The pilot was conducting a landing in a paddock to retrieve a glider from an out landing. During the landing roll the aircraft skipped slightly for approximately 15 m then pitched forward, the propellor struck the ground and the aircraft came to rest inverted.

The pilot said later that he may have relaxed prematurely after a reasonable satisfactory touchdown. The landing had been into a wind of about 10 kts.

The pilot stated that after successfully completing six circuits and landings with an instructor on board he commenced a period of solo circuits. During the fourth circuit, on final approach for runway 29, he was instructed by air traffic control to go around and make a right hand circuit for runway 36 and cleared for a touch and go landing. A normal approach was carried out, then after touching down at 80 knots the aircraft ballooned slightly. The pilot lowered the nose allowing the aircraft to wheelbarrow on its nosewheel and veer sharply to the left. The pilot applied right rudder to correct the swing, but the aircraft continued to slide sideways into a large drain.

When the Roulettes were cleared into the MCG from Point Ormond (PTO) at the start of the rehearsal, the airspace release that was issued by the departures (DEP) controller to the EN aerodrome controller (ADC) was "PTO to the MCG keep clear of the 26 localiser".  Prior to the start of the rehearsal an onwards clearance for the Roulettes that were to proceed to ES was issued by DEP to EN. The clearance was "track direct to MB maintain 5000 feet” Only the Roulette leader was operating a transponder.

After the Roulettes had started the rehearsal the EN ADC requested departure instructions for VH-SRJ who was departing runway 17 at EN to track via the 150 Melbourne (ML) VOR radial to Cowes (CWS) at 3000 feet. A heading of 170 or 180 was also requested to keep VH-SRJ clear of the Roulettes. DEP issued a heading of 170 unrestricted. VH-SRJ departed and remained on EN TWR frequency. The pilot of VH-SRJ was passed traffic advice on the Roulettes and reported that he had them in sight. When VH-SRJ was transferred to DEP frequency abeam Westgate Bridge (WEG), the pilot said he still had the Roulettes in sight. VH-SRJ was then vectored onto the 150 radial at 10 miles from EN by which time the aircraft was cruising at 3000 feet.

Meanwhile, the Roulettes had advised EN ADC that they had completed their Airwork and wanted an onwards clearance. EN ADC then called DEP for a clearance "MCG to Yarragon (YAR)". DEP then confirmed the previously arranged clearance of "direct MB maintain 5000 feet". EN ADC then asked the Roulettes about their details for departure and the leader advised two for LV and four for ES. EN ADC then cleared the two for LV to depart via Station Pier (SNP) at 2000 feet. The leader of the Roulettes then requested that the formation depart on a southerly heading to facilitate the breakup of the formation. This was approved by the EN ADC who then advised the four Roulettes that were bound for ES that once they were south of PTO or clear of controlled airspace to climb to 5000 feet. The EN ADC continually kept the Roulettes and other traffic holding outside EN airspace informed of each other.

At this stage DEP could see the transponder return of the Roulette leader heading for PTO at 2000 feet at 230 knots groundspeed but could not see any primary returns from the rest of the formation. He then asked EN ADC where the Roulettes were as he was expecting to see some return in the MCG area. EN ADC advised they were in the PTO area. At this time VH-SRJ was just south of and abeam PTO cruising at 3000 feet. The Roulettes that were bound for LV, including the leader using a transponder, then did a left orbit at 2000 feet and proceeded to LV.

A few seconds later a primary return was observed approximately four miles west of the 150 radial making a sweeping left arc towards MB. The formation bound for ES then called DEP and was immediately asked their present level which was reported as "left 3400 feet". A transponder code was then issued to this formation which was identified heading east towards MB leaving 4500 feet two miles east of VH-SRJ. The primary return from this formation passed within one mile ahead of VH-SRJ.

Analysis

EN TWR received a telephone call from the Roulette leader to arrange the area for the practice display. There was no consideration given to callsign requirements after the formation breakup. The display area was not specifically co-ordinated between EN TWR, DEP or the Roulette leader via intercom or air to air communication.

The DEP controller expected the Roulettes that were bound for ES to be departing from the MCG direct to MB which would have kept them clear of the 150 radial and VH-SRJ. However, the original airspace release from DEP to EN was PTO to the MCG up to 4000 feet and clear of the EN 26 localiser. Had there been a more precise description of the airspace release and onwards clearance then the EN ADC may have been more aware of the need to co-ordinate with DEP prior to clearing the Roulettes to track south.

DEP was unaware that the EN ADC had cleared the Roulettes to track south to PTO until he asked. When the Roulettes asked to track south, they were already almost over PTO with an airspeed of close to four miles a minute.

