VH-TEQ was conducting circuits and was instructed to report when ready to turn base for runway 12. VH-TAK was on approach for runway 35.

The aerodrome controller (ADC) was under training and when the pilot of VH-TEQ reported ready for base he elected to make that aircraft number one in the landing sequence. He instructed VH-TEQ to make a short approach and then cleared that aircraft for a touch-and-go with a request to expedite crossing the runway intersection. The pilot of VH-TEQ attempted to carry out these instructions to the best of his ability but did not perform as speedily as the ADC expected.

The rated controller observed this action and decided that the runway separation standard would exist by the time VH-TAK needed a landing clearance.

The crew of VH-TAK were twice told by the ADC to expect a late landing clearance and the captain elected to continue his approach as he could see that the runway was clear and air traffic control had given him a landing expectancy. Although realising that another aircraft was on a crossing runway and conducting a lookout, the crew of VH-TAK did not see VH-TEQ until after touch down. Traffic information was not passed to either crew.

When the ADC trainee and training officer realised that the runway separation standard may be infringed, they considered that the safest action was to land VH-TAK as VH-TEQ had commenced rotation from the touch-and-go. A landing clearance was issued to VH-TAK as that aircraft approached the threshold. When VH-TAK was on its landing roll, VH-TEQ crossed the runway intersection at a height of approximately 100-150 ft. As a result, the required landing separation had not been maintained.

Significant Factor

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

1. The ADC trainee misjudged the traffic situation.

2.The ADC training officer did not take sufficient action early enough to prevent a breakdown in separation standards.

3.Traffic information was not given to either crew.

The pilot made an approach to land on runway 35. He reported that conditions in the circuit were turbulent with about eight knots of crosswind on runway 35. Prior to the flare the aircraft entered a high rate of sink. Full power was applied but the pilot was unable to prevent the aircraft from landing heavily. The nose gear collapsed and the propeller hit the runway. The aircraft skidded for a further 80 metres, coming to rest on the grass to the right of the runway.

The pilot reported that whilst in level flight at Flight Level 200 (FL200) at approximately 0910 EST (Eastern Standard Time), he began to feel pain in the lower left of his abdomen. He then began feeling airsick, and asked the Flight Sister for a sick bag. Shortly after, he lost consciousness. The Flight Sister then administered oxygen to the pilot and swabbed his face with a damp cloth, until he regained consciousness about two minutes later.

The pilot stated that after regaining consciousness he initiated the oxygen mask drill, declared an emergency to Brisbane control, and directed the Flight Sister to occupy the copilot's seat and to check all radio communications and directions. The pilot said he carried out descent and approach checks two or three times and requested position information from Brisbane Control to cross check his own interpretation of his position. The pilot stated that he used the autopilot until on short final, as he was fearful of lapsing into unconsciousness again. The aircraft was diverted to Coolangatta, and landed on runway 14.

Medical investigation concluded that the most likely cause of incapacitation was expansion of bowel gas in a full colon and stated that abdominal discomfort resulting from this condition can lead to unconsciousness. Although the cabin altitude was 4000 feet the change in pressure would have been sufficient to cause considerable bowel gas expansion. The pilot said he had been on a high fibre diet which predisposed towards formation of bowel gases.

While enroute between Corryong and Bathurst, the pilot of VH-ICS called Canberra Approach and requested a clearance to enter Canberra controlled airspace. An attempt was made by air traffic control to identify the aircraft but due to poor radar coverage, in the area and the aircraft's altitude, this could not be achieved. In response the pilot was instructed to remain outside controlled airspace.

Subsequently a brief radar return from VH-ICS was observed in the Wagga controlled airspace, about 20NM west of the planned track of the aircraft. There was inadequate radar contact to allow radar separation standards to be applied. The aircraft track conflicted with that of VH-AWW which was tracking in the opposite direction.

The pilot of VH-ICS said, that in hindsight, he should have planned a route that had more navigational aids to assist with track maintenance. He was tracking on a back bearing from the Corryong NDB and was unable to obtain a distance from the Canberra international DME. Hence, he was unable to accurately determine his position and ascertain that he was off the planned track.

Significant Factors

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

1. The route planning by the pilot was poor.

2. The aircraft was not equipped with a domestic DME.

3. The enroute track maintenance by the pilot was inadequate.

The helicopter was engaged in a search for a missing aircraft. The search area was in a valley bounded by sheer cliffs reaching to heights of 2,000 ft above the valley floor. Whilst the helicopter was flying at a height of 1,000 ft about 150 metres out from a cliff face, the main rotor struck and severed a power transmission spur line. The helicopter remained controllable, and the pilot was able to land in a clearing about two kilometres away for damage assessment.

