Boeing 747-238B, VH-EBK, Honolulu, Hawaii USA, 7 July 1988

Summary

The takeoff from Honolulu was being performed by the Second Officer from the right control seat. This pilot was receiving promotional training under the supervision of the Captain. Weather conditions were reported as being fine. Because of a more favourable power decrement, the Captain had elected to use a Flaps 10 setting. Appropriate reference speeds as calculated for this particular takeoff were V1=148 knots; Vr=168 knots, and V2=176 knots. The body angle required at the completion of rotation was calculated to be 13 degrees. This target angle was expected to be reached by V2 as the aircraft passed through a nominal height of 35 feet. The stabilizer trim was set to 8.1 units nose-up, which was in accordance with a forward Centre of Gravity (CG) position. The subsequent flight was conducted without recorded incident. However, during a post-flight inspection at Vancouver, it was found that the aircraft had sustained damage to the undersurfaces of the rear fuselage. The damage was consistent with a tailstrike, although the flight crew had been unaware of such an occurrence. Flight Data Recorder analysis indicated that a tailstrike had occurred at Honolulu. Rotation for takeoff had been initiated at an airspeed of 157 knots. The elevator control input was initially held at an average setting, but the aircraft did not respond by lifting off at about 8 degrees as would have been expected. A further control input was made to achieve liftoff, during which a maximum body angle of 15 degrees was momentarily recorded. The average pitch change rate was calculated to be 3.1 degrees per second. It is estimated that with the mainwheels on the ground, the rear fuselage will contact the runway at a body angle of approximately 12 degrees. It was determined that although the initial elevator control input was consistent with a normal takeoff, the rate of pitch change was almost double the normal rate. It is considered that this was due to a characteristic of the aircraft which results in reduced elevator control pressures at forward CG positions, particularly when combined with a Flaps 10 setting. Company Operations Manuals note that elevator forces encountered during rotation when 8.5 or more units are required, will be approximately 40 to 50 percent of the elevator force experienced at lighter weights and mid or aft CG positions. The Second Officer had not previously experienced a takeoff under the existing weight and flap conditions, and was unaware of the comments in the Operations Manual relating to lighter elevator forces. It is possible that the tailstrike would not have occurred if rotation had been initiated at the correct speed. However, the reason that rotation was commenced 11 knots below the target speed could not be established.

Occurrence summary

Investigation number 198800004
Occurrence date 07/07/1988
Location Honolulu, Hawaii USA
State Other
Report release date 13/12/1988
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Ground strike
Occurrence class Accident
Highest injury level None

Aircraft details

Manufacturer The Boeing Company
Model 747
Registration VH-EBK
Serial number 21140
Operation type Air Transport High Capacity
Departure point Honolulu, Hawaii USA
Destination Vancouver, British Columbia CANADA
Damage Substantial

Cessna A188B-A1, VH-IEV, Clare (35 km SW Ayr) QLD, 31 August 1987

Summary

The pilot reported that shortly after liftoff, as he retracted the flap, he felt the engine lose power. He commenced to dump the load but aircraft performance continued to deteriorate and he was committed to landing straight ahead in a field of young sugar cane. On-site investigation showed that the tailwheel and right mainwheel of the aircraft had struck a 40 centimetre high embankment some 8 metres beyond the end of the 700 metre strip. The aircraft remained airborne for a further 115 metres before the left wingtip contacted the ground. Evidence of load dump began at the same point. The right mainwheel then contacted the ground and the aircraft swung 130 degrees to the left and travelled a further 44 metres before coming to rest. Examination of the engine revealed evidence of loss of compression past the piston rings on four of the six cylinders and past the valves on five cylinders. These faults would have reduced the power output of the engine and resulted in a decreased takeoff performance. It is likely that the aircraft became airborne near the end of the strip, striking the embankment almost immediately afterwards. The engine was due to be changed after a further 15 hours of operation. The Aircraft Flight Manual indicated that, for the takeoff weight applicable at the time, the aircraft required a takeoff distance of 500 metres.

