Loss of separation involving a Fokker B.V. F27 MK 50, VH-FNB and Pilatus PC-9, Bindook, New South Wales, on 2 December 1994

Summary

The F27 was tracking from Canberra direct to Bindook VOR on climb to FL170. At about the same time, a military PC-9 was tracking from Shelleys NDB to Richmond via Bindook VOR, also at FL170.

Both aircraft had just been handed over to Sydney Arrivals by Melbourne Sector Control, with the aircraft on converging tracks at the same level.

The Arrivals Controller experienced problems with the transponder code of the PC-9 and, while attempting to correct the display errors, realised that radar separation would not be maintained. Instructions were given to the PC-9 to change heading, and for the F27 to descend to FL160. However, before the aircraft could respond, the minimum separation standards were infringed.

Occurrence summary

Investigation number 199403741
Occurrence date 02/12/1994
Location Bindook
State New South Wales
Report release date 25/01/1996
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 Fokker B.V.
Model F27 MK 50
Registration VH-FNB
Sector Turboprop
Operation type Air Transport High Capacity
Departure point Canberra ACT
Destination Sydney NSW
Damage Nil

Aircraft details

Manufacturer Pilatus Aircraft Ltd
Model PC-9
Registration Unknown
Sector Turboprop
Operation type Military
Departure point East Sale VIC
Destination Richmond NSW
Damage Nil

Loss of control involving a Cessna 180G, VH-DJS, Nagoorin, Queensland, on 11 December 1994

Summary

The pilot reported that during the landing roll the right brake failed, and the aircraft ground looped to the left. The right landing gear separated, rupturing fuel lines. The aircraft ignited when it came to rest and was totally destroyed.

Occurrence summary

Investigation number 199403711
Occurrence date 11/12/1994
Location Nagoorin
State Queensland
Report release date 08/03/1996
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 Cessna Aircraft Company
Model 180G
Registration VH-DJS
Sector Piston
Operation type Private
Departure point Nagoorin QLD
Destination Nagoorin QLD
Damage Destroyed

Hard landing involving a Cessna 182F, VH-CDN, Avoid Island, Queensland, on 27 November 1994

Summary

The pilot stated that he noticed a large piece of timber on the runway in line with the nosewheel during the landing flare. Power was applied and the nose wheel was raised to avoid the timber. During the subsequent landing the nosewheel struck the runway prior to the mainwheels. After returning to Mackay, the aircraft was inspected by an engineer who discovered damage to the firewall.

Occurrence summary

Investigation number 199403682
Occurrence date 27/11/1994
Location Avoid Island
State Queensland
Report release date 08/03/1996
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Hard landing
Occurrence class Accident

Aircraft details

Manufacturer Cessna Aircraft Company
Model 182F
Registration VH-CDN
Sector Piston
Operation type Private
Departure point Mackay QLD
Destination Avoid Island QLD
Damage Substantial

ANSP info/procedural error involving a Short SD360-300, VH-MJH and Beech Aircraft Corp B200C, VH-AMM, 25km south of Nowra, New South Wales, on 6 December 1994

Summary

VH-AMM departed Sydney at 1426, tracking via Nowra to Moruya and cruising at flight level 160. Nowra control zone extends approximately 19 miles south of Nowra. The base of the control area south of this is 8000 ft, until 30 miles from Nowra. From 30 miles south of Nowra to Moruya the base of controlled airspace is flight level 150.

VH-MJH departed Moruya at 1442, tracking via Nowra for Sydney and cruising at 7000 ft. Advice of this departure was passed by Melbourne flight service to Nowra air traffic control.

At 1448 Melbourne air traffic control advised Melbourne flight service that VH-AMM was on descent 12 miles south of Nowra and would be calling flight service. The descent was continued and as instructed by air traffic control the crew called on the flight service frequency. An estimate of 1501 for arrival at Moruya was given to flight service.

Nowra air traffic control had observed both aircraft on radar and contacted flight service to pass an instruction to VH-AMM to maintain 8000 ft. An error in the call sign used by Nowra air traffic control caused a delay in transmission of this instruction. When the message was passed to the crew of VH-AMM at 1451 they advised they were climbing back to 8000 ft from 7700 ft. The two aircraft passed at about this stage.

Melbourne flight service was required to pass traffic information to both aircraft about each other but had not done so. Nowra was not a compulsory reporting point, and the Melbourne air traffic controller did not pass a position report for Nowra to flight service. Because there was no position report the controller had advised flight service when the aircraft was on descent.

The flight service officer did not have the flight progress strip for VH-AMM in the active bay until after the controller's report of the aircraft being on descent. The procedures adopted left limited time for the flight service officer to assess the traffic situation.

