The pilot reported that, during the landing roll, as the aircraft slowed through about 40 knots, three cows ran on to the runway. The right propeller of the aircraft struck one of the cows and the pilot was unable to prevent the aircraft running off the end of the strip into a fence.

The pilot indicated that the runway was clear when he checked it on downwind, base, and finals. The strip was surrounded by an electric fence, but the fence was not activated at the time the aircraft landed.

During cruise the aircraft suffered an engine failure with oil covering the windscreen. The pilot carried out a successful landing onto a beach 40 km west of Milingimbi.

Later as the tide filled the aircraft, which was undamaged, became immersed in salt water.

An inspection of the engine indicated that the number six cylinder gudgeon pin had failed allowing the connecting rod to separate from the piston. As the engine continued to rotate the loose connecting rod struck and holed the crankcase.

"As a result of these reports, the Authority requested Airservices to issue a NOTAM on 27 October 1995 to correct the position of the chart symbol depicting this operation, which is incorrect on the Brisbane VTC but correct on the Oakey VTC (both dated 7 December 1995).

"In discussion with the operator it appears that, despite his making the required broadcasts prior to parachutists exiting the drop aeroplane other traffic in the area are not responding to those broadcasts and therefore parachutists are not aware of traffic which will pass below them whilst they are still under canopy some five minutes later. This traffic may be up to 15 miles from the drop zone at the time the drop aircraft broadcasts its advisory message and may not recognise the potential for confliction.

"A further difficulty is that the drop zone is only four miles from the frequency change point which coincides with the Amberley CTR boundary, and so broadcasts are often made on both frequencies. As an additional precaution, the target control officer on the drop zone monitors traffic on a portable VHF transceiver.

"The operator has previously sought the advice of the Queensland RAPAC on the establishment of a formal danger area to provide an enhanced warning to itinerant aircraft of the extent of the hazard posed by their overflying this area. However, the Authority is not convinced that a danger area is necessary in this case.

"Nevertheless, since airspace is now the responsibility of Airservices Australia, your report and recommendation have been passed to them for consideration.

"The questions of re-issuing a safety poster about parachuting activity and publishing an article on ways to minimise risks when flying near a parachute drop zone, have been raised with the Authority's Safety Promotion Section and some further educational material is under consideration."

The following response was received from Airservices Australia on 6 May 1996.

"Subject: BASI IR950225 Gatton

"Reference incorrect location of parachute symbol;

A NOTAM was issued alerting pilots to the parachute symbol location. The symbol appears on the 20 June 1996 charts at the amended position.

"The proposal for a Danger area was referred to the Queensland Regional Air Co-ordinating Sub Committee (RACS) for consideration.

"As part of the "Process 5 for the Origination, Co-ordination, Ratification, Promulgation and Registration of Airspace and Air route Amendment Proposals " the recommendation was considered by the Queensland Regional Airspace Users Advisory Council (RAPAC).

"The RAPAC did not support the establishment of a Danger area. Further action regarding chart symbols, pilot education and consultation with CASA is to be undertaken by the RACS."

The Bureau of Air Safety Investigation has classified these responses as: CLOSED - PARTIALLY ACCEPTED.

The pilot completed an airfield inspection prior to joining the circuit for landing. He noted from the movement of the trees that there was a crosswind from the right on runway 30 but he was unable to find the windsock to determine its strength. The pilot flew a normal crosswind approach, with the aircraft yawed into wind, selecting full flap (300) at a speed of 70 kts on short finals. He applied left rudder and right aileron, during the landing, to counter the crosswind. The aircraft bounced on touchdown and began to drift to the left. The application of full right aileron failed to stop the drift, and the pilot applied full power in an attempt to go-around. By this time the aircraft had left the runway and was heading towards a gravel mound. The aircraft appeared reluctant to get airborne and the pilot retracted the flaps to 200 in an attempt to improve performance. The aircraft collided with the gravel mound before it became airborne.

A video of the landing and accident indicated that a strong wind was blowing and that there were significant gusts. The aircraft was affected by one such gust as it touched down the first time and it was evident that the pilot was unable to counter its effect. There was insufficient room following the application of power for the aircraft to become airborne before it collided with the mound. The windsock had been shredded by strong winds and was unusable as an indication of wind strength. The pilot had completed crosswind refresher training on the weekend before the accident flight and had assessed the conditions as difficult but safe.

The pilot was taxiing the aircraft for take-off at the time of the accident. He had been manoeuvring the aircraft from one side of the taxiway to the other in an attempt to maintain adequate forward visibility. The pilot was wearing his goggles, because of a cold wind, and the sun was in a position that reduced visibility significantly. He observed another aircraft immediately ahead and despite closing the throttle and applying the brakes the two aircraft collided. The other aircraft was stationary on the taxiway whilst the pilot completed the pre-take-off check list.

