Circumstances:

After take-off, the pilot had selected gear up. During climb, at about 1600 feet, he noticed that the red gear unsafe light was still illuminated, and by checking the nacelle mirror, that the nose gear was still extended. The wheel also appeared to be turned at an angle. The aircraft returned to Bankstown, where it was observed that the nosewheel was turned through about 80 degrees to the right. Use of full rudder travel and cycling of the landing gear failed to produce any change in the position of the nose gear, although the main gear retracted and extended normally. After seeking engineering advice, the pilot elected to land on grass and an area was prepared on the left of, and parallel to Runway 11 Left. He advised that he intended to shut down the engines on late final and position the propellers to preclude ground contact on landing. At about 200 feet on final approach, he closed both mixtures but had insufficient time to reposition the propellers. The aircraft dropped with a high sink rate and touched down 110 metres short of the intended landing area. On initial ground contact, the left main gear pushed up through the wing and broke off. The aircraft slewed to the left and the nose gear broke off during the 85-metre ground slide. It was found that the right hand nose wheel steering stop had been sheared, probably during ground handling operations. This resulted in detachment of the tiller roller from the steering channel and bending of the torque link pivot bolt. The torque link subsequently failed across the pivot bolt hole, allowing the nose leg to turn approximately 80 degrees.

Significant Factors:

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

1. Rough ground handling by persons unknown, resulting in damage to the nose gear mechanism.

2. Overconcentration by the pilot on attempting to manipulate the position of the propellers.

3. Pilot failed to maintain sufficient speed on approach, resulting in undershoot and heavy landing.

Recommendations:

1. This is another example of a pilot causing a more serious accident by attempting to do the "right thing". For many types of emergencies, no guidance is given by the manufacturer. It is recommended that the Civil Aviation Authority publish an article in the Aviation Safety Digest on the landing techniques to be employed with certain undercarriage malfunctions, such as defective nose gear.

Circumstances:

The Adelaide Flight Data Officer was under training, but he prepared the strip for VH-TJD unsupervised. Due in part to the location of the strips and the pressure of attempting "to do a good job" the officer selected an Alice Springs to Sydney strip by mistake. This was passed to the controller. When the aircraft taxied at Alice Springs it was issued with a clearance by the Alice Springs Tower. Alice Springs then informed the Adelaide controller that the aircraft was taxiing for Adelaide and gave the cleared route and level. The Adelaide controller was busy at the time, but he read back the cleared level. This is an acknowledgement to the Alice Springs controller that he had understood the complete communication. The Adelaide controller did not hear the destination as Adelaide and seeing the strip assumed the aircraft was tracking to Sydney. Twenty one minutes after departing Alice Springs the aircraft was instructed by one Adelaide controller to call another Adelaide controller at position Kalug on the Sydney route. The aircraft captain queried the instruction and confirmed the aircraft was tracking to Adelaide. The pilot was then instructed to descend the aircraft to Flight Level 330 to remain clear of opposite direction traffic. On 12 April 1990 Adelaide Air Traffic Control issued Aeronautical Information Circular (AIC) 8/90 titled "Coordination of Clearances Between Alice Springs and Adelaide". This AIC requires Alice Control to include in its advice to Adelaide Control the first position report. Adelaide Control is required to read back that position while Alice Springs ensures the read back is correct. The same procedure is required both on taxi and departure.

Significant Factors:

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

1. The Trainee Flight Data Officer was not supervised.

2. The Trainee Flight Data Officer selected an Alice Springs to Sydney strip in error.

3. The Adelaide controller did not correctly check the information on the flight progress strip.

Recommendations:

1. The Civil Aviation Authority should investigate better systems of supervision of Trainee Flight Data Officers.

2. The Civil Aviation Authority should examine all non-radar-controlled airspace to determine if the Adelaide AIC 8/90 of 12 April 1990 - Coordination of clearances between Alice Springs and Adelaide - should be extended to other airspace.

The piloo reported that the engine failed shortly after takeoff and that he was forced to land the aircraft on unsuitable terrain. The reason for the engine failure was not determined. This accident was not the subject of a formal on scene investigation.