Significant Factors

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

1. Limited time period available to the flight service officer after advice of VH-AMM on descent.

2. Flight service officer did not pass the required traffic information to either aircraft, reasons undetermined.

Occurrence summary

Investigation number 199403673
Occurrence date 06/12/1994
Location 25km south of Nowra
State New South Wales
Report release date 09/02/1995
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 Beech Aircraft Corp
Model B200C
Registration VH-AMM
Sector Turboprop
Departure point Sydney NSW
Destination Moruya NSW
Damage Nil

Aircraft details

Manufacturer Short Bros Pty Ltd
Model SD360-300
Registration VH-MJH
Sector Turboprop
Operation type Air Transport High Capacity
Departure point Moruya NSW
Destination Sydney NSW
Damage Nil

Fire involving a Piper PA-31, VH-MNT, 155 km north of Adelaide, South Australia, on 3 December 1994

Summary

In cruise at 10,000 ft the pilot noticed the left alternator light had illuminated, and that the right alternator was now taking all electrical loads. The left engine power then reduced from 31hg to 23hg, suggesting to the pilot that the turbo-charger was malfunctioning. As the aircraft was now unable to maintain its cruise altitude the pilot requested a descent to 7,000 ft. He also requested an airways clearance to return to Parafield.

He changed the left fuel tank selection from the main to auxiliary and turned the left fuel boost pump on. This restored engine power for a short period of time before it suffered a complete failure, followed by a complete loss of electrical power and smoke entering the cabin.

The pilot feathered the left propeller and turned the fuel selector and all electrical switches off. He maintained communications with Adelaide FIS using a mobile telephone. A successful single engine landing was made after the pilot manually extended the landing gear.

An investigation indicated that the alternator field wire had chaffed on the engine fuel supply line, wearing through its insulation which allowed the barbed wire to then arc on the line, eventually burning a hole through it. The ensuing loss of fuel supply through the hole, with associated loss in fuel pressure, contributed to the reduction of engine power. Activation of the fuel boost pump assisted in restoring some pressure, and power.

Fuel spraying from the holed line was ignited by the arcing alternator field wire, causing fire damage to the wing leading edge skin, wing structure rear of the firewall, oil pressure, hydraulic and fuel supply lines, and the nacelle fuel tank and vent lines. The electric loom between the engine and cabin had the insulation burnt off, allowing it to short circuit and cause the electrical failure. The magneto earth wires, being part of this loom, and also bared of insulation, grounded both magnetos, shutting down the engine.

The engine failing due to the grounded magnetos, and the pilot's action of turning the fuel off, probably deprived the fire of fuel before it became established, and self-extinguished.

Occurrence summary

Investigation number 199403630
Occurrence date 03/12/1994
Location 155 km north of Adelaide
State South Australia
Report release date 26/08/1996
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Fire
Occurrence class Accident

Aircraft details

Manufacturer Piper Aircraft Corp
Model PA-31
Registration VH-MNT
Sector Piston
Operation type Business
Departure point Parafield SA
Destination Alice Springs NT
Damage Substantial

ANSP info/procedural error involving a Piper PA-31-350, VH-UBC and Short Bros SD360-300, VH-MJH, 90 km east-north-east of Wagga Wagga, New South Wales, on 2 December 1994

Summary

The pilot of VH-UBC reported at Rugby at 1725, cruising at 10,000 ft and estimating Holbrook at 1759. The pilot of VH-MJH reported at Yass at 1730 at 10,000 ft and estimating Wagga at 1755. Both aircraft were operating outside controlled airspace and the tracks of the two aircraft crossed.

The two aircraft passed in close proximity. No traffic information had been passed by Melbourne flight service to either aircraft. The flight service position was manned by a trainee under the supervision of a flight service officer who was rated to operate that area. Neither person had noticed the potential conflict.

The area in which the aircraft were operating has a high level of complexity for flight service. The workload at the time was assessed as moderate.

Significant Factor

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

1. Neither the flight service officer nor his trainee detected a situation of potential conflict.

Occurrence summary

Investigation number 199403623
Occurrence date 02/12/1994
Location 90 km east-north-east of Wagga Wagga
State New South Wales
Report release date 05/01/1995
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 Piper Aircraft Corp
Model PA-31-350
Registration VH-UBC
Sector Piston
Operation type Charter
Departure point Bathurst NSW
Destination Albury NSW
Damage Nil

Aircraft details

Manufacturer Short Bros Pty Ltd
Model SD360-300
Registration VH-MJH
Sector Turboprop
Operation type Air Transport Low Capacity
Departure point Sydney NSW
Destination Wagga NSW
Damage Nil

Forced/precautionary landing involving a Pitts S-1, N540KB, 7 km south-west of Mooroopna, Victoria, on 24 November 1994

Summary

The owner/pilot advised that he was practising an aerobatic sequence for a future airshow when the engine suddenly suffered a partial power loss. At the time the aircraft was vertical. The pilot pushed over to level flight at about 1000 ft AGL and 80 kts. Then the engine stopped completely. He performed a forced landing in a nearby paddock. The aircraft touched down at approximately 115 kts. During the landing roll the aircraft flipped twice onto its back before coming to rest upright but nose down.

Subsequently an engineer discovered that the crankshaft thrust bearing had seized. The pilot and the engineer believe that, during aerobatic manoeuvres, the oil pickup pipe had been exposed and sucked air, thereby starving the thrust bearing of oil.

