Collision with terrain involving a Cessna 402B, VH-FHG, Coolangatta, Queensland, on 12 May 1995

Summary

The pilot reported that when the aircraft was about 300ft on final approach to runway 14, he noticed that the right engine rpm did not change as the propeller controls were set to fine pitch. The aircraft then yawed to the right when it became necessary to introduce power to avoid undershooting the runway.

Both propellers were selected to feather when the yawing moment became uncontrollable, at about 50ft AGL. The right wing struck the ground, the landing gear collapsed, and the right wing was torn off during the ground slide as the aircraft slide off the runway onto the grass flight strip. The two occupants were not injured and evacuated the aircraft unassisted.

Post flight inspection by a licenced aircraft maintenance engineer found that both propellers were on the coarse pitch stops and had not feathered.

Inspection of the suspect right engine failed to find a fault which could have contributed to a power loss.

The pilot was under the impression that he had feather both propellers when he experienced directional control difficulties. Examination of both propeller hubs found that the propeller blades were on the coarse pitch stops. The propeller pitch control levers require a distinct movement to pass the coarse pitch stops into the feather position. It is apparent that the pilot did not position the levers where he intended.

The pilot lost control of the aircraft on late final approach. The reason for the loss of control could not be determined from the evidence available.

Occurrence summary

Investigation number 199501427
Occurrence date 12/05/1995
Location Coolangatta
State Queensland
Report release date 15/11/1995
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Collision with terrain
Occurrence class Accident

Aircraft details

Manufacturer Cessna Aircraft Company
Model 402B
Registration VH-FHG
Sector Piston
Operation type Private
Departure point Bundaberg QLD
Destination Coolangatta QLD
Damage Substantial

Incorrect configuration involving a Mooney M20J, VH-KKN, Kalgoorlie, Western Australia, on 5 May 1995

Summary

The pilots reported that the aircraft was being used for dual night circuits training. The student pilot inadvertently selected the gear up instead of the flaps while on the ground during the third touch and go landing. The instructor immediately took over and selected the gear down. The aircraft slid down the runway and came to a stop.

Occurrence summary

Investigation number 199501394
Occurrence date 05/05/1995
Location Kalgoorlie
State Western Australia
Report release date 17/05/1995
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Incorrect configuration
Occurrence class Accident

Aircraft details

Manufacturer Mooney Aircraft Corp
Model M20J
Registration VH-KKN
Sector Piston
Operation type Flying Training
Departure point Kalgoorlie WA
Destination Kalgoorlie WA
Damage Substantial

Airframe event involving a Cessna 425/A1, VH-EGQ, Kalgoorlie, Western Australia, on 8 May 1995

Summary

The pilot reported that when cruising at FL140 he noticed that the indicated airspeed was only 190 knots (normally 200 knots) and then noticed the nose down gear light was on. Attempts to rectify the problem were unsuccessful. The pilot contacted the company's chief engineer who advised him to return.

The nosewheel collapsed on landing at Kalgoorlie.

The investigation found that the aircraft had been used extensively on rough and soft strips. The nose gear actuator link had failed.

Occurrence summary

Investigation number 199501372
Occurrence date 08/05/1995
Location Kalgoorlie
State Western Australia
Report release date 17/05/1995
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Accident

Aircraft details

Manufacturer Cessna Aircraft Company
Model 425/A1
Registration VH-EGQ
Sector Turboprop
Operation type Flying Training
Departure point Kalgoorlie WA
Destination Jindalee Receiver WA
Damage Substantial

Fumes involving a Boeing 767-238ER, VH-EAL, 440 km north of Perth, Western Australia, on 6 May 1995

Summary

The pilot reported EICAS messages R Gen OFF, L Util Bus and R Util Bus.

Subsequently, acrid smoke entered the flight deck and cabin. Smoke removal procedures were effective.

The APU would not start at FL390, so the pilot informed ATC of the failed right generator and requested FL350 at 1633 WST. At 1638, the pilot advised ATC of smoke in the cabin, the second occurrence, and requested FL310 as the APU still would not start.

