Ditching involving a de Havilland DH-82, VH-TSG, 5 km east of Surfers Gardens, Queensland, on 27 February 1994

Summary

The joy-flight was proceeding northwards over the beach of Surfers Paradise and had been cruising at 500 feet for just over a minute when the engine power reduced to idle. After conducting his trouble checks and finding no way to restore power the pilot selected an area for a landing on the beach. The aircraft came to rest in shallow water after manoeuvring to avoid people on the beach.

On inspecting the engine area, the pilot found that a ball joint in a push-pull rod to the carburettor throttle valve had failed, allowing the throttle to close. Further examination by the maintenance organisation revealed that a plate to which the rod was attached was shaped incorrectly. This caused the spring-loaded ball joint to wear abnormally until it fell off. The engine had been overhauled 200 hours earlier.

Occurrence summary

Investigation number 199400517
Occurrence date 27/02/1994
Location 5 km east of Surfers Gardens
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 Ditching
Occurrence class Accident

Aircraft details

Manufacturer de Havilland Aircraft
Model DH-82
Registration VH-TSG
Sector Piston
Operation type Charter
Departure point Surfers Gardens QLD
Destination Surfers Gardens QLD
Damage Substantial

Wheels up landing involving a Piper PA-28R-180, VH-IBB, Goondiwindi, Queensland, on 26 February 1994

Summary

The pilot was conducting his first solo navigation exercise and had arrived overhead the destination aerodrome. He attempted to identify the wind direction and speed by observation of the windsock. The indications from the windsock were confusing and the pilot continued to observe it as he entered downwind and extended the leg. The resulting landing approach was long and flat, requiring significant power to reach runway 04. As he flared to land and reduced power the landing gear warning horn sounded. He applied power but the aircraft settled onto the runway with the landing gear retracted.

It was later found that the windsock was wrapped around its pole.

Occurrence summary

Investigation number 199400514
Occurrence date 26/02/1994
Location Goondiwindi
State Queensland
Report release date 29/04/1996
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-28R-180
Registration VH-IBB
Sector Piston
Operation type Flying Training
Departure point Lismore NSW
Destination Goondiwindi QLD
Damage Substantial

Total power loss involving a Jabiru aircraft, VH-JQX, 9 km west of Nambour, Queensland, on 27 February 1994

Summary

While cruising at 3000 ft, the engine suddenly lost power to the extent that level flight was no longer possible. The pilot conducted a forced landing on to a rough field, causing damage to the landing gear, fuselage, and propeller. Investigation revealed a failure in the rocker gear of the number four exhaust valve.

Occurrence summary

Investigation number 199400516
Occurrence date 27/02/1994
Location 9 km west of Nambour
State Queensland
Report release date 23/03/1994
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Engine failure or malfunction, Forced/precautionary landing
Occurrence class Accident

Aircraft details

Manufacturer Jabiru Aircraft Pty Ltd
Model JABIRU
Registration VH-JQX
Sector Piston
Departure point Bundaberg QLD
Destination Watts Bridge QLD
Damage Substantial

Collision with terrain involving a Cessna 172P, VH-FCQ, Bonrook Station, Northern Territory, on 28 February 1994

Summary

While enroute from Batchelor to Tindal, the pilot encountered deteriorating weather conditions and landed the aircraft in a suitable paddock, on Bonrook Station. The following day he inspected the landing area and judged the length to be 500 metres and that the area was suitable for take-off. However, the weather conditions were still unsuitable for departure.

The next day, after obtaining a weather forecast and being satisfied that the weather was suitable, the pilot decided to continue the flight. He and his passenger boarded the aircraft, and the pilot configured the aircraft for a short-field take-off. During the subsequent take-off the pilot rotated the aircraft at 55 kts. It became airborne and commenced to climb clear of the 10-metre-high trees at the end of the strip. However, the pilot became concerned about a tall tree directly ahead and commenced a left turn to avoid the tree. The stall warning sounded, one wing dropped, and the aircraft impacted the trees. The pilot suffered minor lacerations to his head, probably as a result of being struck by sections of the broken windscreen, and the passenger received minor bruising.

Checks of the fuel did not reveal any contamination, and the pilot believes that the engine was operating normally during the take-off.

An inspection of the take-off area revealed that the surface was firm and that the grass had recently been slashed.

The performance charts contained in the flight manual show that the strip distance available was adequate for a take-off from a dry grass runway. However, on this occasion, it is likely that the surface was wet and covered in recently slashed grass and that take-off performance was degraded. The pilot was not familiar with operation from such strips.

Occurrence summary

Investigation number 199400499
Occurrence date 28/02/1994
Location Bonrook Station
State Northern Territory
Report release date 19/06/1994
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Collision with terrain
Occurrence class Accident
Highest injury level Minor

Aircraft details

Manufacturer Cessna Aircraft Company
Model 172P
Registration VH-FCQ
Sector Piston
Operation type Private
Departure point Bonrook Station NT
Destination Darwin NT
Damage Destroyed

Collision with terrain involving a Skyfox CA25, VH-PFF, Parafield, South Australia, on 26 February 1994

Summary

The student pilot, returning from a solo training session, carried out a normal circuit and approach for landing, but the aircraft bounced slightly on touchdown. The pilot applied some forward elevator control, but the aircraft veered about 90 degrees to the left and ran off the runway.