This particular aircraft has a more powerful engine installed than the standard Pitts. The additional horsepower enables very high-performance aerobatics.

The owner/pilot, his engineer, the manufacturer and the CAA are involved in achieving an improved oil supply to the thrust bearing before the engine is returned to service.

Significant Factors

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

1. The crankshaft thrust bearing was inadequately lubricated during aerobatic manoeuvres.

2. The crankshaft thrust bearing seized and stopped the engine.

3. During the landing roll, the aircraft encountered an undulation and overturned.

Occurrence summary

Investigation number 199403609
Occurrence date 24/11/1994
Location 7 km south-west of Mooroopna
State Victoria
Report release date 05/01/1995
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 Pitts Aviation Enterprises
Model S-1
Registration N540KB
Sector Piston
Operation type Private
Departure point Shepparton VIC
Destination Shepparton VIC
Damage Substantial

Near collision involving a de Havilland Canada DHC-8-102, VH-TQP and Cessna 172N, VH-STG, Lord Howe Island, New South Wales, on 30 November 1994

Summary

The DHC-8 was inbound to Lord Howe Island and had made all necessary radio calls on the CTAF frequency. As the aircraft passed overhead the airport prior to landing, a Cessna 172 was sighted about 300 ft directly above. Normal radio communications were subsequently established between the aircraft and both landed without further incident.

The pilot of the Cessna later reported that he had been conducting a local flight around the island and considered that VHF communications may have been adversely affected by the mountainous terrain. He thought that was probably the reason why he had not heard any inbound radio reports by the crew of the DHC-8.

Occurrence summary

Investigation number 199403604
Occurrence date 30/11/1994
Location Lord Howe Island
State New South Wales
Report release date 06/12/1995
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Near collision
Occurrence class Incident

Aircraft details

Manufacturer Cessna Aircraft Company
Model 172N
Registration VH-STG
Sector Piston
Departure point Lord Howe Island NSW
Destination Lord Howe Island NSW
Damage Nil

Aircraft details

Manufacturer De Havilland Canada/De Havilland Aircraft of Canada
Model DHC-8-102
Registration VH-TQP
Sector Turboprop
Operation type Air Transport Low Capacity
Departure point Sydney NSW
Destination Lord Howe Island NSW
Damage Nil

Operational non-compliance involving a Fokker B.V. F28 MK 1000, VH-FKF, 4 km south-west of Melbourne, Victoria, on 30 November 1994

Summary

The airways clearance for VH-FKFs departure was runway 16, Strathbogie 1 SID. Soon after VH-FKF became airborne, the Departures radar controller noted VH-FKF turning onto an incorrect heading and queried the pilot. At about the same time the crew realised that they had not selected Fentons Hill VOR but still had Melbourne VOR selected to avail of the international DME. For a short time VH-FKF was intercepting the 200 deg. radial from Melbourne instead of from Fentons Hill. There was no breakdown in separation with other aircraft.

Occurrence summary

Investigation number 199403598
Occurrence date 30/11/1994
Location 4 km south-west of Melbourne
State Victoria
Report release date 18/04/1995
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 Fokker B.V.
Model F28 MK 1000
Registration VH-FKF
Sector Jet
Operation type Air Transport High Capacity
Departure point Melbourne VIC
Destination Canberra VIC
Damage Nil

Loss of separation involving a Fokker B.V. F27 MK 50, VH-FNE and Saab SF-340B, VH-LIH, 56 km north-east of Albury, New South Wales, on 30 November 1994

Summary

VH-LIH was tracking out of Albury for Sydney and was cleared to climb to flight level 120. VH-FNE was inbound for Albury, from Sydney, initially maintaining flight level 230. Because one of the radar stations was out of service the radar coverage in that area was unreliable and procedural separation was employed. The crew of VH-FNE were given descent to flight level 120, in error. The air traffic controller had intended to descend VH-FNE to flight level 130.

The crew of VH-LIH requested a clearance to climb to a higher level. This was not allowed as the controller mistakenly believed that VH-FNE was at flight level 130. The controller gave both crews traffic information on each other and asked them to report sighting and passing each other. In response the crew of VH-FNE told the controller they had been cleared to flight level 120, were currently at flight level 126 and were climbing back to flight level 130. Following discovery of the error in giving VH-FNE flight level 120, this aircraft was maintained at flight level 130 until it had passed VH-LIH.

Significant Factor

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

1. Incorrect level clearance issued by the air traffic controller.

Occurrence summary

Investigation number 199403584
Occurrence date 30/11/1994
Location 56 km north-east of Albury
State New South Wales
Report release date 17/01/1995
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 Fokker B.V.
Model F27 MK 50
Registration VH-FNE
Sector Turboprop
Operation type Air Transport High Capacity
Departure point Sydney NSW
Destination Albury NSW
Damage Nil

Aircraft details

Manufacturer Saab Aircraft Co.
Model SF-340B
Registration VH-LIH
Sector Turboprop
Operation type Air Transport Low Capacity
Departure point Albury NSW
Destination Sydney NSW
Damage Nil