Occurrence summary

Investigation number 198703500
Occurrence date 31/08/1987
Location Clare (35 km SW Ayr)
Report release date 07/11/1988
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Accident
Highest injury level None

Aircraft details

Manufacturer Cessna Aircraft Company
Model 188
Registration VH-IEV
Serial number 18801547
Operation type Aerial Work
Departure point Clare QLD
Destination Clare QLD
Damage Substantial

Thruster Gemini, 25-0044, 6 km NW of Lovely Banks VIC, 18 December 1988

Summary

During the sortie the student overcontrolled the aircraft during the landings. Conditions were hot and humid with slight turbulence. On the fourth landing the aircraft bounced, the right wing dropped and the aircraft veered to the right. The instructor took over the controls and applied full power. She was able to regain straight and level flight but did not correct the veer because the airspeed was low and because she was confident that the aircraft would safely clear a fence ahead. The aircraft failed to gain sufficient height and the gear collided with the fence. The aircraft settled into an isolated pile of rubble a short distance beyond the fence. This accident was not the subject of a formal on-site investigation.

Occurrence summary

Investigation number 198801420
Occurrence date 18/12/1988
Location 6 km NW of Lovely Banks
Report release date 27/06/1989
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Loss of control
Occurrence class Accident
Highest injury level None

Aircraft details

Manufacturer Thruster Aircraft (Australia) Pty Ltd
Model Gemini
Registration 25-0044
Serial number 086-130
Operation type Sports Aviation
Departure point 6 km SW of Lovely Banks VIC
Destination 6 km SW of Lovely Banks VIC
Damage Substantial

Beechcraft BE76, VH-WZA, Parafield Airport, South Australia, on 20 July 1990

Summary

Circumstances:

During a period of circuit training, the instructor simulated an engine failure after take-off. The instructor disabled the landing gear warning horn system to reduce noise and to ensure that the student would remember to lower the landing gear, which he did when turning onto base leg. Assessing his approach to be high, the student conducted a go-around and retracted the landing gear. The subsequent circuit was abbreviated due to changing traffic and weather conditions. Final checks were completed without confirmation of landing gear position by either pilot. The aircraft was flared normally, but experienced an extended float, which the pilots attributed to a downwind component. After approximately 500-600m the aircraft settled onto the runway with the landing gear fully retracted.

Significant Factors:

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

1. The student forgot to select the landing gear down.

2. The instructor failed to adequately monitor the student's vital actions.

3. The crew failed to follow the check list.

4. The landing gear warning horn system was disabled.

5. The pilots were distracted by weather and circuit traffic conditions. This accident was not the subject of an on-scene investigation.

Occurrence summary

Investigation number 199000012
Occurrence date 20/07/1990
Location Parafield Airport
State South Australia
Report release date 10/08/1990
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 Beech Aircraft Corp
Model 76
Registration VH-WZA
Serial number ME377
Sector Piston
Operation type Flying Training
Departure point Parafield SA
Destination Parafield SA
Damage Substantial

Piper PA-28R-200, VH-SLH, Fanning River Station, 65 km south-west of Townsville, Queensland, on 14 March 1989

Summary

Circumstances:

On arrival at Fanning River the pilot lowered the landing gear and obtained an indication that the landing gear was locked down. The aircraft subsequently touched down on the mainwheels and shortly after the pilot lowered the nosewheel to the ground, the nose gear collapsed. The aircraft slid to a stop on the strip, in a nose down attitude. An inspection of the aircraft revealed that the nose gear assembly showed signs of excessive freeplay. This resulted in an excessive load on the down lock bracket and its ultimate failure in overload during this landing. The strip surface was rough, consisting of sandy soil covered with tufts of grass. The nature of the surface probably contributed to the failure.

Significant Factors:

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

1. The strip surface was rough.

2. The nose gear assembly showed signs of excessive wear and had not been maintained adequately.

Occurrence summary

Investigation number 198903756
Occurrence date 14/03/1989
Location Fanning River Station, 65 km south-west of Townsville
State Queensland
Report release date 09/08/1990
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-SLH
Serial number 28R-7135126
Sector Piston
Operation type Private
Departure point Woodstock QLD
Destination Fanning River Station QLD
Damage Substantial

Fuji FA-200-160, VH-FJN, 10 km SW of Beulah VIC, 14 August 1989

Summary

The pilot carried out one spray run at about 10 feet above the ground in an easterly direction over his own barley crop. The weather was fine with a north-easterly wind of about three knots. The area was very open with large, slightly undulating paddocks. About 40 metres beyond a fence marking the end of the spray run, the left wing struck a single strand power line about 18 feet above the ground. Without breaking, the wire severed a small portion of the upper surface of the wing, near the wing tip. Impact marks on the leading edge of the wing indicate that the aircraft was banked about 30 degrees to the right when it struck the wire. The wire was pulled off three adjacent poles which were about 400 metres apart. The aircraft collided with the ground inverted and nose first about 80 metres beyond the wire. At ground impact there was negligible ground slide. The engine partially dislodged from the airframe and the cabin was partially crushed. The sliding canopy slid open and the home-made hopper ruptured. An estimated 100 litres of herbicide spilled from the hopper. The pilot was not a trained, approved, agricultural pilot. The aircraft was not approved for agricultural operations, nor was the hopper installation. The wire was difficult to see because of the large distance between poles.

