Piper PA32T-300, VH-MHU, Archerfield QLD, 30 November 1988

Summary

The aircraft is not frequently used except for short, concentrated periods of activity. At other times it is left parked at Coolangatta Aerodrome and is subject to the harsh coastal environment. During an eight day business trip around Queensland in the aircraft, some gear problems were encountered. At Mackay, several days before the accident, the pilot discovered that a left main gear door linkage had sheared because lack of lubrication had seized the ball joint. Upon inspection, the right gear door linkage was similarly seized. The damaged items were serviced by a licenced aircraft maintenance engineer before the flight continued to Hamilton Island. Later, departing Hamilton Island, the pilot noticed that the GEAR UNSAFE light remained illuminated after gear retraction. Recycling the gear gave a correct gear down indication each time but the GEAR UNSAFE light remained lit after each retraction. A visual inspection by the Tower Controller convinced the pilot that the gear was indeed stowed and he assumed that the problem was of an electrical nature. The unsafe indication continued for the duration of the round trip. When the pilot selected gear down upon his arrival at Archerfield, the right maingear remained in the wheelwell. Attempts were made to shake the gear down but to no avail. With last light approaching, the pilot decided to commence an approach for a wheels-up landing on Runway 04R. During late final approach the pilot shut the engine down. The resultant high rate of descent surprised the pilot who realised that the aircraft would now land short of the threshold. The aircraft landed heavily on cross runway and slid onto the threshold. Investigation has revealed that the right maingear torque link bolt sheared, causing the oleo to over-extend and jam the wheel in the wheelwell. The failed bolt and bushes had corroded and seized in the torque links causing the bolt to shear with movement of the torque links. The torque link bolts are not normally removed and lubricated during routine servicing.

Occurrence summary

Investigation number 198803505
Occurrence date 30/11/1988
Location Archerfield
Report release date 06/03/1989
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-32
Registration VH-MHU
Serial number 32R-7885278
Operation type Business
Departure point Roma QLD
Destination Archerfield QLD
Damage Substantial

Cessna A188B-A1, VH-EUU, 15 km W Innisfail QLD, 20 October 1987

Summary

The pilot was conducting aerial spraying on a banana plantation in hilly country. While flying a clean-up run along one side of a section of the plantation, the aircraft struck a set of powerlines which ran diagonally across its flight path. The wires became entangled in the main landing gear and were dragged 160 metres before the aircraft impacted the ground and caught fire. The cockpit area was burnt out and the engine compartment severely damaged by the fire. The engine and remaining aircraft structure and components were examined and, not withstanding the severe heat damage to some engine components/accessories, no abnormality was found. The pilot, who suffered serious burns, told a friend a short time after the accident that he was distracted by a sprinkler pole and had forgotten about the wires. In hospital two days later, the pilot reportedly spoke of experiencing elevator control problems shortly before hitting the wires. When he was able to be interviewed, some seven weeks after the accident, the pilot maintained that he felt the engine lose power as he was aligning the aircraft for the run and that the aircraft descended into the wires as a result. The nature and extent of the pilot's injuries indicated that trauma induced amnesia was unlikely to have caused his conflicting accounts of the accident. There are, however, unconscious pyschological mechanisms which can explain these conflictions. The banana plants were served by a large number of sprinkler poles of narrow gauge water pipes which protruded above the plant tops. Seeing these would have required considerable attention from the pilot. The power poles supporting the wires the aircraft struck were well outside the pilot's forward field of view and the wires themselves would have been difficult to see against the background of dark vegetation. However, the weight of human behavioural evidence leads to the conclusion that the pilot was probably distracted and forgot about the wires. The pilot reported that he was unable to open the left cockpit door by the normal or emergency method and had to egress through the right door where the fire was more intense. Both cockpit doors were open when the wreckage was examined. No reason was found which would have prevented the emergency exit from operating normally.

