FACTUAL INFORMATION

When VH-BWO called taxiing at Proserpine, the flight service officer (FSO) receiving the call became confused regarding the type of aircraft and operation as he did not have a flight strip for the aircraft. Following its departure, VH-BWO called Flight Service. This confused the FSO further as he expected the aircraft to call Mackay Control direct for a clearance to enter the Mackay control zone, which has a lower limit of 4,000 ft in the area of concern. The FSO asked for the cruising level and was told 5,000 ft.

The FSO calculated a point at which to transfer the crew to the air traffic control frequency and instructed the pilot to call Mackay Control for a clearance at 32 NM from Mackay. The crew complied with this instruction and called at the designated point, to be told by the Mackay Controller that they were already in controlled airspace at their present level of 5,000 ft. There was no other traffic in the area. The boundary at 5,000 ft was 35 NM.

ANALYSIS

There was no flight progress strip on the aircraft available for the flight service officer, which meant that the first information he had on the aircraft was when the crew established radio contact. In his haste to provide information to the crew, he made an incorrect calculation for the position at which the aircraft would enter controlled airspace. This led to the instruction to the crew to call control for a clearance at 32 NM Mackay.

The crew were lulled into a false sense of security by the flight service officer's instruction and failed to obtain a clearance before entering controlled airspace.

SIGNIFICANT FACTORS

1. When BWO called unexpectedly, the flight service officer made some mistaken assumptions and issued inappropriate clearance instructions.
2. The aircrew followed the instructions from the flight service officer without question.

SAFETY ACTION

As a result of the investigation, the Bureau of Air Safety Investigation issued interim recommendation IR940204 to the then Civil Aviation Authority on 2 September 1994:

"The Bureau of Air Safety Investigation recommends that the Civil Aviation Authority review the phraseologies in use by flight service to ensure that:

"1. pilots are fully aware that an airways clearance is not available until they call ATC and that they are responsible for remaining outside controlled airspace until a clearance is obtained; and

"2. pilots are instructed to contact control for a clearance when the pilot judges it is appropriate based on the aircraft's operational criteria rather than at a specific time, place or altitude".

The Civil Aviation Authority replied on 19 July 1995 as follows:

"Reference is made to BASI recommendation R940204 regarding phraseologies used by Flight Service.

"Fundamentally, the responsibility to obtain the appropriate clearances before entering controlled airspace lies with the pilot. This point is very clearly stated in AIP OPS CTLI para 14. 1, which, in part shows "No aircraft shall enter controlled airspace without a clearance.", reiterated at CTL 10 para 20.1 "If the arrival involves entering controlled airspace, the pilot in command of an IFR flight must contact ATC prior to entry for airways clearance.", and again at CTL I 1 para 20.2 "Before reaching the boundary of controlled airspace, a pilot must request airways clearance on the ATC frequency notified in ERSA or MAP." In the cases cited however, the frequency change instructions provided by FS could have contributed to the unauthorised penetrations of CTA.

"The anecdotal evidence and pilot belief that ATC will have received coordination about the flight from Flight Service is, in respect of IFR and MLJ aircraft, correct. MATS 11A 7 FIS SEC and FIS APP/TWR details the coordination responsibilities relating to IFR or MLJ flights intending to enter CTA/CTR.

"AIP OPS CTL 1 and the other references shown above are explicit in the requirement for pilots to obtain clearances before entry. However, to reinforce the point, an amendment will be processed to alter the present text shown in OPS CTL 1 14.1, "No aircraft shall enter controlled airspace without a clearance." to be shown as underlined text "Aircraft must not enter controlled airspace without a clearance."

"In relation to pilots determining an appropriate position or time at which to contact ATC, this point is made at CTL 10 para 20.1 "When determining where the clearance request will be made, the pilot should consider aircraft performance and the possibility of frequency congestion if the airspace is known to be busy.", and again at CTL 11 para 20.2 "In determining how far from the boundary to make the request, the pilot should allow for aircraft performance, and also the possibility of frequency congestion should the airspace be known to be busy."