Occurrence summary

Investigation number 198901549
Occurrence date 14/08/1989
Location 10 km SW of Beulah
Report release date 29/11/1989
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Wirestrike
Occurrence class Accident
Highest injury level Fatal

Aircraft details

Manufacturer Fuji Heavy Industries Ltd
Model FA-200
Registration VH-FJN
Serial number FA-200-44
Operation type Aerial Work
Departure point Private airstrip 16 km WSW of Beulah VIC
Destination 16 km WSW of Beulah VIC
Damage Substantial

Cessna A188B/A1, VH-PQV, 9 km S of Violet Town VIC, 27 April 1989

Summary

The takeoff was carried out downhill, at maximum gross weight, on a 570 metre agricultural strip with a load of superphosphate. When the aircraft had not become airborne with 60 metres of strip remaining, the pilot commenced dumping the load. However, the aircraft overran the strip before becoming airborne and flew very low over the surface of a farm dam. The landing gear impacted the earthen dam wall and the left maingear assembly detached from the airframe. The aircraft continued descending down a gully, through scrub, before settling into rocks. It then slewed around and came to rest upright. As the pilot vacated the wreckage, a fire erupted in the engine bay. The aircraft was subsequently destroyed by fire. An inspection of the wreckage did not reveal any fault that may have contributed to the occurrence. From a witness's description of the combined noise of the engine and propeller during the takeoff roll, it is probable that the pilot attempted the take off without the propeller in the full fine pitch position. Examination of the wreckage found the pitch control setting in the mid-range position.

Occurrence summary

Investigation number 198901541
Occurrence date 27/04/1989
Location 9 km S of Violet Town
Report release date 22/08/1989
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-PQV
Serial number 18801416
Operation type Aerial Work
Departure point 9 km S of Violet Town VIC
Destination 9 km S of Violet Town VIC
Damage Destroyed

Piper PA-28 140, VH-IAJ, Broken Hill, New South Wales, on 17 April 1990

Summary

Circumstances:

The aircraft had been engaged on a flight from Shepparton, Victoria to Pine Creek, Northern Territory, and was scheduled to make a refuelling stop at Broken Hill. After arrival in the circuit area at Broken Hill the pilot decided to carry out an additional circuit to facilitate spacing with another aircraft operating in the circuit. During the second circuit, the engine lost power. The pilot turned the aircraft to enter a long final for runway 14. The aircraft touched down in an area of mine tailings, ran up a slope and became airborne before the right wing struck a tree causing the aircraft to roll to the right and come to rest inverted. An inspection of the wreckage revealed that there was no useable fuel in the left fuel tank, however, the right fuel tank contained approximately 70 litres of fuel. There was also evidence that further fuel had drained from the right tank but not from the left tank. An examination of the engine and other aircraft systems did not reveal any fault that may have contributed to the loss of engine power. The aircraft was refuelled to full tanks five days prior to DEPARTURE from Shepparton, and a preflight inspection carried out on the day of DEPARTURE. Calculations indicate that it is likely that the pilot selected the right fuel tank for the DEPARTURE and that the left tank was selected at the first enroute reporting position, about 30 minutes later. That fuel tank then remained selected until the loss of engine power.

Significant Factors:

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

1. The pilot probably mismanaged the aircraft fuel system.

2. The engine probably failed due to fuel starvation.

3. The aircraft landed on unsuitable terrain.

Occurrence summary

Investigation number 199000582
Occurrence date 17/04/1990
Location Broken Hill
State New South Wales
Report release date 15/05/1991
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Accident
Highest injury level Fatal

Aircraft details

Manufacturer Piper Aircraft Corp
Model PA-28
Registration VH-IAJ
Serial number 28-22927
Sector Piston
Operation type Private
Departure point Shepparton VIC
Destination Broken Hill NSW
Damage Substantial