A number of witnesses observed the aircraft operating in the accident area. A common observation was that it was operating at a lower height (probably between 500 and 1000 feet above ground level) than was usually seen of other light aircraft flying over the area. The aircraft was seen to complete a number of level orbits over a chicken farm and then to head south for about two kilometres. While this was occurring the engine sound died and picked up again a few times, as if the pilot was practising setting the aircraft into a glide. The aircraft then flew a level left turn through about 270 degrees before suddenly entering a 30 to 40 degree dive. At close to tree-top height it abruptly changed attitude and entered a steep, perhaps vertical, climb. Some witnesses felt that the pilot was about to fly a loop. As the aircraft climbed, the speed rapidly decayed. During these manoeuvres, the engine note was heard to die and pick up twice. The aircraft was then observed to fall, nose first and right wing slightly low, into a near vertical dive. Apart from completing one or possibly two rotations, it remained in this attitude until lost from sight amongst trees. The aircraft impacted the ground in a 90 degree nose down attitude. When recovered from the wreckage the airspeed indicator was indicating 105 knots. It was established that the engine was operating at impact. No evidence was found of any abnormality in the aircraft or its systems which may have contributed to the accident. No explanation was found for the apparent operation of the aircraft at a relatively low height, or for the dive to a very low level followed by the steep climb. The carburettor fitted to the engine was equipped with an accelerator pump. A characteristic of carburettors of this type is that rapid or "slam" opening of the throttle can temporarily over-fuel the engine and cause the RPM to fluctuate for a short time. It could not be determined whether this characteristic may have been associated with the engine note dying and picking up twice as heard by witnesses in this instance. Investigation established that the the passenger occupying the front right-hand seat had flown 33 hours dual and 3.5 hours solo on Cessna 152 aircraft during 1983/84. The front seats of the aircraft were adjustable fore-and-aft along rails attached to the floor. Examination of the cockpit revealed the adjustment of the front left-hand seat (occupied by the pilot-in-command) at impact to have been five notches from the front. The front right seat was positioned in the forward-most notch. Tests of these seating positions were conducted in another PA28 aircraft using persons of the same height as those involved in the accident. These tests indicated that the right seat occupant should have been able to comfortably manipulate the engine and flying controls of the aircraft. However, the left seat appeared to be too far to the rear for the pilot-in-command to have been in a normal flying position in relation to the controls. Specific flying techniques are required to recover an aircraft from an extremely nose-high attitude at low speed. The aircraft involved in this accident was observed to develop such an attitude accompanied with low speed, and the low height at which this occurred would have increased the level of pilot skill required to return the aircraft to a safe flight environment. It was established that the pilot-in-command had received no training in the flying techniques required to recover aircraft from unusual attitudes. The seating position tests suggested that the pilot-in-command may not have been manipulating the controls during the final stages of flight, and it is also probable that the person occupying the right-hand seat had not received any training in recovery from unusual attitudes. It is considered probable that once the aircraft had reached the nose-high attitude at low speed, that it was beyond the experience level of either of the front seat occupants to effect a safe recovery, particularly in view of the low height of the aircraft at the time.

Circumstances:

The pilot was engaged in mustering pigs for aerial culling. On spotting a group of animals, he flared the helicopter from about 50 knots to a slow speed and then banked hard to the left at low level. The main rotor blade tips struck long grass and the helicopter rolled over and came to rest on its left side. The area of operations comprised a virtual " sea of grass ", unrelieved by any trees or other vegetation. Judgement of height above the ground under such conditions is more difficult than usual. The manoeuvre flown by the pilot would have exacerbated the problem.

Significant Factors:

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

1. Featureless terrain.
2. Pilot misjudged height above the ground during a rapidly executed turn.

Circumstances:

