Cessna 441, VH-NIF, Mackay, Queensland, on 6 September 1989

Summary

Circumstances:

The pilot reported that some freight was removed through the nose compartment left door during the stopover at Mackay. He was sure that the right door had not been touched during this time. After take-off, the aircraft was climbing through 1000 feet at 160 knots, when the right luggage door opened. The door was torn from its hinges, hit the windscreen, and passed along the right side of the aircraft. Almost immediately, the elevator controls jammed. The pilot applied force to the control column, and the elevators became free. The aircraft was then landed uneventfully at Mackay. Post flight inspection of the aircraft showed damage to the windscreen and the inboard leading edge of the right wing. The elevator restriction was caused by the high frequency radio aerial becoming entangled in the tail plane. The aerial had been severed by the door as it departed the aircraft. Inspection of the damaged door frame and hinge, showed that both door locks were capable of functioning correctly and were undamaged, indicating that the locks might not have been fully engaged prior to take-off. Cessna issued Service Bulletin CQB87-1 on 22 May 1987 which made available a kit for the fitment of a secondary latch for the nose baggage compartment doors, to assist in preventing opening in the event the primary latch failed or was not properly secured. A secondary latch had not been fitted to this particular aircraft.

Significant Factors:

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

1. The precise sequence of events, resulting in the right nose luggage compartment door opened during flight could not be established.

2. Air loads on the open nose luggage door, resulted in the door separating from the aircraft.

Occurrence summary

Investigation number 198903806
Occurrence date 06/09/1989
Location Mackay
State Queensland
Report release date 28/02/1990
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 Cessna Aircraft Company
Model 441
Registration VH-NIF
Serial number 441-0232
Sector Turboprop
Operation type Charter
Departure point Mackay QLD
Destination Proserpine QLD
Damage Substantial

Cessna 441, VH-TFW, Brisbane Airport QLD, 18 December 1988

Summary

The pilot noticed that during the descent and instrument approach the windscreen had become fogged up by condensation on the internal and external surfaces. Cabin temperature had been maintained at about 30 degrees Celsius during the flight in an attempt to reduce this effect. The weather at Brisbane at the time was drizzle with visibility reduced to 5000 metres, cloud 5 octas of stratus at 600 feet, 5 octas of stratus at 1000 feet, and 6 octas of strato cumulus at 1500 feet. Relative humidity was 95 per cent. After landing on runway 19, the aircraft was slowed to a slower than normal taxiing speed, due to the reduced visibility, and was taxied off the runway via taxiway "Alpha 5". The aircraft was not fitted with a windscreen defogger blower, which necessitated wiping the inside of the windscreen clear with a cloth in an attempt to improve visibility. There was no means of clearing the external surface. The aircraft was starting a right turn to enter taxiway "Bravo 5" when the Surface Movement Controller requested the pilot to enter the apron behind a Boeing 727 which was under tow. The pilot was unable to sight the Boeing 727, and forward visibility was severely reduced at that time by the effect of the bright apron floodlighting, which the pilot was facing. The result was, that after entering "Bravo 5", the aircraft ran off the taxiway, crossed the grass verge, and came to rest in a 2 metre deep drainage channel.

Occurrence summary

Investigation number 198803507
Occurrence date 18/12/1988
Location Brisbane Airport
Report release date 14/04/1989
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Accident
Highest injury level Minor

Aircraft details

Manufacturer Cessna Aircraft Company
Model 441
Registration VH-TFW
Serial number 4410023
Operation type Air Transport Low Capacity
Departure point Thangool QLD
Destination Brisbane QLD
Damage Substantial