At 1649 the pilot advised ATC that the smoke had cleared and that operations were normal.

When power was reduced for the final descent, an EICAS message R Gen Drive came on. The right generator was then disconnected.

Following selection of flap 30 for landing, an unusual airframe judder was felt until touchdown.

The generator failure was traced to a lack of oil. No reason for the airframe judder could be determined.

Occurrence summary

Investigation number 199501370
Occurrence date 06/05/1995
Location 440 km north of Perth
State Western Australia
Report release date 17/08/1995
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Fumes
Occurrence class Incident

Aircraft details

Manufacturer The Boeing Company
Model 767-238ER
Registration VH-EAL
Sector Jet
Operation type Air Transport High Capacity
Departure point Den Pasar Indonesia
Destination Perth WA
Damage Nil

Operational non-compliance involving a Boeing 767-200, ZK-NBI and Boeing 767-300, ZK-NCJ, OLPIK, New South Wales, on 7 May 1995

Summary

ZK-NCJ, Auckland to Brisbane, at FL350 estimated position UDIKO at 0921 EST. ZK-NBI, Brisbane to Christchurch, was on climb to FL370 on reciprocal track (A464) estimating UDIKO at 0854. The Oceanic Controller calculated a time of passing at 0907 and on this basis required ZK-NBI to reach FL370 by 0855. The inbound aircraft revised the estimate for UDIKO, and the controller revised the time of passing to 0906.

The controller monitored the climb of ZK-NBI and became concerned that the requirement would not be met. He asked the crew to confirm that they would reach FL370 by 0855. The reply was that they would. At 0855 the aircraft was observed to be at FL355, and this was confirmed by the crew. Traffic information was then passed to both aircraft. ANZ76 reached FL370 at 0857.

FL330 was not available due to other crossing traffic.

The pilot-in-command of ZK-NBI later submitted a report which said that the aircraft's Flight Management Computer gave an indication that they would be able to reach the level by the required time. When they approached within a thousand feet of the level, the aircraft performance dropped off sharply. They then asked for FL350 which was not available.

The aircraft suffered an unexplained loss of performance which was not forecast by the Flight Management Computer. The reason for the loss of performance was not determined.

Occurrence summary

Investigation number 199501360
Occurrence date 07/05/1995
Location OLPIK
State New South Wales
Report release date 11/05/1995
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Operational non-compliance
Occurrence class Incident

Aircraft details

Manufacturer The Boeing Company
Model 767-200
Registration ZK-NBI
Sector Jet
Operation type Air Transport High Capacity
Departure point Brisbane QLD
Destination Christchurch NZ
Damage Nil

Aircraft details

Manufacturer The Boeing Company
Model 767-300
Registration ZK-NCJ
Sector Jet
Operation type Air Transport High Capacity
Departure point Auckland NZ
Destination Brisbane QLD
Damage Nil

Loss of separation involving a Boeing 747-400, G-BNLR and Boeing 737-476, VH-TJK, 160 nm north of Broken Hill, New South Wales, on 4 May 1995

Summary

FACTUAL INFORMATION

Sequence of events

The B747 had departed Sydney and was maintaining flight level (FL) 310 on air route A576. The crew had reported passing the position reporting point MASDA at 1642 EST, with an estimate for reporting point KALUG of 1735.

The B737 had departed Alice Springs and was proceeding on A576 in the opposite direction. The crew had reported passing KALUG at 1616 with an estimate for MASDA of 1702. The aircraft was maintaining FL290.

When the B737 crew made their KALUG position report, the crew of the B747 was monitoring a different control frequency and was unaware of the presence of the B737. However, when the B747 crew made their MASDA position report, the crew of the B737 was on the same frequency, but did not hear the report and was unaware of the presence of the B747 on the reciprocal track.

At 1648, the crew of the B737 requested climb to FL330 and was instructed to "stand by" by Air Traffic Control sector 5 (Sec 5). Sec 5 then co-ordinated the request with the Sec 6 controller who concurred with the change of level for Sec 6 airspace. The Sec 5 controller proceeded to calculate a time of passing so that he could assess when a change of level for the B737 could be initiated.

