The duty runways were 17 left (17L) and 17 right (17R). On arrival VH-USH joined upwind and made a full right hand circuit for 17R. VH-EOT was operating on circuits on 17L.

VH-USH was next observed on final for runway 13R. The air traffic controller for the 17R circuit told the pilot that if he could not land on 17R he should go around.

In response the pilot of VH-USH said he would be landing on 13R. The controller assessed that this could be safely achieved as VH-EOT was expected to be clear of the runway intersection by the time VH-USH touched down. VH-USH landed on 13R.

The pilot of VH-USH had been to Moorabbin only once before and this was a long time ago. During the right hand circuit, he inadvertently lined up on final on 13R. He realised his mistake late on the approach, about when the controller called. The other aircraft had been in sight, and he knew it would be clear of his landing path. The controller's instruction reference landing runway 17R was misunderstood in that the pilot thought he was allowed to continue landing on 13R.

Significant Factors

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

1 The pilot of VH-USH misidentified runway 13R as runway 17R.

2 The pilot of VH-USH misunderstood the instruction from the controller to go around if he could not land on 17R.

3 The pilot was not familiar with Moorabbin.

The crew of VH-YSB had flight planned for an examination flight test to be conducted in accordance with Japanese Civil Air Board procedures which required a practice instrument landing system (ILS) approach to a minimum of 200 ft above aerodrome elevation.  They had briefed for a left turn from the runway 35 minima at Canberra.

Due to equipment limitations at Canberra, air traffic control (ATC) had instituted a system of slot times for any pilot requesting a practice ILS.  The pilot of VH-YSB had obtained approval for such a practice ILS and had also advised ATC that he would be carrying out a Category One ILS.  As ATC had no special instructions relating to the words 'Category One' in the notification of a Category One ILS at Canberra, no further action was taken by them in relation to that part of the flight plan advice.  Their expectation was for VH-YSB to carry out a standard ILS to the normal published decision height of 330 ft above the aerodrome elevation. As far as ATC were concerned, this was the only minimum for this approach and the instructions issued to aircraft were based on the use of this minimum.

The Canberra runway 35 ILS is not approved for Category One operations. The Category One ILS is designed for landings in extremely poor weather conditions and requires additional ground facilities which are not yet provided in Australia.

The crew of VH-YSB were cleared for final by Canberra Approach and were instructed to contact the tower for further instructions, which they did.

VH-ILL had completed a solo training exercise to the north of Canberra and was being processed by the aerodrome controller (ADC) for a right circuit to runway 30.

The ADC was under training and being supervised by an appropriately rated training officer.  The pilot of VH-YSB requested a left break and left circuit from the ILS.  The ADC decided that because of the traffic situation, such a procedure was not appropriate and issued instructions for VH-YSB to make a right break at the minima and then conduct a left circuit for a landing on runway 30.  There was some confusion between ATC and the crew of VH-YSB at this point but a correct readback of the instructions was obtained.

The ADC had been assessing the situation in relation to a landing sequence between VH-YSB and VH-ILL.  He decided that VH-ILL would be number one and issued instructions to achieve this sequence.  Consequently, he re-issued the break instruction to VH-YSB but in so doing included the words 'at the minima or when ready'.  This was misinterpreted by the pilot as an additional approval to continue to a minimum of 200 ft as required by the company's examination procedures.

The ADC decided to add a further requirement for VH-YSB to remain south of the field at all times in the break as this would add an additional safety buffer between the two aircraft.  Although this instruction was issued, no readback was obtained from the pilot and the crew do not believe they received such an instruction.  Examination of the automatic voice recording indicates that the pilot and ADC were probably transmitting at the same time and did not receive each other's message.

VH-ILL had continued an approach to runway 30 in accordance with ATC instructions.  As VH-ILL was on final approach VH-YSB had commenced its go-around from a 200 ft and, realising that he would be unable to make a left circuit for runway 30, the pilot levelled the aircraft wings to overfly runway 30.  His intention was to make a right circuit contrary to the instructions from ATC.  The pilot believed that this was the safest course of action he could perform from his position and that this action would enable him to comply, as near as possible, with the last ATC instruction.

The ADC training officer realised that VH-YSB was not going to remain clear of the flight path of VH-ILL and immediately gave traffic information on VH-ILL to the crew of VH-YSB.  Because VH-ILL was crossing the threshold with a landing clearance and VH-YSB was climbing and seen to be above VH-ILL, the training officer decided that no further action was necessary to prevent a collision and re-cleared VH-YSB for a right base to runway 30.

The aircraft passed within 150-300 ft of each other.

The training manual in use by the flying school states that such flight tests will descend to 200 ft before commencing a break.  However, ATC instructions only refer to the published minima, in this case 330 ft.

