The aircraft Captain had received a Garuda Route Clearance Unit presentation on the Perth route prior to departure from Bali and he had made one previous flight into Perth as the First Officer on a DC-10 in May 1988. After an evidently uneventful flight the aircraft was making an approach to Runway 03 at Perth. The cloud base at the time was approximately 800 feet above sea level. Air Traffic Control had used radar vectoring to position the aircraft for the approach and the crew was then instructed to make a pilot intercept of the appropriate radial from the Perth VOR. The aircraft did not accurately follow the required radial and the aircraft diverged up to about one kilometre either side of the published final approach path. The First Officer who was visually monitoring the approach was unable to sight the runway lighting and an overshoot was commenced when the aircraft was about three kilometres from the runway threshold. At about the same time as the Captain commenced his overshoot procedure the Perth Tower controller who had monitored the aircraft's approach from the time it had descended below the cloud base decided that the aircraft was not in a position to make a normal landing. He therefore instructed the aircraft to overshoot. The subsequent approach and landing were without incident. The investigation revealed that the details of the approach published by the Jeppesen Company in the USA contained an error of 5 degrees in the direction of the VOR radial required for the final approach path for the particular runway. These approach details were contained in company documentation available to the crew. Whether this error had any relevance to the incident circumstances was not established. It was noted that there are areas of significant lighting in the vicinity of Perth Airport which could hamper visual acquisition of the runway lighting under conditions of poor visibility. A precision approach aid such as ILS is not available for Runway 03 and runway approach lighting is not installed.

Circumstances:

The aircraft was climbing 600 ft after take-off when the pilot noticed a buzzing noise. While attempting to isolate the source of the buzzing two loud bangs were heard the right engine fan RPM reduced to zero and the generator dropped offline. Sparks and flames were seen in the right engine inlet area. The pilot shut down the right engine and executed a single engine landing. Initial investigation showed that the low compressor stator had ejected through the compressor casing with parts of the engine and cowlings falling into a residential area. This examination revealed that the low compressor stator also known as the fan stator had been rotated at high speed. The resultant high heat and milling action cut and severed the fan casing which dropped into the fan with destructive results. The stator had split and ejected through the severed case. The outer ring of the stator is positioned axially by mating snaps and is anchored against rotation by a series of 1/16 inch rivets. These rivets had sheared allowing the fan air flow to rotate the stator. The manufacturer advised that they had received reports of occasional loose or missing rivets and had also experienced two previous incidents of total rivet shear associated with stator spin but without the major break-up that occurred in this instance. Rivet failure has been attributed to a resonant condition in the fan area occurring at transient rotor speeds. It is also suspected that foreign object damage (FOD) and birdstrikes could by introducing a single event overload be a contributory factor. One of the two previous stator spin incidents occurred concurrent with a multiple bird strike. The failed engine suffered a bird-strike incident in June 1989. A visual and borescope inspection in accordance with the manufacturer's requirements found no evidence of damage. The engine was internally washed and then satisfactorily test run. It operated for a further 580 cycles and 620 hours before the rivet failure. The manufacturer has introduced two Service Bulletin (SB) modifications in an endeavour to rectify the rivet failures. SB7264 replaced the 1/16-inch rivets with 1/8-inch rivets and SB7268 fitted a silicon vibration dampening ring to the outer periphery of the fan case. Both recommended accomplishment when disassembly afforded access to the area; however, neither was mandatory.

The failed engine was fitted with the silicon vibration dampening ring whilst undergoing the bird-strike inspection some 16 months prior to the incident. However, the larger rivets had not been incorporated as the area had not been opened up since the SB was issued in January 1988. The rivets had not been closely inspected while the engine was in service because a rivet inspection was not specifically called for in the maintenance schedules nor was it listed as a requirement of the FOD/bird-strike inspection. The SBs themselves did not alert operators to the potential for rivet failures, nor did they advise that rivet failures had occurred in service. The rivet replacement SB did not list the engines to which it was applicable. Accordingly, the maintenance organisation responsible for this engine would not necessarily have been alerted that this engine was among those that needed to have the smaller rivets replaced. The reasons given for introducing the vibration dampening ring and for replacing the rivets were unlikely to alert maintenance organisations to the importance of the rivet replacement nor would they be sufficient to initiate specific inspection of these rivets during routine maintenance or bird-strike inspections. As a result of this incident the manufacturer recognised the possible effects of minor bird strikes on the stator securing rivets and called for a field inspection of the subject rivets. Out of 452 responses 43 (9.5) indicated some form of rivet discrepancy. There were no reports of discrepancies with the modified rivets. The manufacturer has revised Service Bulletin SB7264 to upgrade the compliance recommendation such that the rivet replacement be accomplished at either the first workshop visit or prior to the next flight following any foreign body ingestion. The manufacturer also issued specific instructions for inspection of the rivets which will be incorporated into the maintenance manuals and revised the format for Service Bulletins so as to provide operators with more details of the required maintenance action.

Significant Factors:

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

1. Engine design efficiency.

2. The rivets securing the low-pressure compressor stator had a history of failure.

3. The engine had previously suffered a bird-strike incident.

4. The rivets were not inspected as there was no requirement to do so.

5. The rivets were not replaced as the engine had not been subjected to the compliance requirement.

6. The rivets securing the low-pressure compressor stator failed.

7. The engine was severely damaged when the low-pressure compressor stator rotated at high speed and severed the compressor casing.

