There was a strong westerly wind blowing across the main 18/36 bitumen runway at Wangaratta. Accordingly, the pilot decided to use the shorter 09/27 grass strip for landing.

The pilot identified the area he thought was the grass strip and landed on it in the 270 degree direction. During the landing roll the aircraft entered a ditch which ran across the area he had selected. The nose leg collapsed as a result and the propeller blades were bent. He then discovered he had selected the incorrect area for landing.

The grass strip was marked by outer gable markers and also by parallel inner rows of cones, which were visible from the air. The area selected by the pilot was parallel to the strip and next to the gable markers on the south side of the grass strip and had a shape similar to a landing strip.

Significant Factors 

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

1. The pilot mis-identified the section of the aerodrome surface area he was to use for the landing.

2. The landing area selected was unsuitable.

After departing Tyabb, the aircraft was climbed to 2000 feet for the short flight to Penfield. Shortly after levelling at 2000 feet the engine suffered a major power loss. The pilot performed basic emergency checks, but these did not result in a resumption of engine power. An area was selected for a forced landing but on short final approach the pilot had to veer to avoid a man walking his dog. The aircraft touched down heavily, sustaining substantial damage.

After the accident the engine was successfully run in an engine test stand. No faults were found that could have explained the reason for the engine failure. Weather conditions were conducive to the formation of serious carburettor icing at any power setting and there were indications that this could have been the cause of the power loss. Factors The reason why the engine failed was not determined but the most probable cause was carburettor ice.

After arriving in the circuit area, the pilot extended the landing gear and obtained the correct down and locked indications. The right main gear leg subsequently collapsed during the landing roll.

The retract actuator trunnion bearings had collapsed, allowing excessive movement of the actuator in its mount. This resulted in insufficient travel of the actuator to fully engage the downlock. Two separate occurrences involving unsafe landing gear indications, which had been corrected in flight by recycling, had been reported to the operator's maintenance staff prior to the accident. The maintenance staff, unable to duplicate the defect on the ground, had adjusted the downlock switch. Those adjustments finally resulted in the switch jamming in the closed position, giving a safe indication.

The downlock switch has two functions, providing independent safe/unsafe indications of the lock and, in series with the nose and left leg switches, removal of electrical power to the hydraulic pump when the three downlocks are sensed in a locked condition. On the accident flight, with the right downlock switch jammed in the closed position, hydraulic pressure was terminated when the left and nose gears locked down. As the lock function of the right gear lock was compromised because of the failed trunnion bearings, the leg collapsed under the landing loads.

Investigation of the aircraft maintenance requirements determined that the landing gear actuator trunnion bearings had been incorrectly identified as sealed bearings requiring no lubrication. The bearings fitted to the aircraft were of the unsealed type, with a requirement for lubrication every 1000 landings or 30 months.

Safety Action

As a result of the investigation into this occurrence, two other B200C aircraft from the same operator were found to have similar unsealed bearings fitted to the main landing gear actuator trunnion bearings. The operator has taken action to amend the aircraft inspection schedule to include lubrication of unsealed bearings and initiated a retirement life program for all sealed bearings.

The Bureau of Air Safety Investigation issues the following Safety Advisory Notice.

SAN 960030

The Bureau of Air Safety Investigation suggests that the Civil Aviation Safety Authority consider publishing an appropriate educational article detailing the circumstances of this occurrence and highlighting the need to correctly identify the various types of bearings, and their lubrication requirements, in all aircraft components.

After departure the pilot's intention was to track through the Oakey restricted airspace if possible. He contacted Brisbane Flight Watch and requested the status of the Oakey airspace. The operator advised him that the airspace was de-activated. As the pilot believed that this was unusual, he asked for confirmation that the airspace was not active. The response was that that was correct.

The pilot then continued towards Toowoomba and monitored the Oakey MTAF, while operating his transponder in altitude reporting mode. A short time later he heard Brisbane Flight Service make an all-stations call asking the aircraft west of Oakey to call Oakey. He acknowledged that transmission and called Oakey. At this time, he was advised that his aircraft was some eight miles inside controlled airspace.