The pilot unsuccessfully attempted to control the swing with right rudder, then applied full power to go-around. She then observed another aircraft taxiing and turned the aircraft left to avoid that aircraft. The left wing struck the ground and the aircraft cartwheeled.

Occurrence summary

Investigation number 199400486
Occurrence date 26/02/1994
Location Parafield
State South Australia
Report release date 19/06/1994
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Collision with terrain
Occurrence class Accident
Highest injury level Minor

Aircraft details

Manufacturer Skyfox Aviation Ltd
Model CA25
Registration VH-PFF
Sector Piston
Operation type Flying Training
Departure point Parafield SA
Destination Parafield SA
Damage Substantial

Breakdown of co-ordination involving a Boeing 767-238ER, VH-EAM and Boeing 747-300, G-BPFV, 2330 km north of Perth, Western Australia, on 24 February 1994

Summary

The aircraft were operating on the same air route within controlled airspace under the jurisdiction of Jakarta control sector. Although Jakarta was providing control and separation services within the Jakarta Flight Information Region (FIR), Perth Flight Information Service International (FIS INT) was monitoring the common international high frequency (HF) aeromobile facilities being used by both aircraft and Jakarta.

G-BPFV was southbound at FL370 estimating LAMOB at 1914 hours and had established HF Primary Guard with Perth FIS INT.

VH-EAM was northbound, 10 NM right of track, at FL350 until passing waypoint LAMOB at 1858 when a flight planned climb to FL390 was requested from Jakarta.

FIS INT 1 intercepted Jakarta's approval for VH-EAM to climb to FL390 and recognised the potential for a traffic confliction with G-BPFV. FIS INT 1 immediately advised Perth control Sector 1 of the situation and provided traffic information direct to VH-EAM.

Almost simultaneously, Jakarta instructed VH-EAM to maintain FL350, but the aircraft had already climbed to FL365 prior to resuming FL350.

The aircraft had established the required 2,000 feet vertical separation again by approximately 1904, two minutes prior to the point of closest approach, which was approximately 60 NM north of LAMOB, within the Jakarta FIR. It was later established that G-BPFV had been authorised by Jakarta to track 10 to 15 NM west of track.

Neither the amended track for G-BPFV nor the change of level for VH-EAM were co-ordinated with Perth Sector or FIS INT for relay. There was a breakdown of the required separation standards.

Occurrence summary

Investigation number 199400477
Occurrence date 24/02/1994
Location 2330 km north of Perth
State Western Australia
Report release date 19/06/1994
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Breakdown of co-ordination
Occurrence class Incident

Aircraft details

Manufacturer The Boeing Company
Model 747-300
Registration G-BPFV
Sector Jet
Operation type Air Transport High Capacity
Departure point Changi Singapore
Destination Perth WA
Damage Nil

Aircraft details

Manufacturer The Boeing Company
Model 767-238ER
Registration VH-EAM
Sector Jet
Operation type Air Transport High Capacity
Departure point Perth WA
Destination Changi Singapore
Damage Nil

Runway excursion involving a Cessna TR182, VH-SFS, Kalgoorlie, Western Australia, on 23 February 1994

Summary

The pilot reported that he made a normal approach and landing to the wet runway, touching down at around 60 knots. During the landing roll the aircraft began to veer to the right. Attempts to stop the yaw using both rudder and brake were unsuccessful. The aircraft left the sealed runway and the nosewheel was damaged when it entered a soft area.

The wind was blowing at 30 knots with gusts of up to 15 knots and a crosswind of 8 knots from the right.

The precise reason for the loss of control could not be determined but it is possible that it was the result of the combination of the wet runway and the strong and gusting crosswind.

Occurrence summary

Investigation number 199400475
Occurrence date 23/02/1994
Location Kalgoorlie
State Western Australia
Report release date 14/06/1994
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Runway excursion
Occurrence class Accident

Aircraft details

Manufacturer Cessna Aircraft Company
Model TR182
Registration VH-SFS
Sector Piston
Operation type Business
Departure point Jandakot WA
Destination Kalgoorlie WA
Damage Substantial

Loss of separation involving an Israel Aircraft Industries 1124, VH-AJJ and Cessna 550, VH-WGJ, 310 km north of Perth, Western Australia, on 22 February 1994

Summary

VH-AJJ was climbing to Flight Level (FL) 370 (37,000 feet) whilst VH-WGJ was climbing to FL350, and the aircraft were under the procedural (non-radar) control of the Perth Sector 1 air traffic service controller. The aircraft were on reciprocal tracks and a vertical separation of 2000 feet was required at least 10 minutes before the aircraft passed. The climb profiles of the aircraft meant that the required separation would not be achieved by 10 minutes prior to passing. The controller did not recognise the potential confliction.

