Abnormal engine indications involving a British Aerospace PLC BAe 146-300, VH-EWM, 65 km north of Mallacoota, New South Wales, on 15 April 1994

Summary

The number 1 engine was shut due to an indication of increasing vibration. The aircraft diverted to Melbourne where investigation disclosed that the increasing vibration reading was caused by a chafed wiring harness. The harness had chafed due to a poorly positioned support clip allowing contact between the harness and the fan case.

Occurrence summary

Investigation number 199401015
Occurrence date 15/04/1994
Location 65 km north of Mallacoota
State New South Wales
Report release date 30/08/1994
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Abnormal engine indications, Diversion/return
Occurrence class Incident

Aircraft details

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

Hard landing involving a Piper PA-28-140, VH-WJS, Scone, New South Wales, on 18 April 1994

Summary

The instructor pilot reported that the landing approach appeared normal but was a little fast. The initial touchdown was normal, but the aircraft ballooned then touched down on the nosewheel which collapsed.

The instructor commented that the student pilot may have been hurrying his circuit to avoid any delay to two military helicopters that were entering the circuit. In doing so, the student pilot conducted the approach at a higher-than-normal airspeed and then attempted to force the aircraft onto the runway.

Occurrence summary

Investigation number 199400964
Occurrence date 18/04/1994
Location Scone
State New South Wales
Report release date 10/08/1994
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 Piper Aircraft Corp
Model PA-28-140
Registration VH-WJS
Sector Piston
Operation type Flying Training
Departure point Scone NSW
Destination Scone NSW
Damage Substantial

Loss of separation involving a Piper PA-28R-200, VH-WMJ and Douglas C-47, 55 km east of Wagga, New South Wales, on 15 April 1994

Summary

VH-WMJ was tracking from 18 miles south-east of Wagga direct to Young, descending from 8000 ft to 7000 ft. A RAAF DC3, Tester 922, was tracking from over Wee Jasper to over Wagga at 8000 ft. The crew of Tester 922 called Wagga Tower at 33 miles requesting clearance to enter the control area. This position was 2 miles inside the control area and a clearance to enter had not been previously requested or given.

Although the aircraft were well clear of each other the separation standards were infringed.

Significant factors

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

1. The crew of Tester 922 did not follow required procedures and obtain a clearance prior to entry into controlled airspace.

Occurrence summary

Investigation number 199400972
Occurrence date 15/04/1994
Location 55 km east of Wagga
State New South Wales
Report release date 20/06/1994
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 Douglas Aircraft Company
Model C-47
Registration Unknown
Sector Piston
Operation type Military
Departure point Canberra ACT
Destination Edinburgh SA
Damage Nil

Aircraft details

Manufacturer Piper Aircraft Corp
Model PA-28R-200
Registration VH-WMJ
Sector Piston
Departure point Benambra VIC
Destination Young NSW
Damage Nil

Wheels up landing involving a Piper PA-44-180, VH-JDF, Camden, New South Wales, on 15 April 1994

Summary

The aircraft was being flown on the final phase of the student's multi-engine endorsement training. A general handling period was completed before arriving at Camden to carry out normal and asymmetric circuit procedures.

The instructor pilot reported that the first approach was normal, but the aircraft touched down firmly on the mainwheels, followed by a firm touchdown on the nosewheel. A touch-and-go was carried out and the landing gear retracted normally after take-off. On downwind, during the next circuit, the landing gear extended normally with three green landing gear locked indications. The nose gear was also confirmed to be extended, using the mirror on the right engine nacelle. Both pilots again confirmed three greens during the turn onto final. The touchdown was smooth, but the nose gear collapsed, and the aircraft slid to a halt on its nose.

The repair agency later reported that the nose gear downlock was found out of rig to the extent that the hydraulic pump continued cycling with the gear down. It is probable that this condition allowed the nose gear to unlock when it took the weight of the aircraft during landing.

Occurrence summary

Investigation number 199400963
Occurrence date 15/04/1994
Location Camden
State New South Wales
Report release date 10/08/1994
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 Bankstown NSW
Destination Camden NSW
Damage Substantial

Loss of control involving a Robinson R22 Beta, VH-LLK, 35 km south of Brisbane, Queensland, on 15 April 1994

Summary

Witnesses reported seeing the helicopter land in the corner of a fenced paddock. A short time later the helicopter took off again but after climbing to about three metres above the ground, it began rotating and gyrating erratically, contacting the ground a number of times. It came to rest in an upright position but with the tail boom severed and damage to the main rotor assembly and gear box.