Gulfstream 695B, VH-LTM, Mangalore VIC, 17 July 1989

Summary

The aircraft was being used for Examiner of Airmen training. For the first part of the flight from Essendon, the captain flew the aircraft from the left crew seat as captain and the other pilot performed the co-pilot role from the right seat. An instrument approach was flown at Mangalore followed by three touch and go landings. During the touch and go landings the co-pilot operated the flap selection lever and the captain operated the undercarriage lever in accordance with standard operating procedures. The positioning of the flap and landing gear selectors either side of the throttle quadrant is mirrored. After a full stop landing, a shut-down and a mutual briefing, the captain occupied the right crew seat and performed the role of co-pilot as well as supervisory pilot. The other pilot flew the aircraft while acting in command under supervision from the left seat. During a touch and go landing on runway 23 the pilot under supervision lowered the nosewheel to the runway and then advanced the power levers to takeoff power. The supervisory pilot selected flaps up and advised the pilot under supervision of the selection. Unexpectedly the pilot under supervision then selected the landing gear up before the aircraft had left the ground. The supervisory pilot attempted to prevent the gear up selection but was unable to because of the physical location of the landing gear lever and the speed at which the pilot under supervision had moved his hand. The landing gear retraction cycle progressed far enough to turn both mainwheels inwards causing them to drag along the runway whereas the nosewheel remained in the down position. Hearing a loud scraping noise, the pilot under supervision immediately reselected landing gear down. Both pilots elected to retard the power levers and abort the takeoff. The aircraft slid to a halt within 200 metres on its rear fuselage and nose wheel. When the pilot under supervision selected the landing gear up the aircraft was travelling at about 90 knots. It was light on the mainwheels. The oleos were no longer compressed enough to activate the "squat switch" which guards against inadvertent landing gear retraction on the ground. The pilot under supervision had previously been given endorsement training on the aircraft. He had almost completed the thirty hours acting in command under supervision required before being considered for unsupervised command duties. His training had not been concentrated. About twelve months had elapsed since the training began. Prior to joining the Civil Aviation Authority, he had not flown turbo-prop or turbo-jet aircraft nor had he previously experienced two pilot crew techniques. He had experienced some difficulty understanding the particular crew roles during the training because he had flown with several supervisory pilots who used slightly different practices. The pilot's selection of landing gear up was the result of a reflex role reversal at a time of reasonably high workload. The pilot believes his actions were triggered by the supervisory pilot saying "Flaps selected UP".

Occurrence summary

Investigation number 198901547
Occurrence date 17/07/1989
Location Mangalore
Report release date 12/12/1989
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Accident
Highest injury level None

Aircraft details

Manufacturer Gulfstream Aerospace Corp
Model 695
Registration VH-LTM
Serial number 96208
Operation type Flying Training
Departure point Mangalore VIC
Destination Mangalore VIC
Damage Substantial

Cessna A188B-A1, VH-KZB, "Wilgabar" 15 km east-north-east of Walgett, New South Wales, on 26 May 1989

Summary

Circumstances:

The aircraft was engaged in spraying a large paddock. The weather was fine with a light wind. On the third run of the fifth load, the markers were positioned in such a way that there was a tree located directly on the intended swath run. A second tree lay behind, and to the right, of the first tree. The pilot estimated he could carry out a turn and pass between the two trees, to enable the spray pattern to be kept reasonably uniform. The pilot misjudged the manoeuvre and overshot the turn, resulting in the right wing of the aircraft striking a branch protruding from the second tree. About half a metre was lost from the outboard section of the right wing. The right aileron was bent and remained attached to the aircraft solely by the inboard hinge. The right spray boom was ruptured, allowing chemical to escape. Partial control was maintained, and the pilot made an emergency landing, without further damage, on an adjoining paddock. This accident was not the subject of an on-site investigation. The report is based on information provided by the pilot.

Significant Factors:

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

  1. The pilot made an improper in-flight decision in attempting to manoeuvre the aircraft between the trees.
  2. The pilot misjudged a turn in a confined area.

Occurrence summary

Investigation number 198902555
Occurrence date 26/05/1989
Location "Wilgabar" 15 km east-north-east of Walgett
State New South Wales
Report release date 15/01/1990
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Accident
Highest injury level None

Aircraft details

Manufacturer Cessna Aircraft Company
Model 188
Registration VH-KZB
Serial number 18803039T
Sector Piston
Operation type Aerial Work
Departure point Walgett NSW
Destination Walgett NSW
Damage Substantial