"Consideration must also be given to ATS responsibilities for the continuing provision of a flight information service, including traffic information to pilots of IFR flights operating outside controlled airspace. In this regard, a partnership must exist between ATS and the pilot in relation to frequency change management.

"Phraseologies in use will, however, be amended to reflect the need for frequency change instructions to recognise aircraft performance and that frequency change instructions to pilots operating outside controlled airspace are no longer the sole province of Flight Service. A copy of the proposed amendments is shown on the attachment.

"OPS CTL I, para 14.1, amend that portion of the para reading:

"No aircraft shall enter controlled airspace without a clearance.", to be shown as underlined text "Aircraft must not enter controlled airspace without a clearance."

"AIP OPS CTL 10, amend in the paragraph reading:

"FS will instruct an IFR flight to contact ATC approximately lO NM from the lateral boundary or approaching the vertical boundary of controlled airspace.", "to read:

"ATS will instruct the pilot of an IFR flight to contact ATC not later than 1O NM from the lateral boundary or approaching the vertical boundary of controlled airspace. Aircraft must not enter controlled airspace without a clearance."

"MATS 12 4 1, paragraph 2, amend to read:

"2. Pilots of IFR and MLJ aircraft shall be given appropriate frequency change instructions before entering controlled airspace. Frequency change instructions should be timely and consistent with aircraft performance to assist the pilot avoid unauthorised penetrations of controlled airspace"."

The Bureau has assessed this response as: CLOSED - ACCEPTED.

The pilot made a short local flight and in very light wind conditions returned to land on runway 23. During the landing roll the aircraft slowed and as the tail was lowered a swing to the right commenced. The pilot applied maximum left brake but was unable to prevent the aircraft leaving the runway at an angle of about 30 degrees and then ground looping right. The left main gear leg collapsed.

The pilot reported that he believed that the right brake locked on initial application. Ground marks indicate that both brakes were locked when the aircraft ran off the sealed runway. The aircraft is not equipped with a steerable tailwheel and with the flaps lowered for landing, as on this approach, the rudder is ineffective once the tail is lowered.

Factual Information

VH-SQV departed Bankstown for Coffs Harbour at 0855 EST initially via West Maitland then operating outside controlled airspace (OCTA).  Contact was established with Flight Information Service Sector 4 (FIS4) and the pilot requested a clearance into controlled airspace (CTA) via the 015 radial of the Sydney VOR on climb to 9,000 ft.

The Flight Service Officer (FSO) co-ordinated the request with Williamtown air traffic control (ATC) which approved the intent but withheld an airways clearance until the aircraft was closer to its airspace.  This intention was passed by FIS4 to the pilot of VH-SQV who changed heading to intercept the 015 radial and continued to climb beneath the CTA steps.

VH-TQM departed Williamtown for Sydney at 0916 and was cleared by Williamtown ATC to leave and re-enter CTA on climb to FL120.  This clearance was given after co-ordination with Sydney ATC but, due to a combination of workload on other tasks and the short taxi distance to runway 30 at Williamtown, FIS4 did not receive the co-ordination until two minutes after VH-TQM had departed.

The co-ordination was completed at 0919 and Williamtown ATC informed FIS4 that it would hand the aircraft (VH-TQM) off early for traffic, but did not mention the callsign.  This occurred immediately after discussion regarding VH-SQV with the FSO.

At 0919, following the above co-ordination, the FSO, having already given the pilot of VH-SQV traffic on

VH-TQM, asked him to report VH-SQV's distance from Sydney.  The pilot incorrectly advised his distance as 65 DME Sydney which is approximately 10 NM south of Williamtown and in the Williamtown ATC area of responsibility (it is likely that he transposed an indicated "56" to "65" DME).  The FSO believed the aircraft was closer to Williamtown than it actually was and immediately instructed VH-SQV to contact Williamtown ATC for an airways clearance. This transfer occurred at 0920.

Also, at 0920 the crew of VH-TQM contacted FIS4, as instructed by Williamtown ATC, and reported at 12 NM south of Williamtown.  The FSO therefore calculated that, as VH-SQV had reported 10 NM south of Williamtown approximately 1 minute earlier, the two aircraft had passed and that Williamtown ATC must have separated the aircraft in their airspace before giving the crew of VH-TQM its frequency transfer.  The pilot of VH-TQM then reported leaving 7,500 ft and the FSO instructed him to contact Sydney ATC as per normal operation.

