The pilot was making his first flight in the aircraft type having done check flights in two other glider types on the previous day. After a 90-minute local flight he returned to the airfield and joined the circuit for a landing on the 080 degree strip.

The pilot reported that the approach was normal until just before touchdown when he closed the airbrakes. At this point the glider ballooned to approximately two metres above the ground and the airspeed decayed to less than 40 knots. The glider touched down heavily, hitting the ground tail first.

The investigation revealed that the pilot had misinterpreted information from an instructor regarding the use of the air brakes during landing. This resulted in the pilot using a faulty landing technique.

A number of agricultural aircraft were operating on fire suppression work from Snowy Range airfield which is situated in the Victorian Alps at an elevation of 5300 feet. The airfield has two grass strips. The north/south strip is 900 metres long and the east/west strip is 550 metres long. VH-DRO was based at Wangaratta and its pilot had never been to Snowy Range airfield. Because of this, when he arrived at the airfield, he made a touch and go landing on each strip prior to making a full stop landing. The pilot said the wind was a 12-knot westerly. The crosswind limit for the aircraft is 15 knots.

After taking on a load of fire-retardant chemical, the pilot taxied for take-off into the west using the short strip. The aircraft became airborne a short distance before the end of the strip and the pilot estimated it got to a height of about 10 feet. It then sank back towards the strip, clipped a fence at the end of the strip and shortly afterwards hit a dirt mound. The pilot said he realised then that the aircraft was not going to fly so he closed the throttle and let the aircraft slide to a stop over the rough ground.

The landing gear was torn out and the aircraft sustained substantial damage in the ground slide. After the pilot evacuated the aircraft, he noted the wind had dropped to completely calm conditions. This was verified by ground crew at the scene. Aircraft performance data indicated that under the conditions prevailing at the time of the attempted take-off, the aircraft would take about a 450 metre ground roll before becoming airborne which is approximately the distance taken on this occasion. The take-off distance required to a height of 50 feet was about 870 metres.

The pilot said that when the aircraft started to sink, he tried to dump the load, but his attempt was not successful.

The pilot taxied the aircraft for departure, back tracking to the north-west end of the runway. While turning right to line up for take-off, the left main landing gear collapsed, allowing the left propeller to strike the ground, stopping the engine.

The eye bolt attaching the landing gear side brace strut to the spar fitting was found to have suffered a corrosion fatigue failure allowing the gear to collapse inwards, i.e. in the direction of retraction. As this did not effect the downlock latching mechanism or micro switch at the strut elbow joint, all three green gear down lights in the cockpit remained on.

The operator had previously experienced this problems with similar type aircraft, and as the bolt is difficult to see during inspections, he instigated a program to replace it with a modified type. This aircraft had only recently been acquired, and the bolts would have been replaced at the first service by the operator.

During a clean-up spray run flown parallel to powerlines, the pilot inadvertently allowed the helicopter to drift to the left into the lines. The main rotor struck the wires and during an attempt by the pilot to turn away, the tail rotor also struck the wires. The tail rotor/gearbox was severed, causing the helicopter to enter an uncontrolled spin to ground impact.

The clean-up run was from west to east, at an airspeed of about 40 kts. The wind was from the north-east at about 2 kts.

Synopsis

At about 1125 EST (Eastern Standard Time), Rockhampton radar technicians requested approval from the Brisbane Area Approach Control Centre (AACC) Coordinator to close down the Mt Alma radar for five minutes, so that a noise emanating from the antenna turntable could be investigated.  The Mount Alma radar near Rockhampton is the sensor used by Sector 3A to control traffic in the Sector 3 area of responsibility. The coordinator then alerted the Sector 3A radar controller to the request. The Sector 3A position was being operated by a trainee (unrated controller) under supervision. He then called the Sector 7 (Mackay) radar controller to advise him that the Sector 3 radar would be going off for 5 minutes and requested his assistance to monitor separation while the radar was off. Subsequently, a separation breakdown occurred when the Sector 3 controller failed to adequately separate a Boeing 767 and a Boeing 737.

Traffic Disposition

Traffic in Sector 3A area of responsibility at the time included JAL772 a Boeing 747 northbound on route Bravo 462 (B462) at Flight Level 350 (FL350), VH-OGJ a Boeing 767 northbound on the same route at FL350, 36 miles behind JAL772, and a Boeing 737 VH-TAH which was cleared to track direct from Townsville to Gladstone also at FL350. The track of VH-TAH intersected route B462 approximately 22 NM north of Rockhampton and thus there was potential confliction with VH-OGJ and JAL772.

The Sector 7 controller asked the Sector 3 controller to rectify the potential confliction with VH-TAH and to advise him when this had been done. The Sector 3 controller then turned VH-TAH right onto a heading of 190 degrees. At this time, VH-TAH was approximately 50 miles northwest of Rockhampton, JAL772 was approximately 10 miles north of Rockhampton and VH-OGJ was 32 miles South of Rockhampton. After VH-TAH and JAL772 had passed clear of each other the Sector 3 controller cleared the pilot of VH- TAH to track direct to Gladstone and to resume his own navigation. He then gave approval for the Mt Alma radar service to be turned off and made an all stations broadcast to that effect.

