Circumstances:

The pilot had been unable to obtain details of the strip before his departure for the area. On arrival he conducted an inspection of the strip from 500 feet. He noticed that there was no windsock and that a power line had been installed across the northern end since his previous visit. He also noted that the strip changed colour along its length and that vehicles had been driving along it. After this inspection he conducted a landing from the south. On touchdown he saw a bank where the traffic path entered the strip. As it was then too late to initiate a go-around the pilot tried to avoid the bank. This was not successful and the nose gear leg was broken off on colliding with the bank which was about 1.5 metres high. It was determined that the landing area had been de-commissioned about a year earlier.

Significant Factors:

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

1. The pilot did not obtain information from the strip owner or permission to land at the strip.
2. The pilot did not conduct an adequate inspection of the intended landing area.
3. The aircraft was landed on an unsuitable area.

Circumstances:

The aircraft engines performed normally during the run up, taxi and take-off. At approximately 500 feet after take-off, the pilot noticed the right hand engine manifold pressure gauge indication slowly decreasing. Thinking that the throttle friction may have slipped, he advanced the right hand throttle. There was a momentary pause in the decreasing manifold pressure reading. The right hand throttle was gradually advanced to the full power position, however, manifold pressure continued to decay. Following completion of the trouble checks the pilot shut down the right hand engine and feathered the propeller. Because the flight was only a six minute positioning flight, for maintenance purposes and the aircraft was performing to his satisfaction on one engine, the pilot elected to continue to Parafield. He advised air traffic services of the engine failure and of his intention to proceed to Parafield. The aircraft subsequently made an uneventful single engine landing. At the end of the landing roll the pilot who was wearing a headset, heard the fire warning bell. At the same time, he noticed for the first time that the right hand engine bay fire warning light was illuminated. A post-flight inspection revealed substantial fire damage within the right hand engine bay forward of the firewall and a large section of the number four cylinder head was found lying in the lower cowling. The cylinder head had failed at the threaded joint of the head and barrel. Metallurgical examination showed that the fatigue failure had developed over a period of approximately 900 start/stop cycles. However, the development of the crack would probably have been visible to external inspection only during the latter 15 start/stop cycles prior to failure. The failure was probably the result of defective cylinder maintenance and assembly techniques and heat treatment used during overhaul. The engine fire had developed in the vicinity of the failed cylinder and spread throughout the engine bay fed by raw fuel through the cracked cylinder head and burnt fuel lines. It is likely that the fire self-extinguished when the pilot turned the electric fuel pump off and shut the engine down. The engine bay fire warning system apparently activated and because it had not been detected by the pilot, remained activated until after the landing. The warning system did not self-cancel after the fire abated. The aural warning system was found to be inaudible at high power settings and due to the ambient light conditions prevailing during the take-off into bright sun and glare, the steady red fire warning light was not noticed by the pilot. Approved check lists did not include a check of the fire warning system as part of the emergency procedures cockpit drill.

Significant Factors:

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

1. Defective techniques used during cylinder assembly maintenance and inspection.

2. Cockpit visual fire warning system for the engine bay operated but was not evident to the pilot under the ambient light conditions.

3. Aural fire warning could not be heard at high power setting.

4. Aural fire warning bell was not connected to audio system.

5. Aircraft emergency procedures check list did not specify pilot monitoring of fire system following engine failure.

Recommendations:

1. That the Civil Aviation Authority give consideration to: Improving surveillance of maintenance organisations where cylinder heads and barrels are separated by heat treatment with particular emphasis on:

a) techniques used in the control of heat processes during strip down and reassembly procedures such that temperatures attained do not cause softening of the alloy, and

b) reminding maintenance personnel of the necessity to maintain due care during the disassembly and reassembly stages of cylinder overhauls where heating is required, and

c) achievement of sound inspection techniques and practices.

2. Ensuring that general aviation aircraft equipped with on-board fire detection and extinguisher systems are able to provide the pilot with such vital information concerning an in-flight engine fire by:

a) changing any steady fire warning light/s to a flashing red indication;

b) ensuring that such red fire warning light/s are ergonomically placed in the pilot field of vision to permit immediate recognition of activation;

c) ensuring that where an aural fire warning system is incorporated, the minimum volume be adjusted such that it be audible under all power settings with and without noise suppressing headsets;

d) conducting a study of the feasibility of incorporating an aural fire warning alarm for reproduction through the cockpit audio system; and

e) amending emergency procedure check lists to incorporate a check of the fire alarm system where fitted.

The pilot had been conducting a six and a half hour low level survey flight. He stated that on joining the circuit, at the completion of the flight, he lowered the landing gear and obtained a gear down indication. The gear indication was again checked on final approach but during the subsequent landing roll, as the nosewheel was being lowered to the runway, the landing gear handle in the cockpit sprung to the up position. The landing gear retracted and the aircraft slide to a halt on its undersurface. An inspection of the aircraft could find no pre-impact defect with the landing gear or its systems which could have contributed to this inadvertent retraction. The landing gear was found to be capable of normal operation. The reason for the selector deselection remains undetermined.