At 0921 while making the transfer to Sydney ATC, the crew of VH-TQM observed the other aircraft and estimated it was approximately 500 m away and about 1,000 ft below them. This sighting occurred at a distance of 15 NM south of Williamtown.

The pilot of VH-SQV contacted Williamtown ATC at 0921 and gave a correct position of 60 DME Sydney. The aircraft was identified by Williamtown ATC in that position which was 3 NM south of its airspace. This identification was at 0921:50 seconds.

Radar analysis indicates that at 0921:31, the aircraft were 3 NM apart with 900 ft vertical separation.

Analysis

The FSO acted in accordance with the incorrect position report from the pilot of VH-SQV and, had that report been correct, the assumption made would have been reasonable. However, the pilot appears to have transposed the digits on the DME reading and reported 65 DME when he was 56 DME. He made a correct report of 60 DME to Williamtown later in the sequence of events.

For aircraft departing via non-controlled airspace, Williamtown ATC is required to make the co-ordination while the aircraft is taxiing.  In this case the Tower controller had to complete another task before initiating this co-ordination.  When he was able to do this the FSO was busy and unable to answer the intercom line for about 2 minutes.  This resulted in VH-TQM departing before FIS4 received the information and little time remained for the passing of traffic information.  The co-ordination was therefore rushed and did not specify the callsign or adequately clarify the traffic information requirements.

A further factor was the relatively short distance for VH-TQM to taxi in order to reach the threshold of runway 30 and then the short distance between take-off and the Williamtown CTA boundary.

Significant Factors

1. The pilot of VH-SQV gave an incorrect DME distance from Sydney when responding to a position report request from FIS4.
2. The co-ordination for VH-TQM between Williamtown ATS and FIS4 was delayed due to workload and was not of a specific nature.

Safety Action

As a result of the investigation Williamtown ATC has issued a Local Order that, in specified cases, will ensure that co-ordination between Williamtown ATC and Sydney ATS is completed before an aircraft departs.

As a result of this and other occurrences (9400523) the Civil Aviation Authority and the RAAF were advised of the co-ordination deficiencies by Safety Advisory Notice SAN 940093.  The SAN states, in part:

The Bureau of Air Safety Investigation suggests that the CAA and the RAAF conduct a joint review of their procedures with respect to:

(a) The co-ordination of traffic information concerning aircraft departing Williamtown CTR for possible climb or cruise OCTA.

On the flight from Flinders Island an electrical failure occurred. The pilot continued to Latrobe Valley and made a landing approach behind another aircraft. On final approach, for runway 21, the aircraft was too low, and the pilot advanced the throttle to correct for this. The engine missed then fired again. The pilot checked the carburettor heat setting and found that it was in the hot position. He pumped the throttle, and the engine kept losing and gaining power and then ran normally.

Because of the low height and the terrain ahead, which included a power line, the pilot elected to put the aircraft down in a small clear area. A very heavy touchdown followed, and the aircraft ran through a fence before stopping.

Following the accident the aircraft was found to contain an adequate amount of fuel. No inspection of the engine or its systems was carried out, and the reason for the interruption of power was not determined.

Significant Factors

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

1. A partial engine power loss and engine rough running for an undetermined reason.

2. The decision, by the pilot, to land in a small but immediately adjacent clear area.

3. The aircraft was landed heavily.

VH-EWF was on a visual approach to Melbourne runway 34, tracking via the Essendon runway 26 localiser for a right base. VH-HCY took off from runway 34 at Melbourne and was cleared to make a left turn to track across the airfield on a south-easterly heading, to remain east of the runway 34 centreline for a left base for runway 35 at Essendon. VH-HCY had been cleared to maintain 1500 feet.