The Sec 5 controller elected to use the ground speed method to calculate the time of passing. He asked each crew, in turn, to report the ground speed of their aircraft. It was at this time that both crews first became aware of the presence of the other aircraft, and that there was a possible confliction.

The controller made the initial calculation mentally and followed this with a written calculation on a note pad. As both calculations produced a result of 1724, he wrote this time of passing on the flight progress strip.

At 1652, Air Traffic Control approved the B737 to climb to FL330, with a requirement to reach FL330 by time 1714. The crew commenced the climb immediately.

The crew of the B747 received an information symbol indicating "Other Traffic" on their traffic alert and collision avoidance system (TCAS) when the B737 was approximately 40 NM ahead. The target information changed to a proximity alert followed by a traffic advisory warning. At this point, the crew decided that if the TCAS proceeded to a resolution advisory the pilot in command would manually fly the aircraft as directed by the advisory. The co-pilot would simultaneously make a radio broadcast indicating the action being taken.

At approximately 1653.20, the TCAS issued a resolution advisory advising "climb, climb". The pilot in command immediately commenced a climb in accordance with this advice. Aware that the other aircraft was also climbing, the pilot in command continued the climb at the best rate to approximately FL321, before returning the aircraft to the approved cruising level, FL310. The co-pilot made a radio broadcast indicating that they were carrying out a TCAS climb at the same time as the pilot in command initiated the climb manoeuvre.

Analysis of the B747's quick access recorder showed that the aircraft gained approximately 500 ft during the time that the resolution advisory was active and then gained a further 550 ft before descending.

The pilot in command of the B747 did not see the B737. However, immediately before the TCAS resolution advisory warning activated, the co-pilot sighted the B737 straight ahead and at a slightly lower level. He lost sight of it as his aircraft entered the climb. At that point, the B737 was passing directly below the B747.

The B737 was climbing at approximately 1,000 - 1,200 ft/min when the crew heard the TCAS climb radio call from the crew of the B747. They realised that their aircraft must have been the conflicting traffic and initiated an immediate descent. The crew looked up to see the underside of the B747 pass over and slightly to the right of their aircraft. The pilot in command levelled the B737 at FL305 and believed that his aircraft may have reached FL308 prior to the descent.

At 1653.30 (approximately ten seconds after the TCAS resolution advisory) the pilot in command of the B747 requested from air traffic control the position of the other aircraft. The Sec 5 controller responded by instructing the B737 to expedite climb to FL330. This instruction was carried out by the B737 crew.

The aircraft had passed with approximately 500 ft vertical separation and little or no horizontal separation. The required separation standard for two aircraft passing in the opposite direction on the same air route above FL 290 is a minimum of 2,000 ft vertical difference.

Air traffic control

During the investigation, several people involved in the training and performance appraisal of the sector 5 controller indicated their concern with certain aspects of his abilities. These concerns were notably in the area of procedural separation standards. Examination of check reports and interviews with supervisors, training staff, and workface controllers revealed that the official air traffic controller performance and check reports related only to some of the perceived deficiencies.

Many supervisors and training officers (including the former "Check" controllers) prepared formal reports for official filing but also retained other opinions in "private" files which were not readily available to management. However, the records that were available showed that his supervisors considered that the controller's performance was deficient in the area of procedural separation standards. When the controller was selected for training on another sector (Sector 6), the use of radar standards, which he had not used in previous ratings, was required. He subsequently failed this rating due to difficulty with procedural separation standards, rather than the radar standards. At the time of his final check for the Sector 6 rating the controller was experiencing personal problems which were not known to management.

There was no system in place to ensure that the responsible manager was specifically informed of a perceived weakness other than some review of the various reports prior to filing. This applied to ongoing performance appraisal as well as initial training and rating reports. As individual managers were often responsible for numerous controllers, the opportunity for them to adequately review all performance and check reports was not always available.