Occurrence summary

Investigation number 198703516
Occurrence date 20/10/1987
Location 15 km W Innisfail
Report release date 24/08/1988
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Wirestrike
Occurrence class Accident
Highest injury level Serious

Aircraft details

Manufacturer Cessna Aircraft Company
Model 188
Registration VH-EUU
Serial number 18801087
Operation type Aerial Work
Departure point Innisfail QLD
Destination Innisfail QLD
Damage Destroyed

Pilatus B4 PC11, VH-GCF, 3 km E of Tumut NSW, 29 December 1987

Summary

The glider was undergoing a test flight following an annual inspection. After being released the aircraft was climbed to 4300 feet prior to the commencement of a high speed descent. At an indicated airspeed of 110 knots the pilot reported that there was a slight buffet from the tailplane area. The descent was continued and at an indicated airspeed between 118 and 122 knots severe vibrations from the tailplane area were encountered. The airspeed was reduced and after completing a control check the aircraft was landed. Subsequent inspection revealed damage to the rear fuselage near the fin root. This accident was investigated by the Gliding Federation of Australia and was not the subject of an on-site investigation by the Bureau. The Federation's investigation indicated that the amount of freeplay in the horizontal tailplane of the aircraft was just within the limits specified in the manufacturer's manual the pilot was inexperienced for the task he may have actually reached VNE and his reaction to the vibration may have overstressed the aircraft.

Occurrence summary

Investigation number 198702453
Occurrence date 29/12/1987
Location 3 km E of Tumut
Report release date 29/06/1989
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Airframe - Other
Occurrence class Accident
Highest injury level None

Aircraft details

Manufacturer Pilatus Aircraft Ltd
Model PC-11
Registration VH-GCF
Serial number N/K
Operation type Gliding
Departure point Tumut NSW
Destination Tumut NSW
Damage Substantial

Grob Twin Astir, VH-IKL, Stirling Range, Western Australia, on 9 July 1990

Summary

Circumstances:

The accident occurred on the first gliding flight of the day. The air temperature was approximately two degrees Celsius, and a shallow low-level layer of moist air was present. Shortly after take-off on a dual tow, and at approximately 300 ft above the ground, what appeared to be ice formed on the outside of the canopies of both gliders causing a complete loss of forward vision. Although the pilots were able to see the ground through their clear view panels (left hand side) visibility was severely restricted. The pilots of both gliders released their tow ropes (short tow first) and attempted emergency landings. The long tow glider turned left through 90`, sighted a suitable paddock, turned left through 270` and completed a successful landing. The short tow glider (VH-IXL) turned left through 240`, sighted the airfield and had commenced a right turn to line up for a landing when it struck the top branches of a tree, crashing near the base of the tree. The Bureau of Meteorology reported that the most likely cause of the loss of visibility was the rapid deposition of hoar frost on the canopy after the cold aircraft (having radiated energy all of the previous night) ascended from a 200 to 300 ft thick, cold but relatively dry band of air into an inversion layer of warm and relatively moist air. In the Bureau's opinion, it would be virtually impossible to routinely give prior warnings of such an unusual phenomenon, or for aircrew to be able to determine the state of the atmosphere from a purely visual observation. It was considered that the time of the occurrence was significant. The two layers would have mixed together as the sun continued to rise thus diminishing the potential for the occurrence. The air temperature had risen to six degrees Celsius within 75 min of the accident. The pilots were aware of the standard procedure to attempt to land straight ahead following a low-level tow release. However, this procedure assumes forward visibility, and, on this occasion, visibility was severely restricted. Both pilots were forced to manoeuvre in an attempt to sight a clear landing area through their clear vision panels. The procedure worked for one aircraft, and it almost worked for the second. Consideration was given, by at least one of the pilots, to jettisoning the canopy however, this was not done because of the possibility of tail damage and complete loss of control.

Significant Factors:

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

1. There were unusual unobserved meteorological conditions which created a situation where frost could form suddenly on the aircraft's windscreen.

2. Inflight visibility was suddenly restricted due to frost deposits.

3. The pilot was unable to see a large tree to the right and below the aircraft during his final turn towards the landing area.

4. The aircraft became uncontrollable following the collision with the tree.

Recommendations:

The Gliding Federation of Australia (GFA) recommended three specific procedures for operations at the Stirling Range strip.