When the pilot advised the Oakey controller what had transpired the controller undertook to contact Brisbane. The airspace had been active for most of the day.

The Brisbane Flight Service officer was unable to explain why he had told the pilot that the airspace was not active. He had checked the status board and noted that the airspace was active but had reported it as not active. Workload at the time was normal for the position.

The pilot noted the windsock was indicating nil wind and he elected to land on strip 36. The strip is 800 metres long from fence to fence but there is a powerline across the northern end. At the landing flare the aircraft floated and touched down about 200 metres after the threshold. The pilot noted the aircraft did not seem to slow down as expected, but due to concern over the powerlines at the far end he elected not to go around. The aircraft continued on the ground roll and the pilot was unable to prevent it from running into the fence, at low speed, at the northern end.

Significant Factors

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

1. The pilot did not make a timely decision to go around.

A Rockhampton City Council airport vehicle had been cleared by the Aerodrome Controller (ADC) to enter all movement areas for a runway inspection. This clearance enabled the driver to enter any runway without obtaining further clearance. Subsequently, a Fokker F28 VH-EWA was cleared to land on runway 15. When the aircraft was on short final the pilot noticed a vehicle on the runway approximately 1400 metres from the runway threshold. The pilot commenced a go-round and the ADC instructed the vehicle to vacate the runway immediately. The vehicle then cleared the runway, and the F28 made a normal circuit and landing.

The ADC stated that he had inserted the "runway occupied" strip into the active display board as is normal procedure when runway inspections are in progress. When the F28 turned base he scanned the runway, and as he did not sight the vehicle on the active runway he cleared the F28 to land. When the aircraft was on short final, another scan of the runway revealed that the vehicle had moved into view from behind two obstructions, a window mullion in the tower and a concrete light tower on the edge of the apron. The lighting tower is some distance from the tower cab and requires considerable physical displacement by the controller to effectively see behind it. Local procedures have been changed as a result of this occurrence. Vehicles on the movement area are now required to obtain a specific clearance before entering a runway.

Relevant Factors

1. The vehicle was not required to obtain specific clearance to enter the runway and entered the runway without the controller noticing.

2. The vehicle stopped on the runway in a position which was obscured by obstructions.

3. The controller failed to adequately scan the full length of the active runway before clearing the F28 to land.

Initial advice of this occurrence indicated that the accident had involved the aircraft striking a powerline during a practice forced landing. The pilot received a serious injury and spent some time in hospital recovering.

Subsequently, the Civil Aviation Authority advised that they had received information that the accident had resulted from a breach of the Civil Aviation Regulations, and they were pursuing the matter along those lines. Consequently, the Bureau did not continue its investigation of the occurrence.

The pilot reported that when taxiing out of the parking area at Phillip Island for departure, the nosewheel entered a hole. The hole was about 200mm in diameter and about 400mm deep. The pilot was not aware of the hole and did not see it. The nose gear collapsed, and the propeller hit the ground.

The pilot of VH-LGI, enroute from Maningrida to Darwin, reported to Adelaide Flight Service that he had experienced a breakdown in separation with an aircraft travelling in the opposite direction.

He was advised there was no other instrument flight rules traffic in the area, and that the aircraft was VH-AMQ operating under the visual flight rules on a SARTIME flight, and therefore not given as traffic.

Although both aircraft had made all necessary radio calls, the conflict occurred at a Flight Information Service area boundary when opposite direction traffic are monitoring different VHF radio frequencies.

The instructor and student were conducting crosswind training circuits on runway 07 at Redcliffe. At approximately 200 ft AGL after take-off on the third circuit, the engine began to run very roughly. The instructor immediately assumed control and transmitted a Mayday call. A decision was then taken to carry out a landing, onto the clear swampy terrain, straight ahead. The aircraft nosed over soon after touching down onto the soft surface. Both occupants were able to exit the aircraft without assistance.

The investigation found that the number 4 engine cylinder had a large fatigue crack in the non-finned base area, that extended approximately two thirds the circumference of the cylinder wall. No other defect was found with the engine, accessories or engine control systems that would have contributed to the rough running.

It is probable that the rough running was caused by excessive valve clearances and/or piston to cylinder binding, as the crack opened under load.