At about 1130 the Sector 3 controller called the Sector 7 controller, asking him to separate two other aircraft, and advising that the radar had been switched off. The Sector 7 controller then noticed on his radar display that the tracks of VH-OGJ and VH-TAH would conflict and instructed the Sector 3 controller to immediately descend VH-TAH to FL330 and to turn VH-OGJ onto a heading of 270 degrees.

The instructions were carried out but lateral and vertical separation standards between the aircraft were broken.  At approximately 1132:23 VH-OGJ passed directly over VH-TAH in the opposite direction with approximately 1,500 ft vertical separation. The minimum vertical separation required is 2,000 ft.

The pilot of VH-OGJ reported that his Traffic Conflict Alert System (TCAS) had been activated when the aircraft were closing. It indicated a vertical separation of 600 ft. The crew of both aircraft visually sighted the other as the aircraft passed.

The Sector 3 controller had neglected to arrange procedural separation of VH- TAH and VH-OGJ before allowing the radar to be turned off. The traffic conflict was recognised by the Sector 7 controller when it was too late for the Sector 3 controller to achieve a separation standard. The radar was returned to service at 1136 after no fault was found.

Flight Progress Strips

Local Operating Instructions (LOI) for Sector 3A state that, in the event of radar outage 'controllers will make up additional strips as required to highlight conflicts'. In this instance, the Sector 3A controller did not consider it necessary for procedural flight progress strips to be made up as Sector 7 would be monitoring the separation of the aircraft. In the event, the conflict might not have been overlooked if procedural strips had been available.

Traffic Management

The pilot of VH-TAH had planned the route at FL370, a standard level for the particular route, and had been offered this flight level by ATC some minutes earlier. However, he said that he was content to remain at FL350, a nonstandard level for aircraft on that particular track, and one which ultimately brought the aircraft into confliction with the two northbound aircraft. (The 1992 Review of the Australian Air Traffic Services System recommended greater emphasis on traffic planning and conflict avoidance, rather than encouraging situations necessitating conflict resolution).

Systemic Issues

The occurrence raised several issues of a systemic nature which might have been relevant, such as the recently introduced teams concept, the new sectorisation of the airspace involved, the experience level and training of controllers, and standardisation. These issues were addressed in BASI Investigation Report BS/930154 - An Investigation of Systemic Factors underlying Air Safety Occurrences in the Brisbane Area Approach Control Centre.

Relevant Factors

1. The Sector 3A controller (supervisor) did not maintain adequate situational awareness of traffic in his area of responsibility.
2. The supervision of the unrated controller operating Sector 3A was inadequate.
3. The traffic was not procedurally separated before approval was given for the radar to be turned off.
4. Procedural flight strips were not prepared and placed on the flight progress board prior to the radar being turned off.

Safety Action

LOIs were amended following the incident to now require strips to be prepared and placed on the flight progress board prior to a known radar outage.

The pilot left Canberra for Moruya with 70 litres of fuel on board which he reported was evenly distributed in the two wing tanks. He flew to Moruya with the left tank selected and reported that the flight took 40-45 minutes. After a brief stop at Moruya he taxied for the return trip. Pre-take-off checks were completed while taxiing, one of the final checks being selection of the right wing tank for the return trip.

The taxi route involved back-tracking along the main north/south runway. As there were two other aircraft inbound, one of which was already in the circuit for runway 18, the pilot expedited his taxiing and decided to take off using approximately 1000 metres of the 1523 metre runway. He made a left turn on the runway and immediately applied take-off power. Shortly after the aircraft became airborne the engine stopped.

The pilot established the aircraft in a glide and landed it in the water in the Moruya River. The cause of the engine failure was not determined.

The pilot reported that the aircraft was cruising at flight level 230 on track from West Maitland to Point Lookout when the cabin altitude began to increase rapidly at about 80 miles south of Point Lookout. Shortly afterwards the senior flight attendant entered the cockpit advising that the main cabin (passenger) door appeared to be slightly open, and a gap between the door and the frame was clearly visible. The cabin alert master warning illuminated, and a rapid descent was initiated to 10000 feet. The aircraft was diverted to Coffs Harbour and a normal descent and landing was made.

Inspection of the door seal at Coffs Harbour revealed some debris fouling the lower door seal but no other fault could be found. The pressure loss had been due to the door seal being deflated thus causing a gap between the door and the frame. During a flight on 18 January the cabin pressure remained at zero differential until maximum cabin altitude was reached. The pressure controller was replaced after this occurrence and no further problems have been experienced.

The pilot of VH-BXE, who was conducting a scenic coastal flight, was cleared initially at 1,500 feet and instructed to descend to 1,000 feet at Brighton Jetty.

The pilot of helicopter VH-UBH was operating on surf patrol duties, seawards of the coast not above 500 feet. As he was being given traffic on VH-BXE he noticed that aircraft to his right at about the same altitude, with 50-100 feet lateral separation. He queried its assigned altitude with air traffic control, who advised it should have been at 1,000 feet. The pilot of VH-BXE then reported climbing to 1000 feet.

The pilot of VH-BXE later stated that the normal cleared altitude for this particular flight is at 500 feet, and he had mistakenly descended to that altitude, although on this occasion the clearance had been at 1,000 feet.

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.