After the controller had failed to gain a rating on Sector 6, management elected to place him back on Sectors 1 and 5, those sectors on which he was rated prior to the Sector 6 training. The decision was made to retrain rather than refamiliarise the controller. Such a decision indicated a greater than normal concern for his ability to obtain the ratings which he had only recently held.

Having made this decision, management then elected not to provide the controller with simulator training to assist in this re-rating program, even though specific programs were available. The training officer was instructed to concentrate on separation standards during normal on-the-job training, especially time of passing and lateral separation problems.

Airborne collision-avoidance systems (ACAS)

ACAS are intended to improve air safety by acting as a last-resort method of preventing collisions or near collisions. The equipment utilises secondary surveillance radar technology to operate independently of ground-based aids and air traffic control. It monitors other aircraft in the vicinity and assesses the risk of collision by interrogating airborne transponders. Non-transponding aircraft cannot be detected. TCAS II, as fitted to the B747, is a version of ACAS which provides resolution advisories (for vertical manoeuvres only) as well as traffic information. The B737 was not equipped with any form of ACAS.

Time of passing calculation

Several attempts were made to replicate the calculation made by the controller for the time of passing. Neither the investigation team, air traffic services specialists, nor the controller concerned could determine how the time of 1724 was derived.

There was a 3 minute 20 second delay between the time the crew of the B737 requested the climb and the time the controller approved the climb. In this period the controller made two independent time of passing calculations, one mentally and one on a notepad. Whilst performing these tasks he was required to respond to nine separate air-ground and co-ordination communications involving 25 interchanges.

Two-way air routes

On 14 September 1995, a new upper air route network was introduced in the Australian Flight Information Region. The change resulted in numerous one-way air routes replacing many two-way routes and was intended, amongst other things, to reduce the potential for incidents such as this. The route being flown by the aircraft involved in this occurrence was not changed to a one-way route.

Flight crew response

TCAS resolution advisory

The pilot in command of the B747 was aware of the separation standard of 2,000 ft which was applicable at FL310. He chose to continue climb beyond that normally expected for a TCAS event, because of the known position and climbing attitude of the other aircraft. He wanted to ensure that his aircraft would outclimb the B737 and took into consideration the fact that any third aircraft in the area should be at least 2,000 ft above his aircraft.

ANALYSIS

This occurrence involved the provision of an airways clearance to permit an aircraft to climb through the level of another aircraft travelling in the opposite direction on the same air route.

Calculation of the closest point of approach indicates that, had the crews of both aircraft not responded following the TCAS activation, the aircraft would have passed with no horizontal separation and approximately 200 ft vertical separation.

Flight crew response - TCAS resolution advisory

The resolution advisory is an indication given by TCAS II to a flight crew that a vertical manoeuvre should or should not be performed to maintain safe separation from other aircraft. If required, such a manoeuvre should average between 300 ft and 400 ft. To prevent possible secondary separation problems, the manoeuvre should not normally exceed 700 ft. In this occurrence, the pilot in command decided to climb his aircraft in excess of this expected range because of the relative positions of the two aircraft.

The crew of the B737 did not see the B747 until after the TCAS broadcast by the crew of the B747, and the only visual acquisition was by the co-pilot of the B747 some seconds before the TCAS resolution advisory after he had received traffic advice from the TCAS. It is therefore reasonable to say that, had the B747 not been equipped with TCAS, neither crew would have seen the other aircraft in time to commence effective avoiding action.

Time of passing calculation

The separation standard based on the time of passing calculation was correct. It was the calculation itself that was in error.

The controller was confident that his calculations were correct because the time written on his notepad agreed with his mental assessment. However, he had been distracted by the amount of air-ground and co-ordination exchanges required in such a short period of time. This level of distraction would have resulted in a high mental workload and may have contributed to the erroneous time of passing calculation.

Management strategies

Having decided to re-rate the controller on Sectors 1 and 5 instead of refamiliarising his previous ratings, management indicated a greater than normal degree of concern for his performance. Information stored in "private files" would have given management a better insight into these perceived procedural deficiencies.

