VH-EJM was being operated on dual circuit training on runway 30. A mixture of left and right circuits had previously been flown, with the last one being a right circuit. Stop and go landings were being made. On the last approach air traffic control had instructed the pilot to make the next circuit a left circuit.

VH-FNE was lined up on runway 35 and after VH-EJM had crossed the runway intersection the controller cleared VH-FNE for take-off. On climb the crew of VH-FNE observed VH-EJM to be approaching their flight path, on a right circuit. The climb of VH-FNE was stopped and VH-EJM passed about 200 feet above and slightly behind VH-FNE. The pilot of VH-EJM had seen VH-FNE.

At about the same time as the pilots of the two aircraft saw each other the air traffic controller, who had been looking in another direction at a third aircraft, looked back and saw VH-EJM flying a right circuit and in conflict with VH-FNE. Traffic information was given to VH-FNE and the pilot of VH-EJM was advised of the mistake and to continue with the right circuit.

Significant Factor

The following factor was considered relevant to the development of the incident:

1. Misunderstanding of the instruction to make a left circuit, by the pilot of VH-EJM.

The pilot reported that the aircraft accelerated normally during the take-off run and began a normal climb over tree covered rising ground. At about 100 feet above the tree tops a strong down draught was encountered, which the aircraft was unable to out climb. When it became evident that a collision was inevitable the pilot attempted to stall the aircraft into the trees. The aircraft collided with the treetops and nosed over, coming to rest inverted. Both occupants were able to vacate the aircraft with minor injuries.

Circumstances

The B737 was operating on airway B580 and had passed waypoint URGUS at 1234 EST maintaining FL350 and was estimating waypoint MULID at 1322. Flight plan estimates indicated that the B737 would cross airway A464 at approximately 1343 and the next waypoint APORA at 1424.

The B74F was operating on airway A464 and had passed waypoint RELIK at 1251 maintaining FL350 and was estimating over Lord Howe Island at 1323. Flight plan estimates indicated that the B74F would cross airway B580 at approximately 1331 and the next waypoint UDIKO at 1401.

At approximately 1254, Brisbane oceanic control sector 8 (Sect 8) relayed a level change requirement instruction through Sydney Flight Service International (FS INT) for the B737 to descend from FL350 to FL330. The instruction was intended to provide separation assurance between the B737 and the B747F.

The level change requirement was notated on the correct flight progress strip but entered in an incorrect information box relating to waypoint URGUS, the waypoint just passed.  The FS INT officer was provided with a temporary relief break at approximately 1310.  The level change requirement had still neither been passed to the B737 nor been included in the handover/takeover to the relieving officer.

At approximately 1328, the relieving FS INT provided Sect 8 with reports for the B737 passing MULID and the B74F passing Lord Howe Island. Both aircraft were still maintaining FL350. Sector 8 realised that the aircraft level change instruction had not been issued and that lateral separation standards had been infringed.

Due to the prevailing poor communications propagation conditions, FS INT was unable to re-establish contact with the B737 until approximately 1336. The B737 then descended to FL330 and crossed airway A464 approximately seven minutes later.

Although the prescribed separation standards were not maintained, there was no risk of collision.

No new safety deficiencies were identified during this investigation.

The aircraft landed into a very strong wind, and as the tail was being lowered during the landing roll a change in the wind direction violently lifted the left wing. The pilot used full corrective aileron and rudder but could not prevent the aircraft from veering off the right side of the strip or the right wingtip touching the ground. He then applied full asymmetric power to straighten the aircraft, and after regaining control took-off again, returning for a safe landing.

After taxiing to the terminal, the pilot-in-command and co-pilot inspected the wingtip and aileron for damage and checked the controls for full and free movement. They both believed that only superficial damage had occurred and that the aircraft was airworthy. Subsequent investigation revealed that the outboard aileron hinge mounting had been displaced.

The pilot refuelled the aircraft to full tanks on the evening prior to the accident. The aircraft remained parked at Griffith aerodrome overnight.

The next day, the pilot completed two tasks of 0.8 hours each. He then conferred with his chief pilot, about the fuel endurance of the aircraft, before commencing another 0.8 hour task.

After a flight time of 0.7 hours, while completing the "clean-up" run, the engine stopped. The pilot completed the emergency checks but was unable to restore engine power. He was then faced with a forced landing in a rice paddock. During the landing roll, the aircraft struck a dirt bank which bent the landing gear and damaged the fuselage and hopper.

The pilot was familiar with the fuel usage rate of the aircraft and planned on a rate of 100 litres per hour. The fuel capacity of the aircraft was 328 litres and at the expected usage rate should have allowed an endurance in excess of three hours. The pilot believes that the aircraft was tampered with overnight. The fuel contents were not checked prior to departure that morning.

The approximate track of VH-TAH was direct from Malim to Bindook, maintaining flight level 350. VH-CZV was tracking from Wagga to Cowra at flight level 330 and the tracks of these two aircraft crossed. Due to turbulence the crew of VH-CZV requested a climb to flight level 350. A clearance was given for VH-CZV to climb to flight level 370, with a requirement to reach this level in 15 track miles.