The aircraft was on a night freight flight from Sydney to Melbourne, with a planned route via Canberra, Albury, and Eildon Weir, at 8000 feet. Over Canberra the pilot was cleared to climb to 10,000 feet. South of Canberra he amended his plan to proceed via Corryong due to unsuitable weather on the planned route. When the pilot transferred to Melbourne Flight Service frequency south of Corryong at 2329 hours, he advised the aircraft had a partial engine failure and to stand by. Subsequently at 2333 hours he said he had regained the engine. At this time, the aircraft was about 30 miles to the southeast of Albury. Approaching Eildon Weir, the pilot descended to cruise at 8000 feet and shortly after was cleared to commence descent into Melbourne. At 0027 hours when about 20 miles from Melbourne, while descending from 4000 to 3000 feet, he made a mayday call advising that he had a "dual engine failure" and requesting any available assistance. As the aircraft was too far from the lighted airfields at Melbourne and Essendon, the pilot was given radar headings towards Lilydale airfield. The pilot asked about lights at Lilydale and was advised that action was being taken to get them on. At 0028 hours he reported the right engine surging. He subsequently advised at 0029 hours that the altitude was now 1000 feet and when told Lilydale was 5 miles away said he was not going to make it. Radar contact with the aircraft was lost shortly thereafter. Apart from possible patches of ground fog the weather in the Melbourne area was fine, with no significant low cloud or wind. An on-site investigation revealed the aircraft had impacted heavily against the northern face of a road cutting. It was determined that both engines had lost power due to fuel exhaustion. A fuel stain found on the left wing was consistent with an inflight loss of fuel from the left main fuel tank cap. Further examination revealed that, although apparently fastened correctly, the fuel tank cap had been prevented from sealing due to interference from a wire clip attached to the fuel cap securing chain. This resulted in fuel being sucked past the tank cap during flight due to the difference between fuel tank and overwing air pressures. This in turn caused the floor of the bladder type fuel tank to be lifted, resulting in false gauge indications. The aircraft had departed Sydney with adequate fuel to complete the planned flight. It is probable that the engine partial power loss reported by the pilot at 2329 hours was due to fuel exhaustion in the left main tank, resulting from a combination of loss of fuel and normal fuel consumption. The pilot would have been able to regain normal engine operation by moving the left engine fuel selector to cross feed fuel from the right main fuel tank. However, because of the loss of fuel from the left tank, the endurance was significantly reduced. Continued use of fuel from the right main tank by both engines, would have led to total fuel exhaustion of the right tank at about the time the pilot reported the double engine failure. Inspection of other aircraft with similar tank cap systems indicated that it was not possible to lock the tank cap with the pin lodged under it. However, it was noted that the clip could inadvertently be caught under the cap and have force applied to it, such as was likely to cause the clip to become deformed in service. The pin attached to the left main fuel tank cap was found to have been deformed.

Significant Factors:

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

1. Design of tank clip and fuel tank system.

2. Undetected deformation of clip in service.

3. Clip inadvertently lodged under left main tank cap, probably during pre-flight inspection of the tank contents.

4. Undetected loss of fuel in flight and collapse of the left main fuel cell, leading to a false fuel contents indication and fuel exhaustion of the left main tanks.

5. Pilot decision to continue towards destination, rather than divert.

6. Double engine failure at night, following total fuel exhaustion.

The pilot reported that he was opening the throttle to gain height whilst flying over a cane crop at about 100 feet when the engine failed. The aircraft was landed in the cane crop and the landing gear was bent. The factory fitted swaging on the throttle cable at the carburettor end had come off allowing the throttle to close. This occurrence was not the subject of an on-site investigation and the above report is based on information provided by the pilot.

The pilot reported that he was flying at about 100 feet above ground level when the engine failed suddenly and completely over thick scrub. He decided to stall the aircraft into the foliage canopy, but the aircraft did not make contact with the main canopy other than small branches, and impacted the ground at a 60 degree nose down attitude from a height of about 40 to 50 feet. The nose section, undercarriage and fuel tank were totally destroyed on impact. Examination of the engine has not revealed any mechanical defect. The pilot believes he may have inadvertently bumped the "engine kill switch" to the off position with his knee. The Bureau has been advised by the Australian Ultralight Federation that this particular switch has since been fitted with a shroud to prevent inadvertent operation.

Following an aerial search for two people missing in the Dingo area, the pilot stopped the aircraft to let the observers deplane. He then taxied his aircraft along a grassed taxiway to the hangar. During this taxying, the left main wheel entered a deep hole, which had not been sighted by the pilot. The owner/pilot had recently had a "pop-up" sprinkler system installed along the taxiway. The work involved lengthy excavation. The aircraft had been taxied into a hole inadvertently left by the contractor. The pilot had been in the habit of leaving the aircraft near the strip while the work was in progress, but on this occasion he decided to hangar the aircraft to avoid any unnecessary risk of damage to the parked aircraft by stock. This accident was not the subject of an on-site investigation.

At the completion of the student's second flight the instructor believed the glider was too high downwind and used speedbrake in an attempt to recover. As a result the glider got into an undershoot situation. The instructor attempted a landing outside the aerodrome to avoid hitting the boundary fence but a heavy touchdown resulted damaging the landing gear and wheel well area. This accident was not the subject of an on-site investigation.