Cessna A188B-A1, VH-TZS, "The Rookery", 36 km south-west of Cobar, New South Wales, on 5 November 1990

Summary

Circumstances:

The aircraft was conducting spraying operations. The pilot reported that the aircraft failed to remain airborne after encountering a severe "willy willy" at the liftoff stage of the take-off. He initially dumped part of the load, then dumped the remainder as the aircraft was making contact with the ground. An area of long grass and thistles then prevented the aircraft from becoming airborne. As a result, one main landing gear was torn off and the other damaged.

Occurrence summary

Investigation number 199002022
Occurrence date 05/11/1990
Location "The Rookery" 36 km south-west of Cobar
State New South Wales
Report release date 10/04/1991
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Runway excursion
Occurrence class Accident
Highest injury level None

Aircraft details

Manufacturer Cessna Aircraft Company
Model 188
Registration VH-TZS
Serial number 18803156T
Sector Piston
Operation type Aerial Work
Departure point "The Rookery" NSW
Destination "The Rookery" NSW
Damage Substantial

Piper PA-28-181, VH-OPA, Warnervale, New South Wales, on 22 September 1990

Summary

Circumstances:

After an uneventful flight to Tambar Springs, two passengers embarked for the return journey to Bankstown. Approaching Scone, unsuitable weather forced the pilot to divert east of track towards the coast. Whilst cruising at 1500 feet AMSL, about two kilometres north of Warnervale, the engine, without warning, suffered a complete loss of power. The pilot transmitted a Mayday call to Sydney Flight Service and positioned the aircraft for a straight-in approach onto runway 17 at Warnervale. He carried out a trouble check and attempted to restart the engine without success. The aircraft passed over the threshold high and fast and landed well down the runway. The pilot was unable to prevent the aircraft from running off the southern end and it came to rest some 150 metres beyond the runway after passing through a boundary fence which damaged both wings. A technical investigation revealed the complete engine failure occurred as a result of the disconnection of the accessory drive gear from the crankshaft. The locating dowl failed due to fatigue after a loss of tension of a bolt attaching the accessory drive gear to the crankshaft. The reason for the loss of tension was not positively established. However, it is possible that a propeller strike, 593 hours prior to the accident, caused the loss of initial torque on the bolt. The propeller strike and subsequent rectification action occurred in the United States of America before the aircraft was imported to Australia.

Occurrence summary

Investigation number 199002006
Occurrence date 22/09/1990
Location Warnervale
State New South Wales
Report release date 10/04/1991
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Accident
Highest injury level None

Aircraft details

Manufacturer Piper Aircraft Corp
Model PA-28
Registration VH-OPA
Serial number 28-7990441
Sector Piston
Operation type Private
Departure point Tambar Springs NSW
Destination Bankstown NSW
Damage Substantial

Cessna A188B-A1, VH-SUA, 10 km west of Pemberton, Western Australia, on 14 December 1990

Summary

Circumstances:

The pilot reported that he was aware of the location of the three-cable powerline during his spray runs. He had completed three runs under the line and was conducting a clean-up run at the opposite end of the paddock when he collided with the wires during a pullup. The wire deflector snapped, and the top of the vertical stabilizer and rudder were torn off. The pilot was able to land the aircraft safely. He indicated that he had forgotten about the location of the line when he moved to the other end of the paddock and it was no longer necessary to fly under them.

Occurrence summary

Investigation number 199000108
Occurrence date 14/12/1990
Location 10 km west of Pemberton
State Western Australia
Report release date 10/04/1991
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Wirestrike
Occurrence class Accident
Highest injury level None

Aircraft details

Manufacturer Cessna Aircraft Company
Model 188
Registration VH-SUA
Serial number 18802973T
Sector Piston
Operation type Aerial Work
Departure point Pemberton WA
Destination Pemberton WA
Damage Substantial

Collision with terrain involving Cessna A188B-A1, VH-UDK, Ginidgeree' Warren, New South Wales, on 11 December 1990

Summary

The aircraft was engaged in night spraying of cotton crops. The pilot had completed about two and one half hours work on two properties, with a short break between tasks, before arriving at 'Ginidgeree'. The night was clear but dark, with a barely discernible horizon on certain headings. The marker vehicles had assumed their positions at each end of the first spraying run when the aircraft arrived over the paddock. Believing the markers to be incorrectly positioned, the pilot elected to fly orbits over the paddock while clarifying his orientation. After several orbits the pilot accepted the marker positions, and the aircraft departed to the north to begin the approach for the first spraying run. During the turn to intercept the inbound track, the aircraft struck a tree then impacted the ground and continued forward for 130 m, shedding components and starting a fire. The pilot suffered minor injuries and evacuated the burning wreckage without assistance. The aircraft had struck the tree in a gentle descent during the turn. The pilot, believing that the aircraft was flying level, did not notice the descent as he was concentrating on lining up for the first spraying run. The pilot held a Commercial Pilot Licence which had been endorsed for night spraying six days earlier. He had about 700 hours experience in agricultural flying, including about 50 hours of night spraying, in Ag waggon and Air tractor aircraft. At the time of the accident, the pilot was wearing overalls, boots, a high-quality helmet and was tightly strapped into his seat. Damage to the helmet indicated multiple impacts including at least one of extreme severity. In laboratory tests conducted overseas, a force of over 300 g was required to produce damage similar to that on the helmet. It is almost certain that, without the helmet, the pilot would not have survived the accident.

