Beech D-55, VH-MNJ, 25 km N Maroochydore QLD, 24 September 1989

Summary

Passengers reported that after takeoff, there had been a high pitched noise and that a gap had appeared around the top edge of the forward cabin door. The pilot, who was wearing headphones, indicated that he did not hear the noise and was unaware of the gap at the top of the door. A female passenger was seated in the front right seat beside the pilot and adjacent to the door. She was partially resting against the door, watching the terrain below. Her lap harness was secured. Shortly after the pilot commenced descent from 7000 feet, there was a loud bang and the door opened. The events which accompanied, and immediately followed the door opening occurred quickly and could not be determined precisely. However, the female passenger claimed that the door opened 30-40 centimetres, that her right hand contacted the upper surface of the wing, and that her head and shoulders were outside the cockpit. Two articles of clothing she was holding were lost overboard. The male passenger seated directly behind the female passenger thought that the door had opened fully and that the passenger fell so that her upper body was partially outside the cockpit. The pilot reported that he thought the door had popped open only 10-15 centimetres. The male passenger said that he reached around the seat to assist the female passenger and that she then leaned away from the door and held on to the back of the pilot's seat. As the aircraft was slowed to 90 knots, he and the pilot attempted to close the door without success. The pilot then decided to land the aircraft at Maroochydore. The male passenger held the door until the aircraft landed. On a rriva l at M aroochy dor e, the pil ot operated t he door loc king mecha nism a num ber of times an d, as i t appeared t o be fu ncti oning nor mal ly, he ele ct ed to continue the flig ht. The ma le pass en ger offe red to take t he fem al e pas se nger's place in the front rig ht seat adja cen t to the doo r bu t the off er wa s declined. Soon aft er de part ing Maro ochy dor e on the shor t flig ht to Brisban e, a gap again appeared around the top of the door accompanied by wind noise. The female passenger held the door closed until the aircraft landed at Brisbane. The maintenance organization which rectified the fault reported that the upper lock was out of rigging such that it was not held over-centre sufficiently to allow for fuselage flexing in flight. The cable was adjusted and the aircraft returned to normal flight status. The effect on the sequence of events, if any, of the female passenger leaning against the door was not determined. The cause of the the female passenger's injuries was not established. This occurrence was not the subject of an on-site investigation.

Occurrence summary

Investigation number 198904200
Occurrence date 24/09/1989
Location 25 km N Maroochydore
Report release date 17/10/1989
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 Beech Aircraft Corp
Model 55
Registration VH-MNJ
Serial number TE-624
Operation type Charter
Departure point Rockhampton QLD
Destination Brisbane QLD
Damage Nil

Boeing 737, YU-AND, Adelaide SA, 20 November 1989

Summary

The aircraft had been cleared via a Standard Instrument Departure which required the aircraft to turn at three miles by Distance Measuring Equipment (DME) onto a heading of 170 degrees and to reach 2500 feet or above by 5 DME. The aircraft was to maintain heading 170 degrees until 7 DME, then turn onto a heading of 065 degrees to intercept the departure track. However, the aircraft was observed to turn at 3.5 miles onto a north-easterly heading and track to intercept the departure track. This was the first time the Captain had flown out of Adelaide, however, he was familiar with Standard Instrument Departures, having flown similar procedures overseas. On this occasion the Captain was concerned that he complied with the minimum altitude requirement and concentrated on this aspect to the detriment of the rest of the procedure.

Occurrence summary

Investigation number 198901010
Occurrence date 20/11/1989
Location Adelaide
Report release date 29/11/1989
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 The Boeing Company
Model 737
Registration YU-AND
Serial number N/K
Operation type Air Transport High Capacity
Departure point Adelaide SA
Destination Sydney NSW
Damage Nil

Cessna 404, VH-SBG, Kowanyama, Queensland, on 25 January 1990

Summary

Circumstances:

During the take-off run, as power was being increased, the nose wheel broke through the runway surface and the nose gear leg collapsed. The central area of sections of the runway had previously been filled with coarse river gravel. This fill had then been overlaid with finer material and bonded with an oily fluid. When the aircraft broke through the top crust, the wheels sank readily into the gravel, and the nose leg was torn from the aircraft.

Significant Factors:

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

1. The runway surface was of inadequate strength for the operation.

2. Overload failure of nose gear mounting. This accident was not the subject of an on-scene investigation.

Occurrence summary

Investigation number 199003046
Occurrence date 25/01/1990
Location Kowanyama
State Queensland
Report release date 13/12/1990
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 404
Registration VH-SBG
Serial number 404-0095
Sector Piston
Operation type Charter
Departure point Kowanyama QLD
Destination Normanton QLD
Damage Substantial

Bell 47-G2, VH-JCN, Moorabbin VIC, 5 March 1988

Summary

As the pilot lifted the helicopter into the hover he felt an unusual vibration and was unable to prevent an immediate turn to the left. Shortly afterwards the nose of the helicopter pitched up and down sharply and the tail rotor guard struck the ground two or three times. The guard broke and portions of the tail rotor blades were torn off. The helicopter then landed heavily, damaging the landing skid. Engineers found no significant fault with the helicopter. It is highly probable that the pilot took off with the hydraulic assist to the cyclic control inadvertently selected off. This helicopter has an electrical on/off hydraulic switch which is not common on the Bell 47-G2. The pilot was more familiar with the mechanical on/off system. He may have been distracted from completing his pre-take-off checks by explaining them to the passenger. With hydraulics selected off, feed back forces occur through the cyclic control; this could be felt as an unusual vibration. Because of the feed back forces, the pilot began to overcontrol the helicopter thereby causing him to channelize his attention to the cyclic control to the detriment of directional control. Although the pilot had been trained in "hydraulics off" emergency procedures in flight he had never before experienced lifting a helicopter into the hover with the hydraulics selected off.