Boeing 767, ZK-NBC, 7 km South of Essendon VIC, 13 May 1987

Summary

The aircraft was radar-vectored for an approach to Melbourne (Tullamarine) Runway 34. At the time the weather was overcast, with scattered cloud down to 1000 feet above ground level. Cloud and rain affected flight visibility and interfered with the radar display of aircraft position. The flight crew reported they were "visual" when at 2000 feet and about 17 kilometres (9 nautical miles [nm]) south east of Melbourne. The Approach Controller advised the flight of its radar position in relation to Melbourne and requested confirmation that the crew had Runway 34 in sight. When this was acknowledged, instructions were given for the flight to take up a heading of 320 degrees; to intercept the extended centre line of Runway 34 from this heading; and to make a visual approach. Shortly afterwards the Tower Controller at Essendon Airport (5 nm south east of Melbourne) called the Melbourne Approach Controller and reported that a heavy aircraft was on approach for (Runway 35) Essendon. The Approach Controller called the aircraft, requested its present altitude and, on being advised it was "through fifteen hundred" (feet), instructed the flight to climb to 2000 feet and turn left onto a heading of 320 degrees. He also advised that the aircraft was 7 nm south east of Melbourne and still two miles to the right of the runway centre line. Shortly afterwards, the flight crew reported they were at 2000 feet and had "Runway 34 Melbourne in sight". The aircraft was then cleared for a straight in approach and for transfer to the tower frequency. The aircraft landed without further incident. Subsequent readout of the radar recording and the airborne Flight Data Recorder indicated that when the initial clearance for a visual approach was given the aircraft turned onto the required heading of 320 degrees, but very shortly afterwards turned right, in line with Runway 35 at Essendon. The flight crew have confirmed that they initially turned towards Essendon but detected their error at about the time the Approach Controller instructed them to turn (back) to 320 degrees and to climb. The Flight Data Recorder showed that the aircraft reached a minimum altitude of 1280 feet (above mean sea level) about 6 nm from Melbourne. The aircraft then began to gain altitude. There have been a number of instances where Essendon has been mistaken for Melbourne. The two airports are in close proximity and have similar runway configurations. In this instance the flight crew members were not very familiar with the Melbourne area or with the approach to Runway 34. The visibility was poor and a visual approach was undertaken from a point about 9 nm from the runway. The Fentons Hill VOR (to the north of Melbourne) was not utilised to assist the crew with interception of the Runway 34 extended centre line.

Reccomendations:

It is recommended that consideration be given to the following 1 Operators briefing the relevant flight crews on the real possibility of misidentifying the two airports. 2 Operators instructing flight crew to make full use of available radio aids on visual approaches to Melbourne. 3 The Department of Aviation providing visual and/or radio aids to assist ready identification of Runway 34, such as sequenced strobe lights leading to the threshold and/or an instrument approach facility to the south of the airport.

Occurrence summary

Investigation number 198701609
Occurrence date 13/05/1987
Location 7 km South of Essendon
Report release date 10/06/1987
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 The Boeing Company
Model 767
Registration ZK-NBC
Operation type Air Transport High Capacity
Departure point Wellington NZ
Destination Melbourne VIC
Damage Nil

Cessna 152, VH-RNE, 85 km NNW Bundaberg QLD, 14 June 1988

Summary

The pilot had filled the aircraft tanks prior to flying from Rockhampton to Bowen. The stated endurance from Rockhampton was 430 minutes. During the return flight he amended the flight plan by radio and continued the flight towards Bundaberg. The pilot estimated that the aircraft contained about 100 litres of fuel at Bowen and said the gauges indicated that the tanks were about half full overhead Rockhampton. He said that they were indicating about a quarter and a third full over Gladstone. After passing Gladstone both gauge indications moved rapidly towards empty. A descent for a precautionary landing was commenced. The pilot found a suitable area for landing, and commenced an inspection at about 200 feet above ground level when the engine stopped. The aircraft was landed in tall grass and overturned at the end of the landing roll. The accident occurred after about 380 minutes of engine running time, which included 366 minutes of flight time. Investigation of the fuel system failed to disclose any evidence of fuel leaks. The pilot's fuel calculations were based on lower fuel consumption rates than would be expected, given the speed at which the aircraft cruised. This resulted in the planned endurance being greater than the actual endurance possible. In addition to this error, the pilot had planned a flight duration which would have resulted in the aircraft having less than the planned fixed reserve on board on arrival at Bundaberg. This accident was not the subject of an on-site investigation.

Occurrence summary

Investigation number 198803462
Occurrence date 14/06/1988
Location 85 km NNW Bundaberg
Report release date 28/02/1989
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 152
Registration VH-RNE
Serial number 15281093
Operation type Business
Departure point Bowen QLD
Destination Bundaberg QLD
Damage Substantial

Piper PA-31, VH-DER, Marble Bar, Western Australia, on 30 September 1990

Summary

Circumstances:

The aircraft entered the circuit, on the crosswind leg, for a normal approach and landing. The downwind checks were started abeam the upwind end of the airstrip with the pilot referring to a printed roller style check list. The first check, flaps selected to first stage, was carried out normally. Although the pilot lowered full flap during the approach, no other checklist items were completed. The aircraft landed with the landing gear retracted. The investigation indicated that the prime factors leading to this accident were pilot fatigue and channelised attention. The pilot's sleeping patterns had been disrupted during the five days preceding the accident because of health problems with his children. He was awoken five to six times each night and the pilot's longest period of rest, during the evening prior to the accident, was three hours. The pilot reported that he was not aware that he might have been suffering from fatigue and he had not thought to draw his supervisor’s attention to his lack of regular sleep. On arrival over Marble Bar the pilot observed a 20-25 knot wind which required a landing on an airstrip he had only used once before. The pilot concentrated on his approach and landing, in the strong wind conditions, and it is likely that this coupled with fatigue led to his failure to complete his prelanding checks. A higher-than-normal power setting was used during the final approach, and the landing gear warning horn did not sound until the throttles were closed during the flare. Even when the horn sounded the pilot did not associate it with the landing gear position but instead wondered why the stall warning had sounded at such an early stage in the landing. The pilot advised that the landing gear warning horn was not sufficiently distinctive and, as a result, it did not alert him to the approaching problem.

Significant Factors:

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

1. The pilot was probably suffering from sleep pattern related fatigue however he was not aware of this, nor did he think to draw his supervisor’s attention to a possible potential problem.

2. The pilot’s attention was channelled towards the approach and landing on an unfamiliar strip in strong wind conditions.

3. The distraction of the approach and the pilot's fatigue probably led to his failure to complete all the necessary check list items and the aircraft landed with the landing gear retracted.

4. The landing gear warning was not distinctive enough to warn the pilot of impending disaster. This accident was not the subject of an on-scene investigation.

Occurrence summary

Investigation number 199000102
Occurrence date 30/09/1990
Location Marble Bar
State Western Australia
Report release date 27/11/1990
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 Piper Aircraft Corp
Model PA-31
Registration VH-DER
Serial number 31-7912110
Sector Piston
Operation type Aerial Work
Departure point Port Hedland WA
Destination Marble Bar WA
Damage Substantial

Cessna 210, VH-TIU, "Wirribilla" 22 km North of Mt Sandon NSW, 18 October 1989

Summary

In the circuit area while making an approach for landing the pilot allowed himself to become distracted by the dry conditions of his property and did not complete the prelanding checks or extend the landing gear. He did not hear the landing gear warning horn during the landing flare. After touching down the aircraft slid straight for 60 metres. The pilot was not injured and damage to the aircraft was confined to bent propeller blades and distorted lower fuselage structure. The landing gear warning system was found to be serviceable during a functional check of the system at the accident site. The reason why the landing gear warning horn was not heard by the pilot during the landing flare could not be determined. This accident was not the subject of a formal on-site investigation.

Occurrence summary

Investigation number 198900018
Occurrence date 18/10/1989
Location "Wirribilla" 22 km North of Mt Sandon
Report release date 07/11/1989
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 Cessna Aircraft Company
Model 210
Registration VH-TIU
Serial number 21062324
Operation type Private
Departure point Maitland NSW
Destination Wirribilla NSW
Damage Substantial

Piper PA-30, VH-WVL, Canberra Airport, Australian Capital Territory, on 7 July 1989

Summary

Circumstances:

The pilot had considerable rotary wing but limited fixed wing experience, was undergoing type endorsement training. He was carrying out touch and go landings under instruction on runway 30, with a wind of 300/12 gusting up to 22 knots. After completion of a touch and go, it is probable that the landing gear was raised inadvertently, and the aircraft settled back onto the runway. The right and left main landing gear push rods, the landing gear mounting brackets and the landing gear motor mounting brackets were damaged at that time and both propellers touched the runway surface. The instructor took control, the landing gear was selected up, however the gear in transit light remained on. A fly past the tower confirmed that the right landing gear was hanging at about 45 degrees. While performing the emergency lowering procedures, it was noted that the landing gear motor circuit breaker had popped. The mirror showed the nose gear locked down, but a green light could not be obtained. An approach and landing was then made on the grass parallel with runway 30. Both main landing gear collapsed on touch down although the nose gear remained down and locked. The aircraft skidded for about 250 metres and stopped upright.