Significant Factors:

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

1. The night was dark with a barely discernible horizon on certain headings.

2. The pilot, although qualified in night spraying, was relatively inexperienced in the role.

3. While executing an inbound turn for the first spraying run, the pilot did not realise that the aircraft was gently descending.

Occurrence summary

Investigation number 199000031
Occurrence date 11/12/1990
Location Ginidgeree' Warren
State New South Wales
Report release date 18/11/1991
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Collision with terrain
Occurrence class Accident
Highest injury level Minor

Aircraft details

Manufacturer Cessna Aircraft Company
Model 188
Registration VH-UDK
Serial number 18803213T
Sector Piston
Operation type Aerial Work
Departure point Warren NSW
Destination Warren NSW
Damage Destroyed

Fokker F28-4000, VH-EWB, Maroochydore QLD, 21 October 1989

Summary

At the time of the occurrence, the passenger terminal at Maroochydore was being modernised and expanded. A temporary, one metre high, chain wire fence marked the edge of the apron area in front of the building. The area between the fence and the terminal building was bare sand on which lay various building materials including sheets of roof cladding. Access to this area was restricted by a sign on a fence adjacent to the northern end of the building. However, the new sections of the building were open, displayed no warning signs, and allowed ready access to the apron side of the building. The old section of the building was still functioning as the passenger terminal. Access through this area to the apron was restricted to emplaning and deplaning passengers. Prior to the aircraft's arrival, a group of bystanders, some of whom carried placards, had gathered behind the chain wire fence directly in front of the terminal building. These persons gained access to this area apparently via the northern end of the building. As the aircraft taxied to its parking position in front of the terminal, the bystanders directed abuse at the flight crew. This abuse continued until the aircraft departed. After the aircraft captain remarked to the company airport manager that the bystanders could be in some danger when the aircraft taxied, they were asked by the manager to move. The group moved to the new northern section of the building. Some remained adjacent to the fence on which the warning sign was mounted, others were positioned within the new section of the building behind a low brick wall, while the remainder went to the rear of this section of the building. On taxi from the terminal, the aircraft was required to make a sharp right turn through about 180 degrees. Numerous complaints were received alleging that during the turn, the pilot used excessive thrust, endangering the bystanders. Photographic evidence was obtained showing loose sand and one or two sheets of roof cladding being blown by the jet blast. The Digital Flight Data Recorder (DFDR) was removed from the aircraft and analysed. The only engine parameters recorded by the DFDR system installed in VH-EWB are percentage thrust for each engine. This system provides an indication of developed thrust on each engine and records it as a percentage of maximum thrust by measuring the pressure differential between the jet pipe total pressure and the ambient pressure from the auxiliary pitot static system. Engine control by the crew is accomplished via throttle control of N2 RPM. The relationship between percentage thrust and N2 RPM is exponential so that small changes in N2 at the higher levels produce large changes in thrust. The DFDR analysis showed that taxi was initiated with a thrust of 54 percent. After the aircraft had turned through about 90 degrees, thrust increased to a maximum of 60 percent on both engines over a period of 4 seconds and then decreased to 54 percent over the following 6 seconds. The left engine was at 60 percent for 2 seconds and the right was at 60 percent for less than 1 second. During this time the aircraft turned through a further 90 degrees and the jet blast from its engines would have been directed towards the terminal building. The aircraft was turning into wind during this latter 90 degrees of turn. Because of an unserviceable accelerometer in the aircraft, no valid longitudinal acceleration data was recorded. Consequently, no information was available concerning brake application. Other periods of taxiing were examined for comparison with the taxi thrusts used on this occasion. These showed that up to 57.5 percent thrust had been used during taxiing manoeuvres at other locations. However, because the DFDR recorded data contained no other flight into Maroochydore, no meaningful comparison could be made. In any case, the use of an extra few percent around the 55-60 percent thrust level would not constitute a substantial increase the strength of the jet blast from the engines. Therefore, the allegation that the pilot used excessive thrust on taxi at Maroochydore is not supported by the factual evidence available. Immediately following the occurrence, the aircraft operator ceased to use the parking position directly in front of the terminal building. Also, arrangements were made by the Civil Aviation Authority with the airport owner for a safety officer to be in attendance at the terminal for all jet operations to control public access in the vicinity of the terminal construction area.