Occurrence summary

Investigation number 198801385
Occurrence date 05/03/1988
Location Moorabbin
Report release date 09/08/1988
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 Bell Helicopter Co
Model 47
Registration VH-JCN
Serial number 2556
Sector Helicopter
Operation type Private
Departure point Moorabbin VIC
Destination Government House, Melbourne VIC
Damage Substantial

Cessna 152, VH-WLA, Geelong Airport, Victoria, on 1 September 1990

Summary

Circumstances:

The solo student pilot was conducting left-hand circuits on runway 27 in a westerly wind of about 15 knots. When he transmitted his "base" call on VHF frequency 119.1, he neither heard nor saw another aircraft in the circuit. During the landing roll he realised he was on a collision course with a Piper PA28 which had landed on runway 36. He applied brakes and veered left while attempting to avoid a collision. At the runway intersection both aircraft missed each other by about one metre. After the near-miss the student applied full power for a go-around but his aircraft veered further left. As he attempted to steer back on to runway 27, the left side of the horizontal stabiliser struck the airfield boundary fence. The pilot of the Piper PA28 was conducting an Instrument Flight Rules flight via Avalon. The PA28 was equipped with only one VHF radio. The pilot said that while still in the Avalon control zone he called Geelong on 119.1 to advise his ETA. He said he was told the wind was westerly but could not recall being advised of traffic. He then returned to Avalon tower frequency. Geelong Airport personnel said the pilot was advised that the duty runway was runway 27 and that there was a Cessna 152 operating in the circuit. As 119.1 is not recorded it was not possible to check exactly what was said. Passing Avalon control zone boundary (approximately nine kilometres north of Geelong) the pilot selected the Melbourne area frequency 124.9 and remained on 124.9 for the arrival at Geelong. Flight Service advised of following traffic also destined for Geelong. The PA28 joined on downwind for a right circuit for runway 36. On the downwind leg, the pilot saw a Cessna to the left and about 400 feet below. He thought this aircraft was in transit whereas it was actually on the base leg for runway 27. He had no further sighting of the Cessna until established on the landing roll, at which time the PA28 passenger gave warning of a possible collision.

Recommendations:

It is recommended that the Civil Aviation Authority clarifies the practice of using 119.1, particularly at Authorised Landing Areas, and produces relevant documentation for pilots.

Occurrence summary

Investigation number 199001155
Occurrence date 01/09/1990
Location Geelong Airport
State Victoria
Report release date 15/05/1991
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 Cessna Aircraft Company
Model 152
Registration VH-WLA
Serial number 15282749
Sector Piston
Operation type Flying Training
Departure point Geelong Airport VIC
Destination Geelong Airport VIC
Damage Substantial

Loss of control Gyrocopter, Deeral (16 km north of Babinda), Queensland, on 12 August 1989

Summary

Circumstances:

The pilot had owned the gyrocopter for some time but had flown it infrequently due to engine tuning problems. On previous flights, the pilot had flown from a larger strip near Innisfail. Since then, he had enhanced the engine instrument cluster to better monitor the performance of the turbocharged engine. The pilot's intention was to test the new instrument installation at the smaller Deeral strip before proceeding to the larger strip for further flying practice. He had planned to make six runs along the 500 metre long strip without becoming airborne, with a 15-knot crosswind. On the fifth run, the witness noticed that full power was applied for much longer than on the previous runs. The aircraft accelerated to flying speed and became airborne. At a height of about six feet above the strip, the pilot appeared to experience some difficulty with the crosswind. The gyrocopter banked and yawed to the right, it then dived into the ground, and cartwheeled forward before coming to rest in a drain.

Significant Factors:

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

1. The pilot was inexperienced.

2. The wind conditions were unsuitable for the operation attempted by the pilot.

3. The pilot lost control of the aircraft due to crosswind and turbulence.

Recommendations:

In this accident the pilot may not have been injured as seriously if he had been using a harness which prevented him from sliding forward underneath and out of the harness. A five or six point harness with a crotch strap would have held the pilot in his seat where the surrounding structure would have offered more protection.

1. It is recommended that the Sport Rotorcraft Association of Australia should disseminate information to its members on the advantages of using seat belts with additional mounting points.

Occurrence summary

Investigation number 198903857
Occurrence date 12/08/1989
Location Deeral (16 km north of Babinda)
Report release date 28/02/1990
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 Fatal

Aircraft details

Manufacturer JRM Helyplanes
Sector Piston
Operation type Sports Aviation
Departure point Deeral QLD
Destination Deeral QLD
Damage Substantial

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