The go-around instruction given by ATC was designed to be commenced by 330 ft and would provide sufficient room for a safe left circuit to runway 30. Both ATC and the crew of VH-YSB agree that the position of the aircraft at the commencement of the break did not permit a safe execution of this manoeuvre.

The phrase used by the ADC, 'at the minima or when ready', was designed to allow a pilot to commence the break earlier than the minima if an easier transition to downwind leg was required.  However, in this occurrence it only served to reinforce the pilot's belief that he could continue to 200 ft.

Findings

1. The flying training school's advice to ATC of a Category One ILS approach had no meaning to the controllers.
2. There were no ATC instructions referring to runway 35 ILS approach minima below 330 ft.
3. The Canberra runway 35 ILS approach is not approved for Category One operations.
4. The crew of VH-YSB continued below the published minima for the approach being used.
5. The company training manuals used by the crew of VH-YSB specify a Decision Height of 200 ft for this particular examination.
6. The company training manuals used by the crew of VH-YSB had been accepted by the Civil Aviation Authority.
7. The go-around instructions issued by ATC were not able to be safely complied with from 200 ft.
8. The phraseologies used by ATC in issuing overshoot instructions were confusing to the crew of VH-YSB.
9. The ATC requirement for VH-YSB to remain south of the airfield in the right break was not received by the crew of VH-YSB.
10. The ADC was unable to provide adequate visual separation.
11. A breakdown in separation standards occurred.

Significant factor

The implications of the notification of a CAT 1 ILS by the flying training school, had not been disseminated to ATC.

Safety Action

As a result of the investigation:

1. ATS management at Canberra reviewed and amended the phraseologies in use at Canberra for overshoot instructions in similar circumstances.
2. The flying training school has reviewed and amended its notification requirements for ILS training flights.

The pilot reported that the helicopter suffered an engine power loss and that he conducted an autorotation into trees. Damage was caused to the tail rotor assembly and tail boom as well as a main rotor blade. The engine continued to run after the aircraft touched down.

The cause of the engine power loss was not determined.

During the pre-flight inspection the pilot noticed that the left aileron was buckled. Further inspection revealed diagonal wrinkling of the lower surface of the left wing, the leading edge of the left wing outboard of the engine nacelle, and evidence of movement in the left-wing attachment area.

The pilot stated that when he flew the aircraft on the previous day it had handled normally. The weather conditions on that day were such that at cruise the flight was smooth with light turbulence during the descent.

An analysis of the damaged aileron concluded that it had failed in static overload. An engineering assessment of the damaged to the aircraft concluded that the most likely scenario to cause the damage was one involving high speeds and gusts. These conditions were not reported by the pilot.

VH-TJH was departing from runway 27. The clearance was for a radar one departure, initial heading 270 degrees and a requirement to maintain an altitude of 3000 feet. After take-off the crew called on Melbourne departure control frequency at 2029.51, stating they were turning right onto 270 degrees, climbing to 3000 feet and passing 2000 feet. In response they were told they were identified.

A short time later, at 2030.55 they were told to turn right onto a heading of 310 degrees to intercept the 285 radial from the Melbourne VOR. At 2032.25 the crew of VH-TJH told the departures controller they required an immediate climb. The controller immediately cleared them to climb from 3000 feet to flight level 350.

The aircraft track had taken the aircraft towards rapidly rising terrain west-north-west of Melbourne. The higher points along this track are between two and three thousand feet. The aircraft Ground Proximity Warning System operated to give a warning of 'Terrain, pull up.' The crew responded by quickly commencing a climb, and this caused the GPWS to cease operating.

At that time of night, due to decreased traffic conditions, the approach and departures air traffic control positions were combined so that they could be operated by one controller. This also included the radar advisory service, (RAS). For the departure of VH-TJH the controller put an altitude restriction on the aircraft due to an aircraft inbound from the west. Other traffic was handled during this period and a call on the RAS frequency also occurred.

A further call was received from Moorabbin Tower to arrange a clearance for an aircraft taxying at Moorabbin. The situation regarding the aircraft approaching from the west was resolved by the time VH-TJH first called after becoming airborne. The altitude restriction of 3000 feet could have been removed then but was overlooked. While handling other matters the controller omitted to remove the restriction as the aircraft tracked outbound towards rising terrain. The GPWS warning was genuine.

The crew of VH-TJH did not take any early action to request a climb despite the fact they were tracking towards rising terrain while maintaining 3000 feet.

Significant Factors

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

1. The Controller omitted to remove the altitude restriction placed on VH-TJH, in a timely manner. The precise reasons for this happening could not be determined.

2. While tracking towards rising terrain at an altitude of 3000 feet, the crew of VH-TJH took no action to request a climb prior to activation of a GPWS alert.