Occurrence summary

Investigation number 198904244
Occurrence date 21/10/1989
Location Maroochydore
Report release date 19/12/1989
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Miscellaneous - Other
Occurrence class Incident
Highest injury level None

Aircraft details

Manufacturer Fokker B.V.
Model F28
Registration VH-EWB
Serial number 11205
Operation type Air Transport High Capacity
Departure point Maroochydore QLD
Destination Sydney NSW
Damage Nil

Engine malfunction involving Boeing B747-238, HS-TGC, 2 km north-west of Sydney, New South Wales, on 3 August 1991

Summary

Circumstances:

HS-TGC operating as flight TG484 took off from runway 34 on initial climb to flight level 280. At 1518 hours local, following reports from members of the public, Sydney Air Traffic Control advised the crew that an object had been seen to fall from the aircraft shortly after take-off. The captain requested further information before a decision was taken whether to continue the flight or return to Sydney. At 1622 hours the aircraft was transferred to an Adelaide ATC frequency and at 1658 hours a report was passed from the company which provided engineering support to the airline in Sydney. The report indicated two pieces of metal were recovered. They were 30 cm and 45 cm in length and were pieces of an exhaust nozzle although the engine which lost the pieces could not be identified. A recommendation was passed to the captain to monitor all engine indications and if no abnormality were evident, it would be safe to continue to the destination. The captain advised that all engine indications were normal and that the flight would continue as planned. The aircraft landed safely at its destination. After arrival, the long fixed core exhaust nozzle (LFCEN) from number three engine was found to be missing. Subsequently, eight pieces of the exhaust nozzle were recovered in an area approximately 2.4-4.9 km beyond the northern end of runway 34. There were no injuries to persons under the flight path and property damage was minimal. A technical investigation revealed that material failure caused the separation of the LFCEN from the engine body. The attachment fitting which secures the LFCEN to the engine body failed as a result of extensive fatigue cracking. A service bulletin was issued by the engine manufacturer in February 1987 which recommended fitment of secondary attachment hardware for the LFCEN. As an alternative, it was recommended the primary attachment fittings be inspected on a regular basis (every 750 engine cycles) for cracking. The airline complied with the alternative recommendation but with an extension of the time between inspections to every 1,000 cycles. No. 3 engine had completed 666 cycles at the time of failure. In-flight separation of an LFCEN from the type of engine fitted to HS-TGC is an extremely rare event. The engine manufacturer has notified all affected aircraft operators of the circumstances and findings. The manufacturer also renewed its recommendations contained in the service bulletin which advocated the fitting of secondary attachment hardware to the LFCEN. The airline has taken action to ensure a fleet-wide inspection of all LFCEN attachment fittings at the next 'A' aircraft check and fitment of secondary attachment hardware in accordance with the engine manufacturer's service bulletin.

Significant Factors:

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

1. Fatigue cracking of the LFCEN attachment fitting, no. 3 engine.

2. Material failure of the LFCEN attachment fitting, no. 3 engine.

Occurrence summary

Investigation number 199101923
Occurrence date 03/08/1991
Location 2 km north-west of Sydney
State New South Wales
Report release date 15/07/1992
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Engine failure or malfunction
Occurrence class Incident
Highest injury level None

Aircraft details

Manufacturer The Boeing Company
Model 747
Registration HS-TGS
Serial number 21784
Sector Jet
Operation type Air Transport High Capacity
Departure point Sydney NSW
Destination Bangkok Thailand
Damage Minor

Piper PA28-R180, VH-PXL, Caloundra QLD, 23 October 1989

Summary

The pilot had intended to enter the circuit for Runway 05 however when he arrived he found that the circuit for Runway 23 was active. One of his passengers asked to fly over a specific area which was located below a wide downwind position. A preceding aircraft was also making a full-stop landing and would require time to backtrack to clear the runway. As a result of these distractions, the pilot forgot the pre-landing checks and landed with the landing gear retracted. He said that he did not use a written checklist while operating the aircraft. The reason the automatic gear system did not operate was not determined. This accident was not the subject of a formal on scene investigation.

