Loss of separation involving a Boeing 737-376, VH-TAH and Boeing 737-33A, VH-CZV, 70 km west of Rugby NDB, New South Wales, on 29 October 1994

Summary

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.

Occurrence summary

Investigation number 199403203
Occurrence date 29/10/1994
Location 70 km west of Rugby NDB
State New South Wales
Report release date 24/11/1994
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 737-33A
Registration VH-CZV
Sector Jet
Operation type Air Transport High Capacity
Departure point Melbourne VIC
Destination Brisbane Qld
Damage Nil

Aircraft details

Manufacturer The Boeing Company
Model 737-376
Registration VH-TAH
Sector Jet
Operation type Air Transport High Capacity
Departure point Adelaide SA
Destination Sydney NSW
Damage Nil

Navigation - Other involving a Cessna 310R, VH-JOF, Badu Island, Queensland, on 2 November 1994

Summary

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.

Occurrence summary

Investigation number 199403213
Occurrence date 02/11/1994
Location Badu Island
State Queensland
Report release date 15/02/1995
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Navigation - Other
Occurrence class Accident

Aircraft details

Manufacturer Cessna Aircraft Company
Model 310R
Registration VH-JOF
Sector Piston
Operation type Charter
Departure point Boigu Island QLD
Destination Badu Island QLD
Damage Substantial

Hydraulic involving a Fokker B.V. F28 MK 3000, VH-EWF, Norfolk Island, on 29 October 1994

Summary

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.

Occurrence summary

Investigation number 199403198
Occurrence date 29/10/1994
Location Norfolk Island
State International
Report release date 08/05/1995
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Hydraulic
Occurrence class Incident

Aircraft details

Manufacturer Fokker B.V.
Model F28 MK 3000
Registration VH-EWF
Sector Jet
Operation type Air Transport High Capacity
Departure point Norfolk Island NSW
Destination Sydney Qld
Damage Nil

Forced/precautionary landing involving a Rockwell International 114, VH-DDY, Phillip Island, Victoria, on 30 October 1994

Summary

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.

Occurrence summary

Investigation number 199403176
Occurrence date 30/10/1994
Location Phillip Island
State Victoria
Report release date 16/02/1995
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Forced/precautionary landing
Occurrence class Accident

Aircraft details

Manufacturer Rockwell International
Model 114
Registration VH-DDY
Sector Piston
Operation type Private
Departure point Moorabbin VIC
Destination Moorabbin VIC
Damage Substantial

Loss of control involving a Bellanca 7GCBC, VH-MWY, Camden, New South Wales, on 26 October 1994

Summary

During the landing roll of the fifth and final circuit, the student pilot lost directional control in light but variable wind conditions. As a result, the aircraft ground looped, damaging the left main landing gear.

Occurrence summary

Investigation number 199403181
Occurrence date 26/10/1994
Location Camden
State New South Wales
Report release date 08/05/1995
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Loss of control
Occurrence class Accident

Aircraft details

Manufacturer Bellanca Aircraft Corp
Model 7GCBC
Registration VH-MWY
Sector Piston
Operation type Flying Training
Departure point Camden NSW
Destination Camden NSW
Damage Substantial

Breakdown of co-ordination involving a Boeing 737-376, VH-TJA, 166 km south-east of Townsville, Queensland, on 24 October 1994

Summary

The aircraft departed Brisbane for Cairns at 0343 UTC, cleared at FL330. This level was coordinated by the Brisbane Sector 7 Procedural Controller to Townsville Control. At 0435 UTC, the Sector 3 Radar Controller contacted the Sector 7 Radar Controller requesting a level change for the aircraft to FL350. This was approved and the aircraft was recleared at FL350. However, the level change was not coordinated with Townsville Control who were still expecting the aircraft at FL330. At the same time, the level change was not recorded on the flight strip for the aircraft. The request from Sector 3 concerning the level change was not heard by the Sector 7 Procedural Controller as there is no facility for that person to monitor the radar controller's hotlines.

Occurrence summary

Investigation number 199403127
Occurrence date 24/10/1994
Location 166 km south-east of Townsville
State Queensland
Report release date 16/02/1995
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Breakdown of co-ordination
Occurrence class Incident

Aircraft details

Manufacturer The Boeing Company
Model 737-376
Registration VH-TJA
Sector Jet
Operation type Air Transport High Capacity
Departure point Brisbane
Destination Cairns
Damage Nil

Airframe event involving a Hughes Helicopters 369HS, VH-NDC, 55 km south of Waikerie, South Australia, on 25 October 1994

Summary

The helicopter was maintaining an altitude of 2,500 feet when a small vertical jolt, accompanied by a slight roll to the right, was felt by the pilot. A check of the aircraft instruments appeared normal, but application of collective pitch only increased indicated engine torque without any change to the main rotor system pitch setting. The pilot briefed the passengers for a precautionary landing, then carried out a successful run-on landing.