The accident occurred during glider towing operations. After the third landing for the morning, the aircraft was being turned to back track on runway 22. The pilot stated that when power was applied to assist the turn being made with rudder and right brake, the aircraft immediately pitched 45 degrees nose down and the propeller was embedded in the earth strip. The wind was estimated to be 18-20 knots gusting to 25 knots from 230-240 degrees magnetic. The pilot stated that he considered inadvertent relaxation of back pressure on the control column, the power application, and possible excessive brake application causing sudden locking of the right-hand wheel were contributing factors.

Two days prior to the accident the pilot checked the aircraft and found fuel leaking from the right wing near the drain valve. He defueled the right tank to 30 litres to minimise fuel loss if the leak continued. Suspecting that the leak was from the drain valve, he reseated the valve and cleaned the fuel stains from the aircraft. The aircraft was checked again the next day. There was no evidence of fuel leakage, so the right tank was filled to 60 litres. On the following day there was again no evidence of fuel leakage, so the pilot assumed the leak had been from the drain valve.

The purpose of the flight was to transport three passengers from Mittagong to Cudal and return. The aircraft left Mittagong with 120 litres of fuel in the left tank and 60 litres in the right tank. During taxy prior to departure there was no evidence of fuel leakage and a post flight inspection after arrival at Cudal again revealed no evidence of leakage, so the tanks were refilled to 90 litres per side for the return flight.

On the return flight the weather at the destination deteriorated necessitating a diversion. While planning the diversion the pilot noted that the right tank fuel quantity gauge had dropped significantly since he last checked fuel quantities a short time previously. A short time later the pilot noted a moderate smell of fuel in the cabin. He suspected a serious fuel leak and decided to make a precautionary landing.

The pilot informed his passengers of the situation and his intentions. He then selected what appeared to be a suitable area and made three inspection runs over it. On short final approach, at about 20 feet off the ground, the pilot noticed that the selected area sloped sharply upwards. He flared the aircraft but could not arrest the descent. The aircraft touched down heavily and bounced. The pilot relanded and brought the aircraft safely to a stop. An inspection revealed substantial firewall damage as a result of the heavy landing.

After the aircraft had been recovered to a maintenance base an examination revealed a fuel stain down the right side of the fuselage just behind the cabin door. There was also heavy fuel staining on the root rib around the cutout for the right fuel tank aft supply line spigot. Further investigation revealed the right tank aft outlet spigot had fractured through 360 degrees about five millimetres inboard of the root rib cutout. The spigot is about 60 millimetres long and accommodates the aluminium supply line which is secured by a clamp at the inboard end of the spigot. The inboard end of the spigot complete with its supply line and clamp remained with the fuselage. The heavy fuel stain in the area was evidence that the spigot had been cracked for some time.

Significant Factors

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

1. A broken fuel tank supply line spigot permitting fuel leakage from the right fuel tank.

2. The leakage resulted in fuel vapour entering the cabin which led to the pilot making a decision to make a precautionary landing.

3. The area chosen for the precautionary landing had a significant upward slope which was not perceptible from the air. This slope was not noted by the pilot until very late on final approach. The result was that the pilot was unable to flare the aircraft sufficiently to prevent a heavy touchdown.

The pilot, who had limited experience, stated that during the take-off run the aircraft started to drift to the left of the strip due to a gusting crosswind. The aircraft struck a runway marker and the take-off was aborted. The aircraft then ran off the runway and struck a pile of dirt.

The check and training pilot was demonstrating a single engine approach to a simulated helideck in crosswind conditions and towards the setting sun.

As the aircraft entered the flare for landing the pilot misjudged the approach and adopted a higher-than-normal nose attitude. During the manipulation of the controls to complete the landing the pilot lowered the collective control whilst holding aft cyclic control. This resulted in one main rotor blade striking the base of the vertical fin.

The pilot felt the contact but assumed it was a tail skid strike. The skid was inspected, and when no damage was found, the flight was continued.

The blade strike was discovered after the flight was completed.

The possibility of a blade strike on the tail during single engine landings is a known problem and is covered in Sikorsky Aircraft Customer Service Notice 76-62. The pilot was aware of the contents of this notice.

During a maximum power take-off, the engine exceeded Exhaust Gas Temperature (EGT) limits. The outside air temperature (OAT) was reported to be 31 degrees C.

The engine was shut down and the aircraft returned to land. The engine was removed and a subsequent test cell run showed that it had a low EGT margin. This would have resulted in the observed EGT exceedance under high OAT conditions.

The operator has carried out a maximum power assurance run on all engines and has instituted a continual EGT monitoring program to ensure that adequate EGT margins are available.