Occurrence summary

Investigation number 198903817
Occurrence date 23/10/1989
Location Caloundra
Report release date 03/11/1989
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Wheels up landing
Occurrence class Accident
Highest injury level None

Aircraft details

Manufacturer Piper Aircraft Corp
Model PA-28
Registration VH-PXL
Serial number 28R-30338
Operation type Private
Departure point Fraser Island QLD
Destination Caloundra QLD
Damage Substantial

Collision with terrain Wings Hanglider, 2 km W Lobethal SA, 15 July 1989

Summary

The pilot had only recently acquired the hanglider from an acquaintance and was being assisted by two friends to learn to fly the aircraft. Neither the pilot nor his friends had any previous flying experience and there was no evidence that the pilot had joined or contacted the local hangliding association for assistance. Permission of the landowner was gained for use of the property and the pilot chose a hill which had a large dam, fence and power lines at the bottom. Several short flights were made by the pilot prior to the accident flight and his friends helped him carry the glider to the top of the hill for launching. On the final flight, the pilot was seen to be taken higher than before by a gust of wind and to have some difficulty with directional control. As a result, the pilot was seen to make a controlled landing but in the centre of the dam. His helpers ran to his aid and reported seeing movement under the wing fabric of the glider before it sank. This activity they assumed was the pilot attempting to free himself from the harness of the glider. The helpers dived into the water to attempt a rescue but were forced to return to the bank for fear of being overcome by the intense cold of the water. The glider was recovered soon after but the pilot was not in the harness which was still attached to the frame of the glider. The body of the pilot was recovered later by the police and the post mortem found that the pilot had died from freshwater drowning.

Occurrence summary

Investigation number 198900842
Occurrence date 15/07/1989
Location 2 km W Lobethal
Report release date 06/11/1989
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Collision with terrain
Occurrence class Accident
Highest injury level Fatal

Aircraft details

Manufacturer No Aircraft Involved
Model Wings Hanglider
Operation type Private
Departure point 2 km W Lobethal SA
Destination 2 km W Lobethal SA
Damage Nil

Astir CS Glider, VH-WQH, Gympie QLD, 5 October 1988

Summary

Conditions were reported to be very hot with considerable turbulence on the approach to land. On short final the pilot twice had to lower the nose and reduce airbrake. After a larger than normal control movement on roundout the tailwheel touched first, throwing the glider on to the mainwheel which collapsed. Notification of this accident was not received until 16 November 1988 and no on-site investigation was carried out.

Occurrence summary

Investigation number 198803498
Occurrence date 05/10/1988
Location Gympie
Report release date 03/02/1989
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Hard landing
Occurrence class Accident
Highest injury level None

Aircraft details

Manufacturer Grob - Burkhart Flugzeugbau
Model G102
Registration VH-WQH
Serial number 1410
Operation type Gliding
Departure point Gympie QLD
Destination Gympie QLD
Damage Substantial

Collision with terrain involving Piper PA60-601P, VH-MNM, Warnervale, New South Wales, on 22 August 1989

Summary

Circumstances:

Earlier in the day the pilot had flown from Bankstown to Taree with an intermediate landing at Warnervale. Before departing Taree, the pilot said the oil quantities were checked for both engines and found to be adequate for the return flight to Bankstown via Warnervale. The track to Warnervale was via the coastal route of the Williamtown military control zone (CTR) at 500 ft. Leaving the CTR, the pilot initiated a cruise climb to 3,000 ft. Passing 700 ft, the left engine began to vibrate and lost power. The engine was shut down and the climb continued to 1,500 feet. The pilot decided to continue to Warnervale rather than divert to RAAF Williamtown which was closer. He unsuccessfully attempted to restart the left engine whilst tracking to Warnervale. On arrival, the aircraft was positioned to join the circuit on an oblique left base for runway 20. As the aircraft passed over the threshold with the landing gear and full flap extended, the pilot applied full power and commenced a missed approach when he assessed the aircraft was too high and too fast. The rate of climb was less than anticipated following gear and flap retraction and when it became apparent the aircraft might collide with trees beyond the southern boundary of the airstrip, the pilot elected to land wheels-up on the overrun. The aircraft slid along swampy ground and collided with a large eucalypt log. During a subsequent strip examination, it was determined the left engine oil quantity was low. Glazing was also observed in several cylinder bores. As the engine design incorporated hydraulic tappets, it is considered probable that the low oil quantity affected the operation of the tappets and caused the vibration and loss of power. The reason for the apparent rapid loss of oil from the left engine after DEPARTURE Taree was not determined.

Significant Factors:

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

1. Vibration and loss of power in flight from the left engine which required the engine to be shut down.

2. The pilot failed to divert to the most suitable airport.

3. The pilot misjudged height and speed on approach to runway 20.

4. The pilot attempted a single engine missed approach from an unsafe height.

Occurrence summary

Investigation number 198902573
Occurrence date 22/08/1989
Location Warnervale
State New South Wales
Report release date 27/04/1992
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Collision with terrain, Engine failure or malfunction
Occurrence class Accident
Highest injury level Minor

Aircraft details

Manufacturer Piper Aircraft Corp
Model PA-60
Registration VH-MNM
Serial number 61P-0578-7963253
Sector Piston
Operation type Business
Departure point Taree NSW
Destination Warnervale
Damage Substantial