The incident occurred during a peak traffic period when both DEP and EN TWR were handling moderate to heavy traffic levels. Both the DEP controller and the EN ADC were experienced in their respective positions

Significant Factors

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

1. Co-ordination between the Roulettes, DEP, and EN TWR, both before and during the exercise was loose and lacking in specific detail.
2. Callsigns for the Roulettes after the formation breakup had not been addressed prior to the display. This resulted in the DEP controller having to access another transponder code for the ES bound aircraft at a critical period of the flight.
3. The DEP controller never issued a precise description of the airspace that was released to EN ADC.
4. EN ADC likewise did not ensure that the precise lateral and vertical limits of the airspace required by the Roulettes was co-ordinated with DEP. As a result, the Roulettes were not restricted to a specific block of airspace for their display.
5. DEP did not give a precise onwards clearance for the ES bound formation. A clearance should have been issued to ensure the formation set course from the MCG direct to MB. This was critical for separation with VH-SRJ.
6. The EN ADC did not recognise the significance of the need to co-ordinate with DEP the request by the Roulettes to track south to facilitate the formation break.

Safety Action Taken

1. The DEP and EN TWR controllers were taken off their rosters and given appropriate counselling.
2. A standardisation item is to be issued by Air Traffic Services (ATS) in Melbourne to highlight the need for precise descriptions of airspace releases along with a reminder of the need to take performance characteristics into account when formulating airspace releases.
3. Another standardisation item is to be issued to highlight the importance of being specific when defining a route clearance, particularly when it involves separation with another aircraft. This item will include a reminder that it is imperative that co-ordination is effected before any approval is given that may change the conditions of an issued clearance.
4. Discussion is taking place among ATS supervisory staff as to the best way of co-ordinating these types of activities between all involved parties to ensure that correct briefing and co-ordination is achieved.

Sequence of Events

The crew of VH-OGO, when established on final approach to runway 33, reported a TCAS RA (Resolution Advisory) against an unknown aircraft indicating half a nautical mile west at the same level, 1,000 ft AMSL. The other aircraft, VH-HSC, a helicopter, was tracking west of the Cook Highway to the south-eastern training area. A breakdown in separation had occurred.

The pilot of the helicopter had been given a clearance by SMC (Surface Movement Control) to track to the western training area via Green Hill. The ADC (Aerodrome Controller) later amended this clearance for the aircraft to remain west of the Cook and Bruce Highways. The departure of the helicopter was not monitored by the ADC due to distractions in the Control Tower. The ADC expected the helicopter pilot to track directly to the south-western section of the Bruce Highway which is due south of the aerodrome. The pilot instead tracked west of the Cook Highway which closely parallels the final approach path to runway 33.

Analysis

When the two aircraft passed each other, the helicopter which had not reached the junction of the two highways was still being operated within its clearance restriction of "west of the Cook Highway", although this was not what the ADC intended. The ADC failed to monitor the helicopter's departure thus did not ensure adequate separation of the outbound helicopter and the inbound passenger jet.

Safety Action

As a result of this incident, a caution has been inserted in the Air Traffic Services Local Instructions stating that at a departure clearance west of the Cook Highway does not provide separation with final runway 33.

The pilot flared the aircraft for landing too early, in strong gusty wind conditions. Corrective action was not undertaken. As a result, the aircraft landed heavily, collapsing the right main landing gear.

The aircraft made a normal approach and landing on runway 05. As the aircraft was approaching the parking bay tarmac personnel noticed that a section of leading-edge flap was missing from the right wing outboard leading edge. This was later found by the aerodrome safety officer during a runway inspection.

The crew reported that the aircraft had operated normally during the flight.

Investigation revealed that after departure from Melbourne, as the leading-edge flaps retracted, the follow-up mechanism malfunctioned allowing the flap actuator to continue driving the flaps when fully retracted. This caused a flap attachment bracket to fail. When the flaps were selected down the actuator operated normally, with no abnormal indications noticed by the crew. The section of flap associated with the failed bracket separated from the aircraft after landing.

The cause for the follow up mechanism to malfunction could not be determined, and a report from the company has not been forthcoming.

The pilot was conducting joy flights in the vicinity of an active car racetrack. The helicopter type was recently introduced into Australia and is a relatively new design. VH-APM had accrued only 128 hours total time since new.

The pilot took off into a 15-knot wind with three passengers on board. The helicopter was operating at less than maximum gross weight, with a significant power margin. The pilot advised that when the helicopter was about 100 feet above the ground, climbing at about 55 knots, he felt a slight airframe vibration and heard the engine noise increase slightly. The vibration level continued to worsen. The pilot had no idea what was causing the vibration or how serious it was. He elected to land the helicopter as soon as possible. As there was no suitable landing site immediately ahead, he turned back to the departure helipad and instigated a power-on (needles joined) autorotative descent. Nearing the ground the pilot flared the helicopter, which was facing downwind, and applied maximum power, but was unable to eliminate the rate of descent. The helicopter sank through the flare and landed heavily, tail low, short of the helipad, in the clear take-off departure path area, with five to 10 knots groundspeed.

