VH-BPZ was en route from Wynyard to Phillip Island, cruising at 8000 feet and estimating the Marsh reporting point at 0555 UTC. VH-OZT was en route from Moorabbin to Wynyard, cruising at 9000 feet and also estimating Marsh at 0555 UTC. At 0551 UTC the pilot of VH-OZT called Melbourne Flight Service requesting traffic for descent to Wynyard. VH-OZT was advised of traffic (VH-EXC) inbound to Wynyard from the south. About 15 seconds later, the pilot of VH-BPZ asked flight service about "the Navajo for Wynyard". Flight service then gave traffic information to BPZ and OZT on each other's locations/estimates. The two aircraft then effected mutual separation.

The investigation determined that the flight service workload was heavy at the time of the occurrence. Both western sectors were combined at one console, but the traffic was confined to only one of the sectors. The console was staffed by two Flight Service Officers, one acting as a co-ordinator and the other as a traffic information officer. Prior to the occurrence, the traffic information officer had considered the traffic implications of VH-BPZ and VH-OZT but had concluded that they would have 1000 feet vertical separation at the time of passing. Therefore, when VH-OZT requested traffic for descent, the officer concentrated on traffic in the immediate Wynyard area and overlooked VH-BPZ.

Significant Factors

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

1. The flight service workload in the sector of the occurrence was heavy at the time of the occurrence.

2. The traffic information officer had previously assessed the traffic situation of the two aircraft involved and had dismissed them as traffic for each other on the basis of 1000 feet vertical separation. A reassessment was not made when the pilot of VH-OZT requested traffic for descent.

The aircraft was being ferried to the Philippines. An intermediate stop was made at Palau, where it remained idle for about a month. The pilot reported that prior to take-off from Palau he had refuelled the aircraft from drum stock and that subsequent water drain checks were clear. Pre-take-off checks were normal but during take-off, as the aircraft was rotated at about 90 kts, the right engine lost power. The pilot said he feathered the propeller, and retracted the flaps and landing gear, but the aircraft failed to achieve single engine climb speed. Because the left engine oil temperature was at the red line the pilot elected to carry out a wheels up forced landing onto a sandbar on an adjacent island.

Photographs of the damaged aircraft indicated the right propeller blades were not in the feathered position. The propeller did not appear to have been rotating at impact. The reason for the loss of power was not determined.

The aircraft was returning to Camden from Corowa with an intermediate stop at Marulan ALA. Two precautionary circuits were flown prior to landing. During the final approach to the upward sloping strip the pilot reported the landing flare was high and the subsequent touchdown heavier than normal. The right main landing gear collapsed immediately, and the aircraft ground looped before coming to rest facing the opposite direction.

The pilot was spraying a cotton crop in light wind conditions. On the second clean-up run, although aware of the location of a powerline, the pilot could not see the wires due to spray drift contamination of the windscreen. He misjudged the pull up point, and the aircraft struck the wires with the right main landing gear.

The aircraft was retarded by the wires and crashed inverted. The pilot was able to extricate himself before the aircraft was destroyed by fire.

The helicopter was hovering out of ground effect at about 15 m above ground level, with a right crosswind at 8-15 kt. As the pilot applied right pedal to turn more into wind, he felt a vibration and the helicopter commenced to rotate to the right. The pilot applied left pedal, moved the cyclic control forward, and lowered the collective pitch control in an attempt to recover the situation but the helicopter continued to rotate as it descended. After three or four rotations, the main rotor blades struck saplings, and the pilot elected to land the helicopter. During the landing, the tail boom and then the main rotor contacted a log, resulting in substantial damage to the helicopter.

VH-DXO was conducting crosswind circuits on runway 06 (circuit direction right hand). VH-MYS, inbound from the southwest, was given traffic on VH-DXO and instructed to join downwind for runway 14 (circuit direction also right hand). VH-MYS was also instructed to report "approaching the circuit".

As VH-DXO was about to turn onto right base for runway 06, VH-MYS passed in front of VH-DXO at right angles tracking on a right downwind leg for runway 14. The pilot in command of VH-DXO estimated that the two aircraft missed by about 10 metres. The pilot of VH-MYS reported on downwind immediately after the near collision but had not reported approaching the circuit as requested by air traffic control.