Visibility from the Tiger Moth's rear cockpit during taxy is less than optimum at the best of times. It is probable that the sun glare momentarily distracted the pilot, and he did not see the stationary aircraft until it was too late to avoid it.

The pilot reported that the wind on the day of the occurrence, was very strong, approximately 30-40 kts at 120-130 degrees. The runway alignment was 120 degrees. As a consequence of the limited available runway length, the pilot elected to carry out a short field approach and landing. On short final to land the aircraft encountered strong windshear, which resulted in a heavy landing.

After touchdown, the left main landing gear support strut collapsed due to excessive side loads and the gear folded rearward, causing damage to the underside of the wing and flap.

All persons on board were able to exit the aircraft safely.

Aircraft was being vectored for a visual approach at Cairns, with an assigned radar lowest safe altitude of 3600ft. Approximately 18km north-west of Cairns, while heading east towards the coast, the ground proximity warning alarm activated. An immediate climb to 4000ft was initiated. The aircraft did not descend again until after crossing the coast to become visual and then made a visual approach and landing. No breakdown of separation occurred.

Later engineering examination confirmed that the alarm activation was a false indication, which was caused by an electrical fault in the GNS Omega navigation system.

QFA10, VH-OJI, departed Melbourne on radar vectors on climb in stages to 5,000 ft. At the same time VH-UJL was on track Essendon - Owens maintaining 6,000 ft. The radar controller observed QFA10 climb through 5,400 ft and turned the aircraft onto a new heading to avoid conflict with VH-UJL. Separation reduced to 500 ft vertically and 1.5 miles laterally.

Between 3,000 ft and 4,500 ft the first officer and second officer changed seats to enable the second officer to climb the aircraft. The captain had been flying manually until handing over to the second officer at about the time the aircraft was cleared from 4,500 to 5,000 ft. The second officer continued to manually fly the aircraft. 5,000 ft had been dialled up on the altitude selector, but altitude hold had not been selected because the pilots were anticipating a further climb clearance. The flaps were fully retracted normally approaching 5,000 ft. However, once the flaps retracted the flight management computer (FMC) automatically increased thrust to accelerate the aircraft to climb speed of 320 kts. With the sudden thrust increase, the rate of climb increased, and the aircraft overshot 5,000 ft. By about 5,460 ft thrust was manually retarded and the aircraft was descended back to 5,000 ft.

At the time of the incident the traffic alert and collision avoidance system (TCAS) on QFA10 showed conflicting traffic at approximately the 10 o'clock position, two miles ahead and 500 ft higher. No traffic advisory (TA) or resolution advisory (RA) indication occurred because the breakdown in separation was not severe enough.

Significant Factors

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

1. Altitude hold had not been selected so the FMC did not level off the aircraft at 5,000.

2. Aircrew had changed seats not long before the aircraft reached 5,000 ft.

3. The second officer did not anticipate the FMC induced increase in thrust/ rate of climb as the flaps fully retracted approaching 5000 ft.

4. The captain was not properly monitoring the situation.

SAFETY ACTION

QANTAS advised that the company would review when pilots would be permitted to change seats.

As the passengers were boarding, a sudden power surge was indicated by way of relay lights and instrument flags flashing on and off. A flight attendant indicated there was smoke coming from the rear galley area. The crew immediately turned off the galley power switch and all aircraft power and advised all passengers to disembark in an orderly fashion. The first officer then proceeded to the rear of the aircraft with a fire extinguisher, however it was not required.

Later examination found that both the rear galley circuit breakers had popped. The cause for the smoke was traced to a fault in the main three phase coupling plug. A section of the female to male coupling plug had short circuited and burnt. The coupling was replaced and the aircraft returned to service.

The flight was to be the first after the aircraft had recently completed a scheduled 100 hourly maintenance inspection. Soon after departure from Canberra the pilot reported a gear unsafe warning to Air Traffic Control and requested that a visual check of the landing gear be carried out. ATC reported that all landing gear doors appeared to be closed. The pilot continued the flight to Goulburn and completed aerial work in accordance with the flight plan. The aircraft did not land at Goulburn. After departing the Goulburn circuit area the pilot carried out a normal extension and retraction of the landing gear to test the system. Normal indications were received. During a practice ILS approach at Canberra the pilot again selected the landing gear down. The gear unsafe light and warning horn were activated and the nose landing gear "down" light had not illuminated.