Subsequently engineers discovered that the engine cooling fan had come loose on its shaft thereby causing the vibration. A crack was also discovered on the forward face of the fan wheel.

CONCLUSIONS

Findings

1. The engine cooling fan came loose on its drive shaft.

2. The loose cooling fan caused a vibration through the airframe.

3. The loose fan may have caused the engine to "hunt".

4. The pilot did not know what was causing the worsening vibration.

5. The nearest suitable site for a landing was the departure helipad.

6. In an attempt to land the helicopter as soon as possible, the pilot entered a power on autorotation and terminated with a downwind flare.

7. The helicopter landed heavily with the tail low.

Significant Factors

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

1. The pilot reacted quickly to a sudden, unusual, worsening vibration in flight.

2. Because of the tailwind effect, combined with a rapid descent plus a nose high flare, versus the available power, the pilot was unable to arrest the descent.

SAFETY ACTION

The helicopter manufacturer issued R44 Service Bulletin #2 on 24 October 1994 to all R44 owners, operators and service centres for an inspection to be done on cooling fans within 10 flight hours and thereafter every 25 hours until the fan wheel is replaced with a D174-1 Rev. G or later fan wheel.

The Jabiru aircraft was departing Cairns for a dual training flight. At approximately 200 ft AGL during the initial climb, a loud bang was heard, and the aircraft began to vibrate violently. The pilot immediately reduced engine power and was able to land the aircraft straight ahead on the remaining runway without further incident.

Later examination found that the right rear cylinder on the engine had partly detached from the crankcase. The cause for the detachment was traced to the fatigue failure of two of the cylinder tie down bolts. Specialist examination of the bolts by the manufacturer determined that the bolt design was probably inadequate. The manufacturer has since redesigned the bolts.

The aircraft ballooned during the flare out to land. In attempting to correct the flare, the pilot pushed forward the control column which resulted in the aircraft landing heavily and the nosewheel and propeller striking the runway. The pilot appears to have reacted spontaneously by pushing the control column forward instead of overshooting from the approach. The pilot's low aeronautical experience may have contributed to his actions.

Factual Data

This incident involved the RAAF Roulettes aerobatic team operating in close proximity to a media helicopter during an aerobatic display.

During the week prior to the occurrence, the RAAF Roulettes aerobatic team had coordinated plans to provide an aerobatic display during the launch of a Frigate at Williamstown (WMS) naval dockyard. Parties involved in the planning/coordination were the Roulettes administration officer, the Essendon Tower (EN TWR) team leader and the Melbourne Ops District Office Support Specialist (DOSS) staff.

The plan was for the Roulettes to arrive and hold at Freeway Overpass (FWO) at 3000 feet, weather permitting and then to proceed to WMS for the display. The airspace required for the display was a three nautical mile radius around WMS up to 4000 feet. A temporary restricted area was promulgated by NOTAM up to 2000 feet to cover the OCTA portion, the CTA base at WMS being 2000 feet. The controlling authority was EN TWR.

Both the EN TWR team leader and the ML Terminal Area Controller (TAC) were advised of the reason for the NOTAM and the intentions of the Roulettes, including the possible need to operate up to 4000 feet.

When the Roulettes arrived at FWO, the weather was marginal for holding at 3000 feet, so they were cleared to hold at 2000 feet. When they were ready to proceed to WMS for the display, they were cleared by EN TWR to "commence their run". The clearance did not include any reference to an airspace release (i.e. altitude limits) for the display nor a transit altitude for the run-in from FWO to WMS.

A media helicopter, VH-HWA, was operating over WMS at 2500 feet on Radar Advisory Service (RAS) frequency in Departures South (DEP S) airspace with DEP S concurrence. EN TWR passed traffic advice to Roulettes on VH-HWA, but VH-HWA was not advised of the intentions of the Roulettes. On arrival at WMS the Roulettes commenced an aerobatic display which took them to approximately the same altitude as, and in close proximity to, VH-HWA. Although the Roulettes did not acknowledge traffic advice on VH-HWA, they later confirmed they were aware of and maintained separation from, VH-HWA, during the display.

The pilot of VH-HWA was unaware that the Roulettes had him in sight and were maintaining visual separation from him during the display, but he did not report the matter to RAS. Because transponder codes were garbled with the aircraft in close proximity to each other, the Melbourne Approach Control Unit (ACU) were unaware that the Roulettes had conducted their display in close proximity to VH-HWA until after the event when advised by EN TWR.