A re-rating program was devised to assist the controller, but this plan did not require simulator training for procedural separation standards. Such training may have provided a more comprehensive preparation for his rerating. Although adequate simulator exercises were available, finding appropriate training staff for the simulator proved difficult.

SIGNIFICANT FACTORS

  1. The aircraft were travelling on a two-way air route in opposite directions.
  2. Management strategies for the early detection and remedy of perceived deficiencies in controllers' competencies were ineffective.
  3. The controller miscalculated the time of passing of the aircraft.
  4. The TCAS on the B747 provided the only catalyst for avoiding action by the aircrew.

SAFETY ACTION

During the course of the investigation the Bureau of Air Safety Investigation issued the following interim recommendation to the then Civil Aviation Authority on 6 June 1995:

"IR 950117

"The Bureau of Air Safety Investigation recommends that the Civil Aviation Authority:

"(i)   mandate the fitment and use of an Airborne Collision Avoidance System (ACAS) in all aircraft engaged in Regular Public Transport (RPT) operations;

"(ii) consider the requirement for the fitment and use of a suitable ACAS in other aircraft engaged in the carriage of passengers for hire or reward;

"(iii) mandate the activation of any SSR transponder in aircraft so equipped at all times when airborne, irrespective of the class of airspace in which the aircraft may be flying;

"(iv) mandate the standard of ACAS equipment to be carried in each aircraft classification;

"(v)   set a timetable for the introduction of ACAS equipment; and

"(vi) ensure that air traffic services officers are given adequate and timely education and continuation training in the capabilities and operational impact of ACAS equipment."

The following response was received from the Civil Aviation Safety Authority on 21 August 1995:

"I refer to Air Safety Interim Recommendation IR950117 regarding Airborne Collision Avoidance Systems (ACAS).

"In response to the reported air miss occurrences referred to as justification, in part, for this recommendation, the Civil Aviation Safety Authority has commenced an examination and analysis of both BASI and AA incident data in order to identify and better understand the nature of these deficiencies within the Australian aviation system. Significant differences between BASI and AA data, in both number and classification of reported incidents, has complicated and restricted this process to date.

"Apart from analysis of risks in a non ACAS environment, CASA also recognises the need to assess the impact of ACAS on future major projects such as TAAATS and implementation of AACS. The Authority also intends to review any potential disbenefits that may arise from ACAS, including spurious activations and effects of resolution advisories (RAs) in complex air traffic situations.

"Industry and Public consultation will precede any adoption of requirements for aircraft to carry ACAS. The Authority continues to monitor world trends and is currently reviewing recent UK safety studies on ACAS." The Bureau has classified the response as OPEN and has initiated further correspondence on the matter.

Additionally, Interim Recommendation IR950218 was issued to the Civil Aviation Safety Authority and Interim Recommendation IR950219 was issued to Airservices Australia, after the 1995 reorganisation. These were issued on 11 January 1996:

"IR950218

"That the Civil Aviation Safety Authority in conjunction with other operators of TCAS-equipped aircraft, evaluate the initial and recurrent training requirements for aircrew of TCAS-equipped aircraft.

"The evaluation should ensure that the risks associated with excessive vertical deviations in response to TCAS RAs are identified."

The Civil Aviation Safety Authority responded on the 12 February 1996 as follows:

"I refer to your interim recommendation number IR950218 regarding the incident involving Boeing 747, G-BNLR and Boeing 737-476, VH-TJK, on 4 May 1995.

"Summary

"The authority accepts the Interim Recommendation.

"Background to response

"Details of the exact nature and extent of training currently undertaken by TCAS equipped operators will be determined to establish whether or not such training adequately addresses the risks associated with excessive and inappropriate pilot responses to RAs."

The Bureau has classified this response as CLOSED/ACCEPTED.

"IR 950219

"That Airservices Australia evaluate the TCAS initial and recurrent training requirements for ATS personnel. This evaluation should ensure:

"(i) thorough and consistent practical knowledge is achieved throughout ATS; and

"(ii) TCAS RA encounters are practised in simulator sessions."