1. That early morning launches be delayed until the rising sun has caused some mixing of the air, possibly as late as 0800 hours.

2. If ice is present on the parked gliders, it will be allowed to melt off rather than be scraped off thus allowing the airframe to warm up before the first DEPARTURE.

3. The tug check flight will occur as near as practical to the first glider launch, will follow the same flight path as is intended for the gliders and will climb to at least 800 ft before returning. On its return the tug will be checked for signs of leading edge ice. If ice is present launching will be delayed until further warming has occurred. A further GFA recommendation related to the jettisoning of the canopy when complete icing occurs. BASI recommends that the GFA consult with the particular aircraft manufacturer before this course of action.

Occurrence summary

Investigation number 199000091
Occurrence date 09/07/1990
Location Stirling Range
State Western Australia
Report release date 02/12/1991
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Accident
Highest injury level Serious

Aircraft details

Manufacturer Grob - Burkhart Flugzeugbau
Model G103
Registration VH-IKL
Sector Other
Operation type Gliding
Departure point Stirling Range WA
Destination Stirling Range WA
Damage Destroyed

Airframe event involving Boeing 747-238B, VH-EBQ, 230 km north of Cairns, Queensland, on 27 December 1990

Summary

VH-EBQ departed Cairns for Narita at 1202 local time. At 1221, a 'PAN' call (urgency message) was made, and the pilot requested an Air Traffic Control (ATC) clearance to return to Cairns. The captain stated that as the aircraft was climbing through Flight Level (FL) 200, moderate airframe vibration was felt. Checks revealed no abnormal cockpit indications. The second officer carried out a visual inspection from the cabin and noticed a damaged wing panel on the upper inboard trailing edge of the right-hand wing.

A return to Cairns was initiated and a clearance to dump fuel was obtained. Cairns ATC advised the aircraft that they had diverted an Australian Airlines Boeing 737 (B737) to escort the aircraft during the return to Cairns. A fuel dump of approximately 25,000 kg was carried out, followed by a descent and circling approach to runway 33. The captain stated that with the flaps extended, there was a slight tendency for the aircraft to roll to the right. The aircraft was landed at 1259 without further incident.

The escorting B737 landed approximately 5 min ahead of VH-EBQ. A readout of the digital flight data recorder was made to determine the data recorded on climb and during the subsequent landing at Cairns. Examination of this data showed that acceleration traces had minor inconsistencies or scatter as the aircraft was climbing through a recorded pressure altitude of FL 205 from 1214 07 to 1214 13. It is possible that the wing panel failure occurred at this time. No other anomalies were observed in the recorded data to indicate that the loss of a wing panel had occurred.

Data recorded during the landing at Cairns was consistent with a crosswind landing and no evidence of airframe vibration or other anomalies was observed in the recorded data. The failure of the right-hand inboard trailing edge fibre reinforced plastic panel was accompanied by the loss of a 2.7 m by 18 cm section of the fore flap trailing edge, and some damage to the mid-flap. The operator had previously had some 20 incidents involving this panel on Boeing 747 aircraft.

On 19 January 1991, the same panel failed on VH-EBP in flight between Sydney and Narita. The manufacturer indicated that there had been several incidents in the previous 18 months resulting from cracking, delamination and separation of this panel.

The possible related causes for failure of the panel were

(a) Damage caused by personnel stepping on the panel.

(b) Damage caused by tyre burst.

(c) Manufacturing anomalies.

(d) Misrigging. (The panel is an aerodynamic surface and is fixed in position with screw jacks to preload it with flaps retracted.)

The panel is subject to a coin 'tap test' to check for delamination, and a push test on both upper and lower surfaces at each 'A' check (400 hrs). VH-EBQ was last inspected on 8 December 1990. When the trailing edge flaps are fully retracted and the fuel tanks are full, the trailing edge of the fixed panel is deflected upwards by as much as 4.5 cm by contact with the flaps. The operator has re-rigged the trailing edge panels so that the maximum deflection is 3.5 cm, thus reducing pre-load stress.