Significant Factors:

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

1. The pilot was inexperienced on fixed wing aircraft.

2. Inadequate supervision by the instructor.

3. The landing gear was retracted early.

4. Gusting wind conditions resulted in the aircraft settling back onto the runway.

Occurrence summary

Investigation number 198900012
Occurrence date 07/07/1989
Location Canberra Airport
State Australian Capital Territory
Report release date 16/08/1990
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 Piper Aircraft Corp
Model PA-30
Registration VH-WVL
Serial number 30-1986
Sector Piston
Operation type Flying Training
Departure point Canberra ACT
Destination Canberra ACT
Damage Substantial

Bell 206 B, VH-TFH, 170 km SE of Tindal NT, 13 September 1988

Summary

The pilot was engaged in a stream sampling operation. He reported that he was flying at an airspeed of about 20 knots at about 100 feet above the ground when sudden sink was encountered. Power was increased and the descent was arrested, but the main rotor blades struck a dead branch protruding from a tree. The low rotor rpm warning sounded, and the pilot reduced the power and autorotated to a clear area for a safe touchdown. The sink had been experienced in gusty crosswind conditions, while the pilot had been operating at a relatively low power setting. Post flight inspection revealed that the tail rotor had also received damage, probably caused by debris from the branch struck by the main rotor blades.

Occurrence summary

Investigation number 198800731
Occurrence date 13/09/1988
Location 170 km SE of Tindal
Report release date 06/05/1989
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Accident
Highest injury level None

Aircraft details

Manufacturer Bell Helicopter Co
Model 206
Registration VH-TFH
Serial number 1746
Sector Helicopter
Operation type Aerial Work
Departure point Hodgson River Station NT
Destination Hodgson River Station NT
Damage Substantial

Cessna 182, VH-DGG, Murgoo Homestead (230km NE Geraldton) WA, 18 September 1988

Summary

The aircraft had arrived at it's destination and was on final approach when it was subjected to the effects of a downdraught, followed by an updraught. The pilot elected not to overshoot from the approach but attempted to regain the normal glide path by using varying power applications. Wind considerations required that the approach be made into the setting sun and as the windscreen was covered with oil from a leaking oil cooler, the pilot's forward visibility was significantly reduced. This resulted in the aircraft touching down well into the strip. When the brakes were applied, there was no response from the right brake. The pilot was able to avoid some trees in his path but he was unable to avoid ruts on the road at the end of the strip. Had the aircraft touched down at the approach end of the strip it is likely that the pilot would have been able to stop the aircraft, within the confines of the strip, with the limited braking that was available. Had the brakes operated normally the pilot should have been able to stop, within the confines of the strip, even though the aircraft touched down well into the strip. This accident was not the subject of an on-scene investigation.

Occurrence summary

Investigation number 198800132
Occurrence date 18/09/1988
Location Murgoo Homestead (230km NE Geraldton)
Report release date 13/03/1989
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 182
Registration VH-DGG
Serial number 182-55756
Operation type Business
Departure point Tardie Station WA
Destination Murgoo Homestead WA
Damage Substantial

Cessna 188, VH-RBX, Wallaroi (5 km SE Goondiwindi) NSW, 7 May 1988

Summary

The pilot was very experienced, having been an agricultural pilot for a considerable number of years. He had been aerial spraying a paddock for weed prevention with a herbicide, flying in a south to north direction, and passing under power lines which crossed the paddock from east to west.

The aircraft was observed to strike the power lines with the tip of its fin, causing the empennage to separate from the fuselage. The aircraft then dived into the ground approximately 50 metres beyond the power lines, bounced back into the air and slid for another 47 metres with the engine, propeller and right hand fuel tank separating from the aircraft. The fuel tank exploded and set fire to the grass on the steep slope of a creek bed, next to where the aircraft came to rest. The pilot received minor injuries as a result of the impact, but was able to remove himself from the aircraft without help. He then slipped on the steep angled wing-walk and fell into the fire, receiving severe burns to the areas of arms and legs not covered by clothing. There was no medical evidence indicating that the pilot had been effected by the herbicide before the accident. This type of aircraft has been the subject of many wire strikes to the fin, as it is higher than the propeller arc in level flight, and pilots can misjudge its position.

This occurrence was not the subject of an on-site investigation.

Occurrence summary

Investigation number 198802364
Occurrence date 07/05/1988
Location Wallaroi (5 km SE Goondiwindi)
Report release date 31/08/1989
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Wirestrike
Occurrence class Accident
Highest injury level Serious

Aircraft details

Manufacturer Cessna Aircraft Company
Model 188
Registration VH-RBX
Serial number 188-0123
Operation type Aerial Work
Departure point Wallaroi NSW
Destination Wallaroi NSW
Damage Destroyed