Airservices Australia responded on the 22 February 1996 as follows:

"I am writing in response to your Interim Recommendation IR950219 which recommends that Airservices Australia:

"evaluate the TCAS initial and recurrent training requirements for ATS personnel.

"Preliminary evaluation of the level and extent of TCAS training provided to Air Traffic Services personnel indicates that training on TCAS was generally consistent across Air Traffic Services centres.

"The training provided consisted of local team development supported by a video presentation with accompanying booklet detailing TCAS procedures.

"The ATS Operational Training Unit is currently developing a comprehensive package for the purpose of evaluating TCAS training and awareness. The purpose of this evaluation is to assess both the level of initial training and the current appreciation of TCAS.

"Future TCAS training will be dependent upon the results of this evaluation. The focus of any proposal will be on improving and enhancing training delivery to ensure that both initial and recurrent training needs are clearly identified and addressed.

"A variety of instructional methodologies and strategies will be considered during the evaluation process. Any proposal for simulation of TCAS RA encounters will also be dependent on the results of the evaluation and the feasibility of successfully simulating such encounters."

The Bureau classified this response as CLOSED/ACCEPTED.

Note: In December 1996 CASA issued a Legislative Instrument Proposal which proposed the mandatory carriage of TCAS equipment in some classes of aircraft and addressed further the recommendations IR950218 and IR950219.

Final recommendations

The Bureau of Air Safety Investigation made the following recommendations on 1 November 1996:

"R950227

"That Airservices Australia further review the upper air route structure to create, wherever practicable, one-way air routes within the Australian Flight Information Region."

"R950228

"That Airservices Australia review the training given to ATC and Flight Service staff in coping with distractions in the workplace and consider improvements in the techniques to reduce the impact of distractions on staff performance."

"R950229

"That Airservices Australia:

"(i) develop strategies that encourage all officers who carry out performance appraisals to notate all concerns in an adequate and timely manner on the approved proforma;

"(ii) develop strategies for improved management oversight of appraisal reports, especially in the area of "below expected performance" assessments; and

"(iii) ensure that specific training programs, including simulator and desk-top exercises, are developed to address perceived deficiencies in each of the skill and knowledge items contained in any appraisal report."

Occurrence summary

Investigation number 199501346
Occurrence date 04/05/1995
Location 160 nm north of Broken Hill
State New South Wales
Report release date 16/01/1997
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 The Boeing Company
Model 737-476
Registration VH-TJK
Sector Jet
Operation type Air Transport High Capacity
Departure point Alice Springs NT
Destination Sydney NSW
Damage Nil

Aircraft details

Manufacturer The Boeing Company
Model 747-400
Registration G-BNLR
Sector Jet
Operation type Air Transport High Capacity
Departure point Sydney NSW
Destination Bangkok THAILAND
Damage Nil

Fuel exhaustion involving a Beech Aircraft Corp E55, VH-USP, 34 km west-south-west of Camden, New South Wales, on 5 May 1995

Summary

The pilot said that he had been working for the operator for one week prior to the accident. He was employed on a casual basis, based in Cootamundra.

After conducting his normal freight flight to Hay, he arrived back at Cootamundra at about 1845, whereupon he unloaded the freight he had been carrying, and went to his car to collect personal belongings for a ferry flight to Bankstown. At the same time, the aircraft was being refuelled. A total of 313 litres of fuel was added to the aircraft, filling all tanks with the exception of the right auxiliary, which was filled to 20 litres less than capacity. By the time the pilot had returned to the aircraft the refueller had left. He said he carried out a fuel drain but then became distracted by the imminent arrival of another aircraft. He subsequently believes he did not check the status of the fuel caps.

The aircraft departed Cootamundra at about 1912 for an IFR flight to Bankstown. The planned cruising level was 5000 feet in order to minimise delays with entry to controlled airspace. Main tanks were selected for take-off and initial climb. Shortly after take-off, the left and right auxiliary tanks were selected to feed their respective engines. During the cruise the pilot said that he noticed, after some time, that the fuel contents indicators appeared to be giving erratic readings. He was not concerned at this because he was confident the aircraft was carrying a very large margin over the fuel required for the flight.

