. This departure required a track of 155 degrees after take-off to an altitude of 800 ft, then a right turn to intercept the 163-degree radial from the Sydney very high frequency omni-directional radio range beacon (VOR). The B737 had been cleared to depart from Sydney for Brisbane via a Runway 16 Left West Maitland Seven standard instrument departure (SID). This departure required a track of 155 degrees after take-off to an altitude of 600 ft, then a left turn to intercept the 126-degree radial from the Sydney VOR.

After receiving the clearance from air traffic control, the B747 crew read it back correctly.

The B747 took off from runway 16R, followed by the B737 which took off from runway 16L. When the B747 reached 800 ft altitude, the pilot initiated a left turn, putting the aircraft in conflict with the B737. The Departures North controller asked the pilot of the B747 to confirm that he was turning right to intercept the 163-degree radial, and the pilot replied that he was turning left to intercept the 126-degree radial. The controller immediately instructed the B747 to turn right onto a heading of 180 degrees and passed traffic information on the B737 to the B747 crew. The B747 crew complied with the instruction immediately.

The pilot of the B737 reported that he had the B747 in sight and that both aircraft were turning away from each other. Recorded radar information indicated a minimum separation of 0.5 NM horizontally and 200 ft vertically. The procedural separation standard of 1,000 ft vertically and the radar separation standard of 3 NM horizontally had both been breached.

The aerodrome controllers observed both aircraft become airborne, but they became diverted by other tasks and did not see the B747 commence the left turn. As a result, visual observation was not maintained, and a breakdown of separation standards occurred.

Pilot's understanding of procedures

Two days before this occurrence, a B747 crew of the same operator, with the same pilot in command and carrying out the same departure, had made the same error. However, on that occasion, the Departures North controller instructed the crew to take up headings to achieve the required departure track. The crew was not advised of its error and no conflict with other traffic occurred.

After the second occurrence, the pilot reported that he had felt some confusion due to the naming of the departure procedures but had realised his mistake when he looked at the departure chart after being advised to alter heading to 180 degrees.

While admitting his mistake, the pilot added that there were contributing factors, namely:

1. the two departures were depicted diagrammatically on the same sheet of his documentation (Atlas chart number7);
2. he had not been aware of his error two days previously; and
3. the aircraft taking off from runway 16L was on a different tower frequency and he had no information on this traffic.

Documentation

The pilot was using the Atlas chart entitled "JET 3 DEPARTURE RWY 16L/R, 34L", dated 22 June 1995. The chart was bounded by a border 27.0 cm by 18.5 cm in width (approximately A4 size) and depicted three departures plus airspace and terrain information to 40 NM by distance measuring equipment (DME). The chart was designed to be read in the landscape orientation. Despite the size of the sheet, the departure details were depicted within a circular area 10.7 cm in diameter. The details of the procedures out to 10 DME were depicted within a circular area 7 cm in diameter. There were no warnings about parallel runway operations on runways 16L and 16R to alert crews not to turn toward the other runway centreline after take-off.

The Atlas documentation included another page headed "SIDs RWY 16R...SYDNEY (Austr)". The sheet was bounded by a border 18.3 cm by 13 cm (approximately A5 size) and was designed to be read in the portrait orientation. The page contained textual descriptions of seven SIDs from Sydney runway 16R. The description of the Jet-3 departure was headed "Sydney Jet 3" and was written in letters approximately 2 mm in height. The description was contained within an area 10 cm by 1cm and was worded:

"Sydney Jet 3, Climb on 155 (degrees), Initial turn at 800, RT to intercept R163 SY, 115.4. Expect radar vectors at or before BELLA (DME 15 SY)"

Nomenclature of procedures

There were three Sydney Jet Three departures differentiated only by the runway designator, runway 16R, 16L or 34L. All three procedures were totally different, despite the similarity of their names. The pilot in command reported that he found the similarity of procedure naming confusing and conducive to error.

The use of the one title, differentiated only by the runway designator, for a number of departures was common practice. There were five (Sydney) Radar Six, three Wollongong Three, three Shellys Three, two Richmond Five, two Mudgee Five, two Katoomba Five, three West Maitland Seven and three Williamtown Seven departures.

ANALYSIS

Crew awareness

Despite the crew's correct readback of the allocated departure to Air Traffic Control, the crew members were obviously unsure of the procedure. The fact that the same pilot in command had made the same error two days earlier and that the air traffic services staff did not highlight the error to the pilot, meant that an opportunity to clarify any uncertainty in the pilot's mind was lost.

Tower monitoring

The closest proximity between the two aircraft was 0.5 NM horizontally and 200 ft vertically, thus breaching the procedural and radar separation standards. This would not normally have been a problem as the tower controllers would be providing visual separation; but on this occasion, they were concentrating upon other traffic and did not observe the B747 turn left. As there were no radar or procedural standards in place, this action resulted in no separation being applied by Air Traffic Control. However, as the B737 pilot had the B747 in sight throughout the sequence of events, no serious collision risk was present. The rapid response of the Departures North controller, who detected the error and instructed the B747 crew to turn right onto 180 degrees immediately, prevented the situation deteriorating further.