The Melbourne Aerodrome Controller (ADC) intended that VH-HCY pass behind VH-EWF and that he would provide visual separation. When VH-HCY was over the airfield, the ADC momentarily diverted his attention to the radar screen. When he looked back to check the position of VH-HCY he was unable to see the aircraft. As VH-HCY had already been transferred to Essendon Tower frequency, the Melbourne ADC asked the Essendon ADC if he could provide visual separation. The response was that he could not. The Melbourne ADC then instructed VH-EWF to climb immediately to 2000 feet. Separation between the two aircraft reduced to less than the minimum required. When the confliction was resolved VH-EWF was cleared to continue the visual approach.

The pilot of VH-HCY said that he had VH-EWF in sight from when it was east of Essendon and was watching the situation closely. The Melbourne ADC had not given traffic information to either aircraft on the other on the basis that he was providing visual separation. When he instructed VH-EWF to climb to 2000 feet he advised that the climb was due to conflicting traffic.

There were other options available to the ADC for the processing of these two aircraft, but these were not adequately considered at the time. Hazy conditions existed on the day of this incident.

Factors

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

1. The option chosen for tracking VH-HCY was a poor option in that it put the aircraft into airspace that created a potential conflict with VH-EWF.

2. Having tracked VH-HCY in the manner chosen, the ADC then inappropriately relied on visual separation between the two aircraft on converging headings in hazy conditions.

3. The ADC did not maintain vertical separation by restricting VH-EWF's descent to 2500 feet in a situation where radar and visual separation were reducing in hazy conditions.

4. The ADC did not recognise the deteriorating situation and initiate alternative action until it was too late to prevent the loss of separation.

The aircraft had been cleared to Melbourne via Plenty and Essendon. When it was in the Wonthaggi area it was re-cleared to track direct for an 8 NM final for runway 34 at Melbourne. At about 18 NM from Melbourne, the crew were requested by air traffic control to report when the Melbourne runway was in sight. The crew reported they had that runway in sight and were cleared to track to join final inside 8 NM from Melbourne. The crew requested and were given further track shortening until they were instructed to make a visual approach for runway 34 and to call Melbourne Tower.

The Approach Controller then diverted his attention to other duties for a short period. On rechecking the progress of the aircraft it appeared, to him, to be on final for runway 35 at Essendon. The aircraft was at an altitude of approximately 1500 feet. The Approach Controller advised Melbourne Tower who instructed the aircraft to turn left for Melbourne. The aircraft subsequently landed without further incident.

The flight crew subsequently advised that when they were given the visual approach, they believed they had the Melbourne Airport in sight and its position was confirmed by checking the map displayed on the aircraft flight management computer. However, they had not used any other aircraft navigational systems to confirm their position in relation to Melbourne. The flight management computer was checked and found to be operating normally, and no subsequent unserviceability reports have been received. The crew further reported that the weather conditions at the time of the approach were hazy.

Significant Factors

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

1 The aircraft was diverted from the standard inbound track.

2 The weather conditions at the time of the approach were hazy.

3 The flight crew did not follow the standard procedure of using available navigational systems to cross-check the position of the aircraft.

Information supplied by the pilot and the operator indicated that the pilot landed at the strip, without problems, on the day prior to the occurrence. On the day of the occurrence, she decided to fly the aircraft to a longer strip so that she could refuel and depart, with the planned load, for Bunbury. The pilot decided to carry a passenger for the short flight.

Although the strip was 730 metres long the pilot decided to use only the last 600 metres. The strip was partially covered with bush, in places, up to 1.8 metres in height. The density altitude at the time of take-off was approximately 4,000 feet.

In order to avoid rough parts of the strip the pilot elected to fly the aircraft off the ground at 55 knots and allow it to accelerate in ground effect before climbing away. Shortly after lift-off the airspeed reduced to 40 knots and the aircraft did not accelerate.

The pilot decided to reject the take-off, and the aircraft touched down with 150 metres to run to the end of the strip. Although the pilot applied heavy braking the aircraft overran the strip and collided with a fence and trees. Skid marks extended from the touchdown point to where the aircraft stopped (250 m).

There were no indications that engine power was a factor in the occurrence.

The Pilots Operating Handbook indicated that between 800 (short dry grass) and 1050 metres (long wet grass) of runway was required to reach a height of 50 feet above ground level in the prevailing conditions and using a take-off safety speed of 56 knots.

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.