Significant Factors

The following factors were relevant to the development of this occurrence:

1. The pilot of VH-MYS did not report approaching the circuit as requested by air traffic control.

2. Lookout by the pilots of both aircraft was ineffective.

3. The instruction issued to VH-MYS by air traffic control to report approaching the circuit was too vague as this is not a specific position and is open to individual interpretation.

Safety Action

It was considered that this incident may have been averted if VH-MYS had been instructed to report at a specific location approaching the circuit rather than instructed to report approaching the circuit area which was vague and open to interpretation. This aspect was discussed with air traffic control supervisory personnel at Melbourne who will be taking standardisation action on the matter.

A report from the pilot indicated that he made a steeper than normal approach to a private strip. The aircraft landed some distance in from the threshold before bouncing back into the air. The pilot elected to apply power and go around for a further circuit. Despite application of full power, the aircraft did not clear obstacles beyond the end of the runway, and the pilot was forced to land in an adjacent paddock. The aircraft landed heavily.

The Boeing 767 crew requested departure from Perth via a scenic flight along the Swan River. Air Traffic Control (ATC) advised the crew to expect approval for this modified departure track. Due to traffic and noise abatement requirements, the aircraft was initially cleared to maintain runway heading after take-off. The crew acknowledged the clearance.

The aircraft was seen to commence a right turn, at 1600 ft, after take-off, conflicting with traffic departing off another runway. Shortly after ATC queried the crew's actions, the aircraft was seen to return to runway heading. By the time runway heading was regained, the aircraft had reached 2500 feet and was subsequently cleared to track via the Swan River.

Although separation reduced to below the minimum required, there was no danger of collision due to the horizontal displacement, between the aircraft, and the high rate of climb of the Boeing 767.

Runways 31 (left and right) were in use at Moorabbin. VH-IBL landed on runway 31L and vacated the runway via runway 22. VH-NBE was then given a clearance to take-off. Just after the aircraft became airborne, the student pilot abandoned the take-off. VH-IBL had inadvertently re-entered runway 31L and the student pilot of VH-NBE believed that his aircraft would not clear the other aircraft. The instructor assumed control of the aircraft and manoeuvred it around VH-IBL.

The pilot of VH-IBL had only recently been issued his private pilot licence. Although he was an experienced glider pilot, he was not very experienced at Moorabbin. He said that after vacating the runway he had had to taxi around a stationary aircraft and believed he had become disoriented and re-entered runway 31L.

The instructor in VH-NBE had watched both VH-IBL and the aircraft ahead of it land and taxi. He stated that VH-IBL had not taxied around the preceeding aircraft. He said the preceeding aircraft was well ahead of VH-IBL and was not a factor in the occurrence. He also believed that it was unnecessary for his student to abandon the take-off as their aircraft would have been well clear of VH-IBL.

After a normal preflight check had been carried out, the aircraft departed Bankstown. Soon after levelling off at 1500 ft the crew noticed an air noise from the left emergency exit which appeared to be partially dislodged. The pilot informed air traffic control of his intention to return to the airport but almost immediately the exit hatch separated from the aircraft. The aircraft landed without further incident.

The design of the emergency exit release mechanism permitted the handle to be moved to the locked position while the forward latch remained unlocked. The preflight inspection involved viewing the position of the handle through a cutout in the handle cover to ensure that it was locked. While the pilot had completed this inspection, it provided no guarantee that the exit was properly locked because the pilot cannot see if the locking pins have located correctly.

The investigation established that maintenance on the exit was not required, nor was it performed during the aircraft's last periodic inspection on 16 December 1993. The aircraft was not subsequently flown until the incident flight. However, on 29 December 1993 the operator reported that this aircraft may have been tampered with, together with two other aircraft belonging to him.

Significant factors

1. The emergency exit handle may have been moved by an unauthorised person or persons.

2. There was no means of alerting the pilot that the locking pins were not correctly located in the emergency exit locking mechanism.

Safety Action

As a result of this investigation the Bureau issued the following Safety Advisory Notice:

Safety Advisory Notice SAN 940101

The Bureau of Air Safety Investigation suggests that the Civil Aviation Authority consider the applicability of the provision of a suitable method(s) by which a pilot can obtain positive information on the locking status of the forward latching mechanism of the emergency exit in PA-44 aircraft.

The Bureau also suggests that the Civil Aviation Authority ascertain whether a similar problem exists with other aircraft types.