As the aircraft passed Bindook VOR the pilot said he changed back to both main tanks. Shortly after this the left engine stopped. He commenced to go through the appropriate checklist items when the right engine also stopped. He immediately changed back to the auxiliary tanks without effect, then tried a number of tank/crossfeed selections, combined with various fuel pump and mixture settings. A momentary surge of power from one engine was all that could be achieved. The pilot gave a Mayday call, extended half flap and reduced speed to 75-80 knots. Nothing could be seen outside the aircraft due to darkness, low cloud and rain.

The aircraft collided with trees in rugged terrain and came to rest, relatively intact. The pilot said he struck his head on the instrument panel, sustaining a small cut on the forehead. At the time of impact, he did not have his shoulder harness secured, being only restrained by his lap belt. He had unbuckled the shoulder straps during cruise because they were chafing his neck. After the loss of engine power, he did not have sufficient time to refasten the harness.

Immediately after the aircraft came to rest, he kicked open the main door and rapidly evacuated the aircraft, as he was concerned that the aircraft may have caught fire. There was no fire and so he was able to re-enter the aircraft after a short time and use the aircraft radio to notify his position, and to communicate with rescuers. Although located that evening by rescue helicopter, due to poor weather conditions, and hazardous terrain, he was not extracted from the crash site until the following morning.

Inspection of the wreckage revealed that all four fuel tank caps were unlatched, allowing fuel to be vented overboard during flight. It was subsequently reported that the refueller had been specifically instructed by a previous company pilot not to latch the fuel caps after refuelling. This procedure required the fuel contents to be checked, then the fuel caps to be fastened, by the pilot-in-command. The new pilot of VH-USP was aware of this procedure, however, when he failed to check the fuel caps there was no fail-safe capability to prevent a consequent loss of fuel during flight.

Occurrence summary

Investigation number 199501327
Occurrence date 05/05/1995
Location 34 km west-south-west of Camden
State New South Wales
Report release date 17/05/1995
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Fuel exhaustion
Occurrence class Accident
Highest injury level Minor

Aircraft details

Manufacturer Beech Aircraft Corp
Model E55
Registration VH-USP
Sector Piston
Operation type Charter
Departure point Cootamundra NSW
Destination Bankstown NSW
Damage Destroyed

ANSP info/procedural error involving a British Aerospace PLC BAe 146-300, VH-EWS, Maroochydore, Queensland, on 26 April 1995

Summary

SEQUENCE OF EVENTS

When the crew of the aircraft listened to the Automatic Terminal Information Service (ATIS) before commencing their descent, there was no advice that an instrument approach could be necessary. After initial contact with Maroochydore Tower, the crew were cleared to descend to 3,000 ft. The controller co-ordinated another IFR aircraft and one VFR aircraft to give the regular public transport jet priority. However, the Aerodrome Controller did not advise the crew to expect an instrument approach but gave them the option of a DME Arrival or an 18 VOR/DME approach via the 10 DME arc. As the aircraft was still at 4,000 ft and close to the aerodrome, the crew accepted the only viable option of an 18 VOR/DME approach.

The aircraft did not become visual at the minimum descent altitude and the crew elected to divert to Brisbane where a 19 ILS approach was flown to a safe landing.

The captain later complained of the lack of operational information, "indecision" by the ADC, and no advice of an amended terminal area forecast (TAF), special forecast (SPECI) or advice from Brisbane Approach that an instrument approach would be required.

ANALYSIS

The captain's complaint about the lack of operational information regarding an "expect instrument approach" message is valid. He misunderstood the ADC's offer of a choice of instrument approaches as indecision.

The Bureau of Meteorology reviewed the forecasting aspects and conceded that the Maroochydore TAF should have continued with INTER which would have alerted the pilot to expect weather difficulties and to plan for it by carrying extra fuel.

The crew cramped their approach by descending to only 4,000 ft when they had been cleared to descend to 3,000 ft. They apparently did not remember the clearance even though the automatic voice recording tape revealed that they had acknowledged the 3,000 ft clearance.