The pilot completed his pre-takeoff checks before launching for a local flight. He subsequently advised that while he was manoeuvring behind a glider ahead of him in the circuit the canopy rattled and flew open. He was unable to close the canopy and shortly afterwards it tore free from the glider structure. A successful and uneventful landing was then carried out. Investigation revealed that it was possible to close the canopy locking handle fully without the locking pins engaging in the lock studs. In this type of glider the unsecured canopy was then not easy to detect from inside the cockpit. The pilot had limited experience on type and was not aware of the difficulty in detecting an unsecured canopy. Physical checks for canopy security by pushing on the canopy were discouraged by the gliding club for fear of damage. The launching crew had not noticed that the canopy was unlocked during the hookup procedures.

Surface conditions were; strong south-easterly winds of 30 knots with gusts to 40 knots, water surface choppy. The pilot made three unsuccessful attempts to align the aircraft for a takeoff. On his fourth attempt he was successful and the takeoff run was commenced. Shortly afterwards, a gust of wind lifted the left wing, the right float dug into the water, and the aircraft nosed over. Both occupants swam clear of the aircraft which had come to rest upside down on a submerged mudbank. The takeoff attempt had been made on the town reach of the river in a crosswind. An into-wind takeoff would have been possible if the pilot had taxied the aircraft to the next reach of the river.

The touchdown was reported as being smooth but during the landing roll, just after braking was commenced, the right mainwheel and strut came free of the aircraft. The strut bounced and struck the right horizontal stabiliser, severing a large section of it. The aircraft slewed to the right before running off the strip into trees. Inspection of the aircraft revealed that the bolt holding the landing gear strut to the inboard gear mounting assembly had failed. The failure resulted from fatigue, believed to have been initiated by a heavy loading applied to the bolt some time previously.

Circumstances:

The pilot was tasked to lift bundles of steel rods about 100 metres to the top of a small knoll. He briefed a fellow fixed wing pilot on hooking procedures and, as no lifting devices were available at Yalara, instructed him to wrap the load's chain twice around the hook to form a loop and prevent the load from slipping. The accident occurred on the second flight to the knoll. As the helicopter began to move forward, a partial power failure was experienced. The front of the load then dug into the ground and the rear swung up until it struck the tail rotor. The helicopter began to rotate to the left followed by a left roll. The pilot rapidly applied full right cyclic to level the helicopter before it struck the ground. During the sequence, the pilot attempted to release the load three or four times using the electric release button. He then reached for the manual release handle but was unable to operate it before the helicopter struck the ground. The helicopter had a history of recent, unreported engine chip detector warning light illuminations which included at least one precautionary landing. It also had a history of high engine oil consumption which was supported by the high level of sooting on the exhaust stacks. The absence of engine oil in the oil tank and the pilot's reported grinding feeling through the airframe indicate a malfunction with the engine. A specific reason for the power failure could not be determined, although the fuel system was found to be in a very poor condition and a section of the drive spline for the power turbine governor was missing.

Significant Factors:

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

1. The helicopter had a history of unreported engine chip detector light warnings and high engine oil consumption.

2. The pilot was tasked to conduct a hook operation without the correct equipment being supplied.

3. The helicopter suffered a partial power failure.

4. The load support chain jammed in the hook, and the load could not be released.

5. The helicopter's tail rotor struck the load, and the helicopter struck the ground heavily.

When the pilot was about 600 feet above the ground he realized that he was committed to an outlanding. He noted that the selected paddock had one set of powerlines parallelling his intended landing direction. On short final at about 100 feet above ground level the pilot saw a second powerline obliquely crossing the intended landing path. He turned right and carried out a landing in another paddock. The glider landed downwind and the pilot initiated a groundloop in an attempt to avoid a collision with a fence. The manoeuvre was not successful and the glider came to rest straddling the fence. The pilot had evidently delayed his planning for an outlanding until the glider was substantially below the minimum height of 2000 feet recommended by the Gliding Federation.

The helicopter was operating just above trees with little forward speed when the engine gradually lost power. The pilot was forced to attempt to land in an area covered with small trees. The engine stopped after the main rotor blades struck foliage and the helicopter fell heavily on its skids, which collapsed. The helicopter subsequently caught fire and was burnt out. Examination of the engine discovered that the number two big-end bearing had failed. It was also noted that the engine was internally damaged by pre-crash overheating and scoring. The reason for this damage could not be determined.

The pilot attached his harness hangloops to the retaining strap instead of the keel tube. During a tight turn after takeoff the retaining strap parted due overload and the pilot plummeted onto rocks from approximately 200 feet altitude. The pilotless hang-glider flew into a tree. The retaining strap is a non structural part of the hang-glider designed to stop the hangloops sliding back along the keel tube.

The pilot stated that he rounded out too low, touched down too fast, and the aircraft bounced slightly. He attempted to correct with back pressure on the control column, together with increased nose up elevator trim. The aircraft appeared to climb and the pilot eased the back pressure. The nose dropped, the aircraft touched down again in a flat attitude, and porpoising commenced. After three oscillations the nose gear moved rearwards and upwards, shattering the windscreen, and causing the propellers to contact the runway surface. Investigation revealed that there was an intermittent fault in the elevator trim switch, which caused the trim to move only in a forward direction, irrespective of the selection made by the pilot.