Nine minutes prior to the aircraft passing, VH-AJJ requested an amended level of FL350 but was given FL330 because the controller assumed VH-WGJ was already at FL350.

Seven minutes prior to passing, the controller ascertained that VH-WGJ was passing FL320. He then realised a conflict existed and instructed VH-WGJ to descend to FL310. VH-WGJ started its descent back to FL310 as VH-AJJ reached FL330 on the climb. The aircraft reached the standard vertical separation requirements approximately three minutes prior to passing.

Although the controller was an experienced procedural sector controller he had not been involved in this type of control for about 12 months and had only recently been re-categorised.

Occurrence summary

Investigation number 199400466
Occurrence date 22/02/1994
Location 310 km north of Perth
State Western Australia
Report release date 19/06/1994
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 Cessna Aircraft Company
Model 550
Registration VH-WGJ
Sector Jet
Operation type Air Transport Low Capacity
Departure point Wiluna WA
Destination Perth WA
Damage Nil

Aircraft details

Manufacturer Israel Aircraft Industries Ltd
Model 1124
Registration VH-AJJ
Sector Jet
Operation type Air Transport Low Capacity
Departure point Perth WA
Destination Telfer WA
Damage Nil

Wheels up landing involving a Piper PA-39, VH-MMN, Wagga Wagga, New South Wales, on 23 February 1994

Summary

The pilot extended the landing gear but failed to get a down and locked indication from the single green indicator light on the instrument panel. The pilot recycled the gear twice, checked the indicator light was in the day mode but still did not get a down and locked green light.

The pilot raised the gear, proceeded to the west of the airfield and reduced speed, and then carried out a manual extension of the gear. He still did not obtain a green light. The pilot advised that during the manual extension he was unable to push the extension lever to the stop and the handle felt slightly spongy.

The pilot was advised that a visual inspection of the landing gear from the control tower showed that the gear appeared to be fully down, however, during the subsequent landing the gear collapsed.

Later investigation showed that the green light bulb was loose in its socket. After it was properly secured the green light illuminated satisfactorily.

The manual landing gear extension system was found to have been not correctly manipulated. For the gear to be successfully manually lowered, two actions are required; the electric motor must first be disconnected and then the gear must be manually lowered. It was found that the motor release arm used to disconnect the electric motor had not been pushed fully forward and the motor was still partially engaged. Consequently, the emergency gear handle was unable to be pushed fully forward to its stop. This meant that the gear was not able to be locked down, and the restriction caused by the partially disconnected electric motor led to the spongy feel reported by the pilot.

Significant Factors

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

1. The landing gear down and locked globe was loose in its socket.

2. The pilot did not get a safe indication when he extended the landing gear normally, even though the gear was most probably locked down.

3. The pilot retracted the landing gear and then attempted to manually lower it.

4. The manual extension system was not able to lock the gear down because the electric motor was still connected.

Occurrence summary

Investigation number 199400458
Occurrence date 23/02/1994
Location Wagga Wagga
State New South Wales
Report release date 15/02/1995
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-39
Registration VH-MMN
Sector Piston
Operation type Charter
Departure point Hoxton Park NSW
Destination Wagga Wagga NSW
Damage Substantial

Smoke involving a Socata TB-10, VH-YTD, Coonabarabran, New South Wales, on 15 February 1994

Summary

Shortly after carrying out a touch-and-go landing, at night on runway 29, a loud 'chuffing' sound was heard. Safety checks were begun, but the cockpit commenced to fill with smoke with no obvious sign of fire. Fresh air vents were closed, and a close circuit was carried out for a normal landing.

It was subsequently found that a number of exhaust pipe slip joint bolts were missing. One exhaust pipe had become detached and the escaping hot exhaust gases had burnt through the lower cowling.

Safety Action

As a result of the investigation into this and other similar occurrence (OASIS 9201731), the Bureau of Air Safety Investigation met with the Civil Aviation Authority Airworthiness (Powerplants) staff and discussed the apparent deficiencies with the exhaust clamping arrangements.

The CAA researched the available data and located a SOCATA Service Bulletin (SB), SB 10-073-78, which had been released in January 1994. The CAA subsequently isssued Aerospatiale (SOCATA) TB9, TB10 and TB20 Airworthiness Directives (ADs) AD/TB10/20, AD/TB10/21 and AD/TB20/27 effective 26 May 1994 mandating compliance with the manufacturers SB within 50 hours of time of service.

This prompt action by the CAA, in full consultation with the Bureau of Air Safety Investigation, obviated the need for any formal safety output.

Occurrence summary

Investigation number 199400441
Occurrence date 15/02/1994
Location Coonabarabran
State New South Wales
Report release date 11/08/1994
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Smoke
Occurrence class Incident

Aircraft details

Manufacturer SOCATA-Groupe Aerospatiale
Model TB-10
Registration VH-YTD
Sector Piston
Operation type Flying Training
Departure point Tamworth NSW
Destination Coonabarabran NSW
Damage Minor