SAFETY ACTION

Airservices Australia's Maroochydore procedures were modified on 17 May 1995 to include an "expect instrument approach" message in the ATIS when appropriate.

Occurrence summary

Investigation number 199501324
Occurrence date 26/04/1995
Location Maroochydore
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 ANSP info/procedural error
Occurrence class Incident

Aircraft details

Manufacturer British Aerospace
Model BAe 146-300
Registration VH-EWS
Sector Jet
Operation type Air Transport High Capacity
Departure point Sydney NSW
Destination Maroochydore QLD
Damage Nil

Navigation - Other involving a Beech Aircraft Corp 58, VH-LAP, Hobart, Tasmania, on 1 May 1995

Summary

VH-LAP was cleared to track to Tea Tree (TTR) at 7000 feet.  Approaching TTR, the aircraft was instructed to enter the holding pattern and shortly afterwards was cleared to descend to 4000 feet and to make an ILS approach for runway 12.  Three minutes later, at 1812 hours, the pilot reported an ADF failure and asked for a climb. He was cleared to 5500 feet. He was then cleared to track outbound between the 301 and the 310 radials, and to turn inbound as required to establish the aircraft on the localiser at approximately 20 DME.  He could then expect an ILS approach.

Over an extended period, the pilot tried to establish himself on the localiser, with assistance from the pilots of two other aircraft holding above, both of whom had VH-LAP in sight from time to time.  Eventually another ILS was commenced but this was abandoned because the aircraft was too high (4500 feet at five miles from the aerodrome on final approach).

At the suggestion of the tower controller and with controller assistance a runway 30 VOR/DME was then successfully completed and the aircraft landed at 1859.

The pilot was using a GPS to establish distances, as he could not obtain distance readings from the international DME.  Use of the GPS as a primary navigation aid was not permitted. The pilot had selected the Hobart ILS frequency on both the NAV selector and the international DME selector. The pilot thought the international DME selector was a second NAV selector.  The number two NAV indicator, which the pilot thought was for a second NAV receiver, was in fact driven by the GPS.  Hence the tracking indications on the two NAV indicators were different. Because of the pilot's misunderstanding over the purpose of the second indicator, the indication differences created confusion in his mind.

The ADF equipment was later established to have been operating normally and the reason for the pilot reporting it had failed was not determined.

Another company pilot was holding at TTR and attempted to pass advice to the pilot of VH-LAP.  Recorded communications of the occurrence showed that the stream of instructions was considerable and may have contributed to overloading the pilot of VH-LAP.

Significant Factors

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

  1. The pilot was not adequately familiar with the navigation equipment fitted to the aircraft and hence became confused over the indications obtained.
  2. The pilot had a low skill level in regard to orientating the aircraft to proceed on the localiser track.

Occurrence summary

Investigation number 199501313
Occurrence date 01/05/1995
Location Hobart
State Tasmania
Report release date 16/05/1995
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Navigation - Other
Occurrence class Incident

Aircraft details

Manufacturer Beech Aircraft Corp
Model 58
Registration VH-LAP
Sector Piston
Operation type Charter
Departure point Queenstown TAS
Destination Hobart TAS
Damage Nil

Wheels up landing involving a Cessna 210K, VH-PQY, Horn Island, Queensland, on 25 April 1995

Summary

When the pilot selected the landing gear down, only the nosewheel locked down. He then followed the landing gear emergency extension procedure. This resulted in the left main gear being locked down but the right gear remaining unlocked. After discussing the problem with his company, the pilot landed the aircraft with the nose gear locked and both main gear unlocked. During the landing, the fuselage underside was scraped and the left tailplane bent. An inspection revealed that a seal in the right main gear actuator had failed.

Occurrence summary

Investigation number 199501242
Occurrence date 25/04/1995
Location Horn Island
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 Wheels up landing
Occurrence class Accident

Aircraft details

Manufacturer Cessna Aircraft Company
Model 210K
Registration VH-PQY
Sector Piston
Operation type Private
Departure point Unknown
Destination Unknown
Damage Substantial