The Manual of Air Traffic Services, Chapter 4, "Separation Standards", Section 1, Para 26 describes the obligation of a controller to issue a safety alert when he/she believes that an aircraft is in an unsafe proximity to terrain, obstructions, or other aircraft. The paragraph recognises that a controller cannot immediately see the development of every situation where a safety alert must be issued, but he/she must remain vigilant for such situations and issue a safety alert when the situation is recognised.

Documentation

The Atlas chart depicted the departure procedures in a small central section of the chart but also showed a considerable quantity of additional detail that was not part of the procedures. In contrast, the Airservices and Jeppesen charts showed only the details of the procedures. The Jeppesen and Airservices charts carried warnings about parallel runway operations, but the Atlas chart did not carry this warning. Although any useability comparisons must be subjective, as crews become accustomed to the charts that they use, the Atlas chart seemed to be less convenient for crew use than either the Airservices or Jeppesen charts.

The Airservices and Jeppesen charts depicted the procedures both diagrammatically and in text on the same sheet. The Atlas chart depicted the procedures only diagrammatically on the sheet, the description in text was on a separate sheet. Arguably, this would further reduce the Atlas chart's user convenience.

None of the Jet Three departure charts contained a hachured region between the 126 and 163-degree radials as a clear warning to crews that parallel runway operations take place and that aircraft must not turn toward the extended centreline of the other runway. However, other Airservices charts depicting the standard instrument departures for jet aircraft departing north, south and west contained hachured areas with warnings.

Nomenclature of procedures

In the case of parallel runways where the nomenclature of different procedures differs by only the words "left" or "right", there may be a greater likelihood of crew confusion and error than in the case of a single runway. In addition, if parallel runway operations are taking place, the consequences of an error could be more serious than in the case of a single runway.

SIGNIFICANT FACTORS

1. The Sydney Jet Three departure chart used by the B747 crew was relatively easy to misread.
2. The B747 pilot did not follow the departure procedure as cleared by Air Traffic Control.
3. The tower controllers did not adequately monitor the B747 from its take-off to the commencement of its turn, resulting in a breakdown of separation standards.

SAFETY ACTION

As a result of this investigation, on 21 September 1995, the Bureau issued Interim Recommendation IR950203 to Airservices Australia as follows:

'IR950203

"The Bureau of Air Safety Investigation recommends that Airservices Australia review the presentation of parallel runway operations on the Sydney Jet Departure charts, to improve the indication of the dangers of turning across the departure path of the other parallel runway.

"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."

An information copy of the interim recommendation was issued to the Civil Aviation Safety Authority.

On 13 November 1995, the Civil Aviation Safety Authority responded as follows:

"I refer to your interim recommendation IR950203 concerning an incident involving Boeing 747, F-GEXA and Boeing 737, VH-TJN near Sydney Airport on 25 August 1995.

"Summary

"A revised Sydney Jet Departure Procedure plate will become effective on 7 December 1995.

"A forthcoming "Terminal Area Workshop" sponsored by Airservices Australia and attended by industry representatives will discuss the adequacy of the current SID naming convention.

"Background to Response

"Following the earlier similar incident by this operator, the Sydney Jet Departure Procedure plate was amended by the hachuring of the area between the two runways and the re-organisation of the presentation of the departure wording in the text section of the procedure. The line weight of the Caution note was also increased to make it more prominent. The revised presentation reflects the intent of the BASI interim recommendation. The revised plate will become effective on 7 December 1995. Copy of the 07 DEC 95 plate is attached.

"With reference to the BASI comments on the naming of the multiple departure instructions, the naming format used conforms with the ICAO Annex 4 naming convention. This format was introduced with the revised SID presentation some years ago which allowed the number of SID procedures to be considerably reduced. For instance, the Sydney SIDs were reduced from 72 to the current 11 procedures and the DAP page numbers from 22 to 6. At that time, this initiative was applauded by both industry and ATC.

"The foregoing notwithstanding, the subject of SID naming will be discussed at the Terminal Area Workshop on

20 - 21 November 1995. This workshop is sponsored by Airservices Australia and will be attended by representatives of the industry. The discussion should give a good indication of the adequacy of the current SID naming convention."

On 22 January 1996, Airservices Australia responded as follows:

"I refer to your interim recommendation IR950203, concerning an incident near Sydney Airport on 25 August 1995.

"In response to your recommendations, I can advise that a revised Sydney Jet Departure Procedure plate became effective on 7 December 1995. The main amendments involved hachuring of the area between the two runways and the re-organisation of the presentation of the departure wording in the text section of the procedure. In addition, the line weight of the caution note has been increased to make it more prominent.

"In respect of your comments relating to the naming of the multiple departure instructions, I am advised that the naming format complies with the ICAO Annex 4 naming convention."

Classification of response: CLOSED - ACCEPTED