In addition, 'NO STEP' signs have been painted on the panels to reduce possible damage during maintenance. The failed panel from VH-EBQ was not available for examination; however, the subsequent failed panel from VH-EBP was available, and a specialist examination was carried out. Specialist opinion was that both failures were of a similar type, whereby trailing edges had peeled off as a result of debonding and bending due to pre-load rather than aerodynamic forces.

The manufacturer has incorporated design changes to overcome this type of failure. The operator has increased the frequency of periodic inspections of the panel, and it is considered that sufficient corrective action has been taken to overcome the problem. A comprehensive investigation of Air Traffic Services (ATS) aspects was carried out. The investigation concluded that the decisions and actions taken by the ATS personnel involved in the handling of the situation were prompt and effective.

The provision of an escort aircraft was justified in view of the information received initially from VH-EBQ and is consistent with the relevant operational practices and techniques documented in the Airways Operations Instructions (AOI). The captain of VH-EBQ initially felt some concern about the provision of an escort aircraft because of a lack of a clear understanding as to the function of the escort aircraft in relationship to his aircraft.

Selection of the aircraft to perform the intercept/escort was in accordance with published AOI guidelines, and implementation of the escort action was efficient and effective. Consideration of weather conditions was not included as a factor in determining the provision of an escort aircraft in the current AOI.

Occurrence summary

Investigation number 199004040
Occurrence date 27/12/1990
Location 230 km north of Cairns
State Queensland
Report release date 18/12/1992
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Diversion/return, Fuselage/wings/empennage
Occurrence class Incident
Highest injury level None

Aircraft details

Manufacturer The Boeing Company
Model 747
Registration VH-EBQ
Serial number 22145
Sector Jet
Operation type Air Transport High Capacity
Departure point Cairns Qld
Destination Narita Japan
Damage Minor

Cessna A188B-A1, VH-IQI, 5km South of Casino NSW, 15 March 1989

Summary

During a spray run, the pilot heard a loud bang, followed by a power loss and smoke in the cabin. He elected to land the aircraft in a paddock ahead. The mainwheels struck a log during the landing role and the aircraft nosed over. Inspection revealed that the top of the number three cylinder head had separated at the second barrel attachment thread. This failure caused a drastic loss of power and allowed combustion products into the engine cowling and cabin. Specialist examination indicated that the cylinder head separated due to metal fatigue cracking. The age of the cylinder could not be established.

Occurrence summary

Investigation number 198903755
Occurrence date 15/03/1989
Location 5km South of Casino
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 Cessna Aircraft Company
Model 188
Registration VH-IQI
Serial number 18801348
Operation type Aerial Work
Departure point Lismore NSW
Destination Lismore NSW
Damage Substantial

Gemini Thruster, AUF 25-0046, Wellington, New South Wales, on 29 July 1990

Summary

Circumstances:

The aircraft was engaged in circuit training in the 05 direction. Wind conditions were reported to be 030/5 to 8 knots and gusty. A number of normal take offs and landings were safely executed before the instructor attempted a downwind take-off in the 23 direction. The aircraft was observed to take a longer than normal ground roll. When it reached a height of about 50 feet the left wing dropped, and the aircraft commenced to rotate to the left before striking the ground in a steep nose down attitude on a heading of about 050 degrees. A witness who was standing near the north eastern end of the strip said the wind gusted to about 15 knots from the north east immediately prior to the accident. It would appear that during a critical stage of the take-off, the aircraft stalled after suffering a sudden a loss of airspeed associated with a significant wind shear. This accident highlights the dangers of attempting downwind take-offs in ultra-light aircraft.

Recommendations:

It is recommended the AUF publicise the circumstances of this accident to highlight the dangers associated with downwind take offs in ultra-light aircraft.