An inspection of the helicopter revealed that the main rotor drive scissors link had failed, and that sometime in the past the scissor crank had been installed upside down. Examination of the aircraft records did not indicate when the scissor crank had been fitted but showed that the failed scissor link had been recently installed, having acquired 65 hours time in service since new.

It was found that fouling had occurred between the scissor link and the incorrectly fitted scissor crank when the collective pitch control was raised towards the full up position. This caused bending stresses in the scissor link which eventually failed in flight. The fouling had not occurred prior to the installation of the new scissor link as the old scissor link had had some free play in its bearings allowing sufficient clearance between the two units.

The end of the broken scissor link jammed in the rotating swashplate and maintained some integrity between it and the main rotor head. The pilot's action in restricting collective movement during the emergency descent and landing, which kept the scissor link in contact with the swashplate, probably prevented a more serious problem from developing.

Occurrence summary

Investigation number 199403137
Occurrence date 25/10/1994
Location 55 km south of Waikerie
State South Australia
Report release date 06/04/1995
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Incident

Aircraft details

Manufacturer Hughes Helicopters
Model 369HS
Registration VH-NDC
Sector Helicopter
Departure point Adelaide SA
Destination 18km SE Loxton SA
Damage Nil

Runway excursion involving a Cessna 310R, VH-FSR, Taree, New South Wales, on 28 October 1994

Summary

The pilot reported that during the take-off run the cabin door opened. The take-off was rejected, and the pilot closed the throttles and applied the brakes. The aircraft overran the runway, ran through a dirt and a fence before coming to rest.

The aircraft sustained damage to the landing gear, propellers and the fuselage.

Occurrence summary

Investigation number 199403174
Occurrence date 28/10/1994
Location Taree
State New South Wales
Report release date 30/10/1995
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Runway excursion
Occurrence class Accident

Aircraft details

Manufacturer Cessna Aircraft Company
Model 310R
Registration VH-FSR
Sector Piston
Operation type Charter
Departure point Taree NSW
Destination Port Macquarie NSW
Damage Substantial

Collision with terrain involving a Grob Twin Astir, VH-IKO, 2 km south of Waikerie, South Australia, on 23 October 1994

Summary

The pilot of the accident aircraft released from an aerotow about 4 km south-west of the airfield at 1,800 ft above ground level and immediately encountered strong sink so decided to return for a landing.

At about 2km short of the airfield he realised that the glider would not reach the runway and turned towards a suitable open field for an outlanding. Strong sink was encountered throughout the approach causing the glider to undershoot and strike small fruit trees in an orchard at the edge of the field.

The day had been fine but very hot, with other pilots also reporting areas of strong lift and equivalent sink.

Occurrence summary

Investigation number 199403122
Occurrence date 23/10/1994
Location 2 km south of Waikerie
State South Australia
Report release date 12/02/1996
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Collision with terrain
Occurrence class Accident

Aircraft details

Manufacturer Grob - Burkhart Flugzeugbau
Model Twin Astir
Registration VH-IKO
Sector Other
Operation type Private
Departure point Waikerie SA
Destination Waikerie SA
Damage Substantial

Wheels up landing involving a Piper PA-44-180, VH-JDF, Bankstown, New South Wales, on 16 October 1994

Summary

On first contact with Bankstown Tower the pilot advised that he had an unsafe landing gear indication. A flypast of the tower confirmed that the nose gear was only partially extended. Emergency services were called to attend. The nose gear leg collapsed during the subsequent landing.

An inspection later revealed that the left nose gear door actuating rod had separated from its attachment ball end due to excessive wear. The rod had become jammed in the nose leg shimmy damper, thus preventing the full extension of the nose leg. During repairs to the aircraft an internal leak in the nose leg actuator was detected. This was rectified by replacing the internal seals.

In subsequent cycling tests of the landing gear system, the nose leg failed to fully extend. The hydraulic power pack was dismantled and found to have been in poor condition, to the extent that normal operation may have been compromised.

Occurrence summary

Investigation number 199403102
Occurrence date 16/10/1994
Location Bankstown
State New South Wales
Report release date 08/05/1995
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 Piper Aircraft Corp
Model PA-44-180
Registration VH-JDF
Sector Piston
Operation type Flying Training
Departure point Schofields NSW
Destination Bankstown NSW
Damage Substantial