The pilot reported that he had not seen the cable, which stretched in a single span from the cliff top to the valley floor, nor had he experienced any handling difficulties with the helicopter after the collision.

The pilot was taxiing towards his parking spot along a narrow taxiway. He noticed a fuel tanker parked on the edge of the taxiway and moved to one side of the taxiway to avoid contact. Unfortunately, he did not allow sufficient room and the right wing, then the nose, struck the tanker.

The pilot reported that on lift off, the helicopter rolled to the left. Right cyclic control was applied but did not appear to have any effect. The helicopter was landed immediately but contacted the ground heavily. The pilot later said that he must have pushed the left pedal during the landing, which spun the helicopter through 90 degrees, causing most of the damage. He also thought the cyclic friction control may not have been fully released before flight.

The aircraft was taxiing towards Gate 53 at Perth International Terminal. The visual docking guidance system in use at Gate 53 consists of a centreline guidance light and two side marker stop boards. The rear side marker board is for DC10 type aircraft and aircraft using a middle or second entrance door. The side marker board closer to the aerobridge entrance is for most aircraft using a forward entrance door, including the A310. The pilots did not see the side marker board adjacent to the aerobridge, as the aerobridge weather shield almost completely obscured it, and were taxiing towards the second board when the top of the left engine collided with the aerobridge structure.

The pilots were not familiar with Perth Airport and relied on information supplied in the Jeppesen documentation for their pre-arrival briefing. Investigation revealed that Jeppesen use information from the Australian Aeronautical Information Publication (AIP), Aerodromes (AGA) section to provide briefing material in their documentation regarding visual docking guidance systems.

The information available to the pilots about the side marker boards was not clear and did not indicate that there may be more than one board on the gate they were to use.

Further investigation revealed that there are a number of different visual docking guidance systems in use at Federal Airports Corporation (FAC) airports and that operational use of these systems is not clearly explained in an easily accessible format in the AIP and Jeppesen documents.

Significant factors

The following factors are considered relevant to the development of the incident.

1. The information presented in the Jeppesen documentation about the side marker boards was not clear and did not indicate that on the selected gate there may be more than one marker board; and
2. The FAC airports have a number of different visual docking guidance systems in service. Instructions for use of the differing systems are not clear, nor are they presented in an easily accessible format in the AIP and Jeppesen documents.

SAFETY ACTION

From this investigation the Bureau issues the following Safety Advisory Notice: SAN 960061

The Bureau of Air Safety Investigation suggests that the Federal Airports Corporation:

1. reviews the positioning of side marker boards at gates used by international operators. The review should ensure that the boards are sufficiently visible to the pilot to permit full understanding before the aircraft moves into the parking position; and
2. reviews the number of different types of visual docking guidance systems in use at both domestic and international terminals under its jurisdiction. The review should aim to reduce the number of different systems in use and to standardise the presentation of the system to users.

The exercise for the student was to be an engine failure on take-off before the decision speed of 88 knots. On take off the engine was failed at 80 knots. The student re-acted incorrectly and lifted the aircraft off, instead of closing the throttles and rejecting the take-off. The instructor took control, closed the throttles and landed the aircraft on the runway. As the aircraft slowed an uncontrollable swing right developed and the aircraft came to a stop to the right of the runway.

Inspection of the aircraft showed that the right main gear leg had collapsed. The upper section of the gear leg had split and allowed the lower section to detach. The damage was consistent with a heavy touch down on the right gear leg.

One observer reported that the aircraft appeared to descend rapidly to the runway from a height of about 30 feet, touching down on the right gear leg first.

Significant Factors

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

1. Unexpected reaction by the pilot under check in lifting the aircraft off when the speed was below the decision speed.

2. Heavy touch down on right main gear leg, following instructor actions when he took over at a low airspeed.

At about 120 kts on the take-off roll, the crew heard a loud bang followed by a series of lesser bangs, accompanied by significant vibration. The take-off was rejected, and the aircraft was brought to a stop without further incident.

The initial investigation found substantial internal damage to the number two engine. Later specialist strip examination of the engine determined that a single stage nine blade from the high-pressure compressor had failed due to progress of high cycle fatigue cracking. It was found that the cracking had propagated from an impact mark at the trailing edge of the blade, close to the root. The specialist report considers that this mark, caused by impact from a foreign object, was the root cause of the failure event.

The investigation found that there were no operational aspects associated with the occurrence.