Subsequently, the radar controller realised VH-CZV would not reach this level in time. An instruction was issued to VH-CZV to turn right by 90 degrees. The required separation was not maintained, with the lateral distance reducing to 3 miles when VH-CZV was 1500 feet above VH-TAH. The climb was continued and vertical separation established.

Significant Factors

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

1. Controller technique in allowing insufficient track distance to achieve the level change.

2. Aircraft crew acceptance of the requirement and then not advising they could not achieve the required level in time.

3. Slow recognition by the controller that the climbing aircraft would not reach the required level in time.

The pilot reported that on final approach, he noticed that the runway surface appeared uneven and unsuitable for landing, so he conducted an overshoot. During this manoeuvre, the left main gear struck the ground or an object. The pilot retracted the landing gear and diverted to Horn Island. The left main gear collapsed on landing.

The runway at Badu Island had been closed for maintenance.

The strip and windsock were appropriately marked. Badu Island airstrip is not a licenced aerodrome and as such a NOTAM regarding works in progress was not issued. The local council reported that it notified the regular operators who serviced the island. However, the operator involved in this occurrence was not aware that the strip was closed.

The No. 1 hydraulic system failed soon after take off. The flaps retracted to 6 degrees and the right main landing gear warning light illuminated. The pilot declared an emergency and the aircraft was held until emergency services were in place. Emergency landing gear extension was successful, and a normal landing followed, but without nosewheel steering, requiring the pilot to use asymmetric braking.

Subsequent investigation revealed the No. 1 engine hydraulic pump pressure outlet elbow had failed, allowing a complete loss of fluid from the No. 1 system. The operator has consequently revised the inspection criteria for all hydraulic system elbows fleetwide.

On arrival at Moorabbin the pilot asked a staff member the fuel state of the aircraft. The staff member said he thought it was full but for the pilot to check. The pilot said he checked the tanks visually during his pre-flight inspection and believed they were full. He could not recall what the fuel quantity gauges were indicating. Engine runup prior to departure was normal. The fuel selector was selected to the BOTH position and was left at that position for the entire flight.

The purpose of the flight was for the pilot to practise intercepts on the Cowes navigation aids. There was a safety pilot in the right seat whose task was to watch for traffic and to "keep an eye" on the pilot. The safety pilot was not familiar with the aircraft type. After completing the Airwork and while preparing to return to Moorabbin, the engine gave a short miss. At this time, the pilot said they were about five miles to the east of Phillip Island airstrip at an altitude of 3500 feet.

Shortly afterwards the engine missed again. This missing then occurred at more frequent intervals. The pilot therefore decided to make a precautionary landing at Phillip Island. At this time, the aircraft was still at 3500 feet and in a high wide base position for the 220 degree strip, which he decided to use. The pilot said he checked the magnetos, turned the electric fuel pump on, checked the mixture was rich and checked the fuel selector was in the BOTH position. He did not move the selector.

Because the aircraft was high, the throttle was selected to the idle position and landing gear and full flap were extended. Some S turns were made on final approach to lose altitude, but the aircraft still arrived over the strip far too high. At the upwind end of the strip the pilot pushed the throttle forward hoping there would be power available for a go around but there was no response from the engine. He then pulled the aircraft up into a left turn, to avoid going into the sea, and crash landed in sand dunes to the east of the airstrip.

The investigation revealed that there was approximately 40 litres of fuel in the left tank but the right tank was probably empty.  The right-wing tank fuel lines had been severed in the accident so fuel could have escaped from these lines after the accident. However, when refuelling records were checked against known fuel usage, 40 litres was about what should have been remaining and that much was drained from the left tank. The tank filler necks on this aircraft are fitted with anti-syphon (flapper) valves which have to be depressed to visually check tank contents. The pilot did not depress those valves during his pre-flight inspection.

After the wreckage was recovered. the entire fuel system was inspected, and no faults were found. The engine was removed and placed in a test rig where it ran faultlessly through its entire power range. In the Emergency Procedures section of the Pilot's Operating Handbook, for the Engine Failure in Flight checklist, item 5 of the checklist says, "Fuel Selector - FULLEST TANK (check other two positions)". In the Air start checklist, item 2 of the checklist says, "Fuel Selector - FULLER TANK". This item is followed by a note which says "To minimise restart time, select the fuller tank. Do not use the BOTH position".

Although the pilot was not attempting an air start, he did leave the selector in the BOTH position. A study of the fuel system suggests that if one tank is empty and the other contains fuel, then it is possible that the engine will be supplied with a "fuel air cocktail" through the fuel selector if the selector is in the BOTH position. Tests done on another Rockwell 114 confirmed that this was probably the cause of the engine malfunction.

Significant Factors

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

1. The pilot was unaware of the fuel state of the aircraft prior to departure from Moorabbin.
2. When the engine started to miss, the pilot did not take appropriate corrective action.
3. The precautionary landing approach was badly misjudged.
4. When the pilot attempted to go around from the misjudged approach, engine power was not available.
5. The pilot then had no option but to land the aircraft on unsuitable terrain.