A check of the mirror on the aircraft, which is situated to enable the pilot to determine if the nose landing gear is down, confirmed that it had not extended. The pilot requested a missed approach and a further circuit. During this period, attempts were made to lower the nose landing gear using the standard emergency extension method. The pilot then requested a departure from the circuit area so that further attempts could be made to rectify the problem. The aircraft was yawed vigorously and a number of abrupt 'pull up' manoeuvres were carried out to assist the extension of the nose landing gear. Throughout this time the pilot continued attempting to lower the nose landing gear by the emergency method, without success. The aircraft returned to the circuit area and the pilot requested that the safety officer report on the current position of the nose landing gear. The safety officer indicated to the pilot that the nose landing gear doors were partially 'cracked'. The officer also reported that he could not see the nosewheel. The pilot requested emergency services and an inspection of the grass strip parallel to runway 30 in preparation for an emergency landing. While this was being carried out the aircraft departed the circuit area to enable the pilot to carry out a further attempt to extend the nose landing gear, after which it returned to the airfield for a landing. Soon after the main wheels touched down the nose of the aircraft settled and slid along the grass for a short distance. Emergency shutdown procedures were completed. The pilot and passenger subsequently evacuated the aircraft without injury. Examination of the aircraft revealed minor damage to the nose area and to both propellers.

The aircraft nose was raised in preparation for relocation of the aircraft to a maintenance facility. The nose landing gear then extended immediately and locked down. Examination of the nose landing gear revealed that a bolt in the centering spring assembly had been incorrectly re-installed after the aircraft had undergone recent maintenance. The bolt had been installed with the bolt head uppermost as is the case with all other Piper models with the same landing gear system. However, in the PA-34-200 Seneca and PA-34-200T Seneca II, this bolt is to be installed with the head down and the nut uppermost to prevent fouling on the nose gear door actuation aft tube assembly during retraction and extension. The engineer concerned also stated that he had added an extra washer under the bolt head which further reduced the bolt's clearance from the aft tube assembly. After re-assembly, the landing gear operation was tested with the aircraft on jacks, but the error was not revealed during this test. Once airborne, however, the air loads affected the track of the nose landing gear sufficiently for the bolt to come into contact with the aft tube assembly and thus affect the extension cycle.

On 11 October 1988 the Piper Aircraft Corporation issued Service Bulletin, Number 893, to ensure installation of the correct type of bolt into position with the head down. The Service Bulletin also stated that a placard warning against incorrect installation must be placed on the nose landing gear leg where it would be seen. In October 1992 the Australian Civil Aviation Authority issued an Airworthiness Directive - AD/PA-34/41. The AD refers to the Service Bulletin and explains that when the bolt is installed incorrectly, there is a significant risk of the nose landing gear failing to extend. The aircraft maintenance logbook indicated compliance with this Airworthiness Directive. On 2 February 1995 the CAA issued an Airworthiness Advisory Circular alerting operators to the risk of incorrect bolt installation and reminding all maintenance staff to refer and strictly adhere to the maintenance manual procedures and to ensure that the correct type of bolt was used and correctly fitted. The familiarity with the bolt in a particular position in all other similar Piper aircraft may have led to a skill-based error on the part of the engineer concerned. The engineer stated that the bolt had been incorrectly installed before the recent maintenance work. The placement of the bolt with the head down is not in accordance with 'general engineering practice' that is taught to maintenance staff.

It was most likely that, due to this learned behaviour, the re-assembly had been carried out without close reference to the aircraft maintenance manual and the engineer replaced the bolt in the position in which he had found it. The placard, stating that the bolt must be installed with the head down, had not been placed in the correct position on the landing gear leg. The placard had been placed on the inside of one of the nose gear doors. The engineer who had last assembled the centering spring assembly stated that he did not see the incorrectly located placard.

Findings

1. The nose landing gear of the aircraft failed to extend.

2. The pilot carried out an emergency landing with the nose landing gear in the retracted position.

3. A bolt in the nose landing gear centering spring assembly had been re-installed in the incorrect position during recent maintenance.

4. The engineer had placed an extra washer under the bolt head which further reduced the bolt's clearance from the aft tube assembly.

5. The bolt had been installed incorrectly before recent maintenance work. The engineer re-installed the bolt in the position in which he had found it.

6. Post-maintenance ground tests of the landing gear operation indicated that it was functioning correctly.

7. A Service Bulletin, Airworthiness Directive and Airworthiness Advisory Circular had been issued alerting maintenance personnel to the potential problem.

8. A placard advising maintenance personnel to install the bolt with the head down and nut uppermost was installed in the incorrect position. The engineer did not see this placard.

9. The aircraft maintenance logbook indicated compliance with the Airworthiness Directive.

10. The aircraft maintenance manual contained correct installation instructions for the bolt.

11. The incorrect installation of the bolt resulted in the centering spring mechanism coming into contact with the nose gear door actuation aft tube assembly during flight, thus preventing full extension of the nose landing gear.

Factors

• The engineer did not comply with the instructions in the Aircraft Maintenance Manual and Airworthiness Directive in reference to the installation of the bolt in the centring spring assembly.
• The engineer failed to see the placard which warns maintenance personnel to fit the bolt with the head down.