The incident occurred during a high traffic load at EN TWR and a moderate to high traffic load in DEP S. In addition, there was ADC training in EN TWR that necessitated the ADC letting the trainee take control of the situation, with the ADC providing as little assistance as possible.

Analysis

Melbourne Area Approach Control Centre (AACC) controllers had no specific handover in the morning from the TAC to make them aware that the Roulettes would be conducting a display at WMS and requiring ML Terminal Area (TMA) airspace. They received the NOTAM on the restricted area but thought it was only to protect the launch of the ship, even though the NOTAM actually stated, "due air display". Details of the air display, including the controlling authority and possible airspace requirements, had previously been advised to the TAC who had made an appropriate annotation in the daily diary. However, the daily diary had not been checked by the oncoming morning TAC. In addition, there was nothing in the handover/takeover sheet advising of the Roulettes display.

On the flight plan received from the Roulettes there was no mention of an air display nor any request for a higher level at WMS. When ML RAS requested from DEP S a level for VH-HWA to operate at WMS, both controllers agreed that 2500 feet would give the required tolerance with the restricted area. ML DOSS had informed the EN team leader of the proposed restricted area and the Roulettes requirements. The team leader had prepared a briefing note, but the EN aerodrome controller (ADC) was busy supervising a trainee and had not assimilated the information in the note, in particular the possible need for a climb above the restricted area.

Regarding ML TMA, the TAC handover/takeover sheet did not give a reason for the restricted area (upper limit 2000 feet) and the daily diary was not checked. The Airways Data Systems Officer (ADSO) staff did not show the flight plan to the TAC, however, the flight plan did not indicate any air display at WMS.

The EN ADC did not specify any altitudes in his clearance to the Roulettes when he cleared them to “make their run", nor did he ascertain their requirements. In addition, the Roulettes then accepted a clearance, without question, that included no reference to altitudes. VH-HWA was not passed traffic information on the Roulettes because ML RAS were unaware, they would be operating above 2000 feet, the upper limit of the restricted area. Further, VH-HWA and the Roulettes were on different frequencies.

There had been no coordination between EN TWR and DEP S regarding the possibility (or intentions) of the Roulettes to operate above the upper limit of the restricted area (2000 feet) in DEP S airspace.

Factors

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

1. The restricted area at WMS was only promulgated to the base of CTA. Had it been promulgated to 4000 feet (the original highest planned operating altitude for the Roulettes) then it would have been under one controlling authority and VH-HWA would not have been over WMS at 2500 feet at the same time the Roulettes were conducting an air display.
2. The Roulettes were not given a proper clearance by the EN ADC to proceed to WMS and to conduct the display. The clearance was deficient in that no altitudes were specified, either for transit to WMS or for the display at WMS.
3. The Roulettes accepted a clearance that did not specify altitudes. This was probably as a result of an expectancy that they could operate up to 4000 feet, such expectancy being created by the planning for the event that occurred the previous week.
4. There were numerous breakdowns in communication/coordination between elements of ATC because controllers failed to follow standard procedures which would have averted these breakdowns. In failing to follow such procedures, certain elements of ATC were unaware of the intentions of the Roulettes.
5. The flight plan received from the Roulettes made no mention of an air display at WMS and contained no request for a higher level at WMS. Consequently, the flight progress strips were prepared without this knowledge.
6. The pilot of the helicopter was not given traffic information on the Roulettes. This was because ML RAS was unaware that the Roulettes would be operating above the upper limit of the restricted area.
7. The incident occurred during a high traffic load at EN TWR when ADC training was in progress. In addition, there was a moderate to high traffic load at DEP S.

Safety Action

All controllers involved were counselled. The counselling included a reminder of the need not to be complacent, to ensure that all control instructions are correctly carried out and coordinated so that no controller is left in any doubt.

ML DOSS and Manager Ops Support were consulted to ensure a standardised method of advice to all relevant parties, including the contents of NOTAMS, the way information is disseminated and the need with the initial briefing to ensure the responsibilities of the controlling authority are understood. Had the NOTAM included the vertical limits with the relevant tolerances, this incident may have been avoided.

A standardisation item is to be issued to highlight the need for precise descriptions of airspace releases plus a reminder that performance characteristics need to be considered when formulating airspace releases.

A standardisation item is to be issued highlighting the importance of being specific when defining a route clearance.

The ML TMA Stream Specialist conducted counselling for all ML TACs to ensure that correct handover/takeover procedures apply. In addition, TMA staff were to be reminded of their responsibilities for ensuring a correct handover is carried out.

All controllers were to be reminded of the separation requirements for formation flights.

ADSOs were to be reminded of their responsibilities to pass this type of flight plan to the TAC.