The pilot reported that he had recently recovered from a viral complaint which was characterised by severe coughing bouts but had been free of these symptoms for a few weeks. As he flew over the area of the accident, however, he had experienced the incipient stages of a coughing fit, so he landed the helicopter, shut the engine down, and walked around for a short time until the symptoms disappeared. He then reboarded the helicopter to continue the flight but shortly after lift-off was overcome by a severe coughing fit. This caused him to partially lose control of the helicopter, and it contacted either the fence or the ground.

Occurrence summary

Investigation number 199400960
Occurrence date 15/04/1994
Location 35 km south of Brisbane
State Queensland
Report release date 20/09/1994
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 Robinson Helicopter Co
Model R22 Beta
Registration VH-LLK
Sector Helicopter
Operation type Business
Departure point Archerfield QLD
Destination Logan Reserve QLD
Damage Substantial

Rejected take-off involving a Fokker B.V. F27 MK 50, VH-FNC, Albury, New South Wales, on 7 April 1994

Summary

The take-off was rejected when the left engine torque indication was noted to be 13% below target torque. The subsequent investigation found that a fuel control unit drive shaft seal failure had allowed fuel to wash the lubrication from the shaft bearings which then failed. The drive shaft and spacer were badly worn and had caused a restriction to the governor flyweights which had signalled the lower torque during take-off.

Occurrence summary

Investigation number 199400927
Occurrence date 07/04/1994
Location Albury
State New South Wales
Report release date 30/08/1994
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Rejected take-off
Occurrence class Incident

Aircraft details

Manufacturer Fokker B.V.
Model F27 MK 50
Registration VH-FNC
Sector Turboprop
Operation type Air Transport High Capacity
Departure point Albury NSW
Destination Sydney NSW
Damage Nil

Fuel contamination involving a Hughes Helicopters 369D, VH-MHE, Port Augusta Power Station, South Australia, on 11 April 1994

Summary

Circumstances

The helicopter had just lifted off and was about 30 feet above the ground when the pilot noticed that main rotor RPM was beginning to decay. He reduced collective pitch, but the helicopter lost height as the engine power slowly decreased towards flight idle.

Height could not be maintained with the power available, so the pilot had no option but to perform a downwind run-on landing onto rough terrain. The tail rotor struck the ground, and the tail boom was damaged by the main rotor blades. The engine was still running at reduced RPM when the helicopter came to rest.

Investigation revealed significant contamination in the airframe and engine fuel filters. The filters were not completely clogged, and the material was mainly of a sandy nature. Some of the material found in the filter bowls was probably displaced from the filter surface during the rough landing.

Engine components, including the fuel control unit, power turbine governor, fuel nozzle, PC air filter and all pipes and hoses were inspected by an approved overhaul facility.

Some of these components showed signs of wear sufficient to require overhaul before being returned to service but no fault could be found that would have definitely caused the power loss.

During the investigation it was found that the fuel supply hose became discoloured after being in contact with jet fuel for only a short period of time. Samples of the hose (both new and used) were sent for laboratory testing which revealed that the rubber compound used was not fuel proof, although it was rated for use with jet fuel.

Neither the partial filter clogging, the effects of wear in the engine fuel supply components nor the dissolved material from the faulty hose, individually, could explain the power loss. A combination of these factors at a time of high-power demand may have been sufficient to cause the loss of power.

Safety action

The Civil Aviation Safety Authority is aware of the information relating to the degradation of the interior of the fuel hose assembly and has taken it up with the hose manufacturer.

Occurrence summary

Investigation number 199400876
Occurrence date 11/04/1994
Location Port Augusta Power Station
State South Australia
Report release date 01/09/1994
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Fuel contamination
Occurrence class Accident

Aircraft details

Manufacturer Hughes Helicopters
Model 369D
Registration VH-MHE
Sector Helicopter
Operation type Aerial Work
Departure point 7km E Port Augusta SA
Destination 7km E Port Augusta SA
Damage Substantial

Wheels up landing involving a Cessna 210M, VH-AQH, Gove, Northern Territory, on 16 April 1994

Summary

When the pilot selected the landing gear down in the circuit area the gear down light failed to illuminate. He recycled the landing gear then carried out the emergency extension procedures, but without success. The aircraft was fitted with a mirror and the pilot was able to observe that although the main landing gear appeared to be down and locked, the nose landing gear had not extended.