Occurrence summary

Investigation number 199002041
Occurrence date 29/07/1990
Location Wellington
State New South Wales
Report release date 04/10/1990
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 25-0046
Serial number 086-132
Sector Piston
Operation type Sports Aviation
Departure point Wellington NSW
Destination Wellington NSW
Damage Substantial

Agusta Bell 206B, VH-BHV, 15km North-west of Karratha WA, 19 November 1986

Summary

The helicopter was tasked to sling load two large metal hooks between two points on a wharf. The first hook was off-loaded, but as the helicopter was lifting the second hook, the tail rotor contacted a solar panel at the top of a light pole. Control of the aircraft was lost and it was observed to perform a nose high turn before striking the water. The helicopter floated inverted and the pilot was able to evacuate himself and swim to a boat. It is considered likely that while concentrating on the position of the load, the pilot diverted his attention from the operation of the helicopter and allowed it to descend, which resulted in the tail rotor strike.

Occurrence summary

Investigation number 198600152
Occurrence date 19/11/1986
Location 15km North-west of Karratha
Report release date 13/01/1987
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Wirestrike
Occurrence class Accident
Highest injury level Minor

Aircraft details

Manufacturer Bell Helicopter Co
Model 206
Registration VH-BHV
Sector Helicopter
Operation type Aerial Work
Departure point "Dampier Salt" Wharf, Dampier WA
Destination "Dampier Salt" Wharf, Dampier WA
Damage Destroyed

Total power loss - Gemini Thruster TST-E, Beebyn Station, Western Australia, on 24 November 1989

Summary

Circumstances:

The pilot had planned to carry out a bore-hole inspection on his property. During the start-up sequence the pilot noted that more choke than normal was required, however, after start-up the engine ran smoothly. Approximately 30 minutes after take-off the pilot observed air bubbles flowing through the transparent fuel line. The engine began to run roughly and stopped. The pilot commenced forced landing procedures and attempted to restart the engine by hand priming the fuel system using the rubber manual priming bulb. The bulb, once compressed, did not return to its original size. The pilot was forced to carry out a forced landing on unsuitable terrain and the aircraft was damaged. The engine fuel pump non-return valve was found jammed in the open position by black rubber particles. These particles had come from the inside wall of the manual priming bulb. An open non-return valve will cause a loss of pressure within the fuel system and engine failure. The fuel tank is mounted well below the engine. Once the particles were removed from the fuel system the engine ran normally. The aircraft's history indicated that it had been left standing in hot and dry conditions for some time allowing the rubber priming bulb to dry out. Manual operation of the dry bulb probably caused internal cracking and allowed rubber particles to contaminate the fuel system.

Significant Factors:

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

1. Deterioration of the rubber manual priming bulb when it was used after having been allowed to dry out over an extended period of time.

2. Contamination of the fuel system by rubber particles from the priming bulb.

3. Interruption to fuel flow and engine stoppage caused by fuel system contamination.

4. Forced landing in unsuitable terrain.

Recommendations:

It is recommended that the Australian Ultralight Federation draw the attention of its members to the possibility that rubber seals and components used in fuel systems, can deteriorate if they are left to dry out. These components, if left for an extended period of time, should be checked for serviceability before they are placed back into use.

Occurrence summary

Investigation number 198900259
Occurrence date 24/11/1989
Location Beebyn Station
State Western Australia
Report release date 26/04/1990
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Accident
Highest injury level None

Aircraft details

Manufacturer Thruster Aircraft (Australia) Pty Ltd
Model Gemini Thruster
Sector Piston
Operation type Unknown
Departure point Beebyn Station, WA
Destination Beebyn Station, WA
Damage Substantial

Total power loss Winton Sapphire, 1.5 km E Mungallala, QLD, 23 November 1988

Summary

The pilot was taking part in an ultralight safari from Boonah to Cloncurry and return. The propeller separated from the aircraft in flight, damaging the tailboom and right wing. The pilot carried out a successful landing on the Warrego Highway. Investigation revealed that the propeller shaft had failed due to a flaw in the metal. This accident was not the subject of an on-site investigation.

Occurrence summary

Investigation number 198803524
Occurrence date 23/11/1988
Location 1.5 km E Mungallala
Report release date 06/03/1989
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Accident
Highest injury level None

Aircraft details

Manufacturer Scott Winton
Model Winton Sapphire
Operation type Private
Departure point Roma, QLD
Destination Charleville, QLD
Damage Substantial