The pilot decided to divert to Gove and advised Adelaide Flight Service of his intentions. He requested that Emergency Services be made available.

On arrival in the circuit area the pilot discussed the problem with company engineers, then over a period of about 30 minutes made several unsuccessful attempts to extend the nose landing gear.

When the Emergency Services were in place, the pilot made an approach to runway 13. He shut down the engine on short finals, landed on the main wheels and held the nose up as long as possible. As the airspeed decreased, the nose dropped and slid along the runway, damaging the propeller and nose cowls.

Subsequent investigation revealed that the nose gear doors were jamming and had trapped the nose landing gear in the up position. The aircraft had suffered a landing gear collapse during a take-off run some months previously and had only been flown a few hours in the two months since the repair. The nose landing gear doors had been causing extension problems during that time which had not been correctly rectified.

Occurrence summary

Investigation number 199400956
Occurrence date 16/04/1994
Location Gove
State Northern Territory
Report release date 26/08/1994
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 210M
Registration VH-AQH
Sector Piston
Operation type General Aviation
Departure point Milingimbi NT
Destination Elcho Island NT
Damage Substantial

Wheels up landing involving a Cessna 210L, VH-BEC, Elcho Island, Northern Territory, on 8 April 1994

Summary

After selecting the landing gear down the pilot reported that the hydraulic pump motor made an unusual sound for about 20 seconds, then stopped. He attempted to pump the gear down manually but was unable to obtain a safe indication although all landing gear legs appeared to be in the down position.

Because of failing light, he decided to land as soon as possible, and when flares had been arranged made an approach for runway 10. During the landing roll the pilot applied heavy braking which was evident due to scuffing and a flat on the right main wheel tyre tread. This caused the right main gear leg, which had not locked down, to rotate rearward around the hinge point and collapse. The aircraft slewed to the right, coming to rest in a shallow ditch alongside the runway.

A corrosion hole was found in the left main gear door hydraulic line which had allowed hydraulic fluid to escape overboard.

Occurrence summary

Investigation number 199400873
Occurrence date 08/04/1994
Location Elcho Island
State Northern Territory
Report release date 22/08/1994
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 210L
Registration VH-BEC
Sector Piston
Operation type Charter
Departure point Gove NT
Destination Elcho Island NT
Damage Substantial

CFIT involving a Bell 206L-3, VH-LIA, 15 km east-south-east of Point Nepean, Victoria, on 9 April 1994

Summary

The helicopter was engaged in a search and rescue (SAR) training exercise over the sea at night, in visual meteorological conditions. The task was to drop two small, improvised marker buoys from the helicopter in flight and for the pilot to record the latitude and longitude of the buoys by using the global positioning system (GPS) fitted to the helicopter. Small boats were tasked to search for the buoys.

As planned, the helicopter crewman dropped the two marker buoys through the left rear passenger window while the pilot flew at 100 feet radar altitude above the sea with about 15 knots forward airspeed. As soon as the buoys were released the pilot directed his attention to the GPS to obtain a fix. Then, just as the pilot raised the collective lever to climb, with the helicopter moving forward at about 15 knots, its landing skids, fitted with emergency popout floats, contacted the water and the helicopter nosed into the sea. The four persons on board, none of whom was wearing a life vest, were rescued within 20 minutes. There was no life raft in the helicopter. The helicopter was swamped before the pilot had a chance to inflate the emergency floats.

The radar altimeter had been set for its warning light to illuminate at or below 100 feet above terrain or water. The pilot confirmed the operational serviceability of the radar altimeter (RADALT) enroute to the buoy drop site which was two kilometres out to sea. During the buoy drop and the position fix, the helicopter was facing towards land where the pilot could see lights. While fixing the GPS position of the buoys, the pilot was unaware that the helicopter was descending.

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

1. The pilot channelised his attention to the GPS while flying at a low height at night.

2. The pilot was not aware that the RADALT warning light had illuminated.

3. The visual cues available to the pilot were insufficient to enable him to monitor the height of the helicopter above the water.

Occurrence summary

Investigation number 199400871
Occurrence date 09/04/1994
Location 15 km east-south-east of Point Nepean
State Victoria
Report release date 19/06/1994
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Controlled flight into terrain (CFIT)
Occurrence class Accident
Highest injury level Minor

Aircraft details

Manufacturer Bell Helicopter Co
Model 206L-3
Registration VH-LIA
Sector Helicopter
Operation type Aerial Work
Departure point Sorrento VIC
Destination Sorrento VIC
Damage Destroyed