The pilot was conducting a short cross country flight. As he approached the end of the final leg he realised that there was insufficient height available for the aircraft to make a safe landing at the destination aerodrome. A decision was made to attempt an out-landing as the aircraft passed through 1200 feet on the descent. At that height the choice of fields was restricted and the one that was chosen for the landing was unsuitable. The landing area was covered with long grass and sloped downwards and from right to left. A shallow gully also crossed the area. During the final stages of the approach the right wing touched the ground and long grass causing the aircraft to yaw violently and enter a ground loop. The aircraft finally touched down whilst it was travelling sideways and it came to rest after travelling backwards along the paddock. The pilot was not authorised to conduct cross country flights in the particular aircraft type as he had not completed the required number of flight hours and landings. This accident was not the subject of an on scene investigation.

Circumstances:

On the day of the accident, the pilot took three of her work colleagues on a tour of the mine pits to the North of the camp. When the aircraft returned to the mine's airstrip, the pilot made a low pass over the camp with the canopy fully opened to drop water bombs, before commencing a climbing left turn to rejoin the circuit for a landing. Whilst the aircraft was climbing, the aircraft stalled. The pilot could not regain control before the aircraft collided with the trees. The pilot had been previously instructed not to make low passes over the campsite. The aircraft flight manual indicates that flight with the canopy partly open, but not fully open, is permissible. The effect of a fully opened canopy on the aerodynamics of the aircraft was not determined. The pilot apparently failed to ensure that she maintained a sufficient margin above the stalling speed during the climb out following the pass. This accident was not the subject of an on-scene investigation.

Significant Factors:

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

1. The pilot ignored previous instructions not to make low passes over the campsite.

2. The pilot operated with the aircraft canopy fully open, which may have affected the performance of the aircraft.

3. The pilot failed to maintain adequate airspeed.

4. There was insufficient height available for the pilot to recover before the aircraft collided with the trees.

The pilot and his support crew arrived at the site in the late afternoon and decided to only carry out taxi trials. This was to allow the pilot to get the feel of the controls of his recently purchased, powered hang-glider before flight testing it the next morning. During the last taxi run, it appears that the aircraft became airborne inadvertently. The aircraft climbed steeply to a height of about 150 to 200 feet. Large pitch changes were noted before the attitude stabilised in near level flight. Almost immediately, a shallow right turn commenced which rapidly deteriorated into a descending spiral. The aircraft struck trees and the ground in a vertical dive. Total flight time was 15 to 20 seconds. The pilot had held a Private Pilot Licence some 18 years previously. An offer of flight training had been made by an experienced powered hang-glider pilot, but this offer has been refused because the pilot wanted to teach himself. The control logic of the powered hang-glider was exactly opposite to that of the conventional aircraft on which the pilot had experience.

The pilot was conducting superphosphate spreading operations from a short narrow agricultural strip. During the landing roll on the trip prior to the accident the pilot felt something unusual about the landing gear so he inspected the wheels but found nothing abnormal. The oleos and torque links were not inspected. During the subsequent take off the left mainwheel and oleo strut separated from the landing gear assembly fracturing the hydraulic brake line. The pilot flew the aircraft to his base aerodrome and carried out a landing on the grass strip without further damage. An inspection of the landing gear showed that the left main torque link attachment bolt had failed allowing the oleo and wheel to separate from the landing gear assembly. The bolt was not recovered therefore the precise reason for the failure of the bolt was not determined. The investigation revealed that this is a recurring problem with this aircraft type due to shear load fatigue of the attachment bolt.

The deceased and two of her friends had gone to Toogoolawah to participate in a "First Jump" parachute training course. They arrived at about 0900 hours and after completing registration procedures joined another 18 persons on the 21 student course. The training was initially conducted by a senior parachute instructor until the acting chief instructor and another instructor arrived about an hour later. The course then proceeded under his supervision with the other two instructors assisting. Following the completion of the practical and theory parts of the course a written examination was completed by each of the students and the course was divided into smaller groups for the parachute descent from the aircraft. The first group of eight students successfully completed their descents. The parachutes were repacked and issued to the second group of seven students. Prior to them boarding the aircraft the acting chief instructor, who was performing the duties of the jumpmaster and supervising the descents from the aircraft, checked each student's equipment. When he was satisfied, the students, the jumpmaster and another experienced parachutist boarded the aircraft. The aircraft took off at 1724 hours and climbed to 3000 feet, the planned exit altitude for the students. Two students jumped successfully and the deceased then took up the exit position in the aircraft doorway. She was given the instruction to jump by the jumpmaster, who then observed her descent. He reported that the body position that she adopted, after leaving the aircraft, was not correct in that her body was not arched sufficiently. The student then rolled slightly to her right with her left arm becoming fouled with the pilot parachute used to extract the main parachute. The student then turned to fall stomach down before being pulled upright. The jumpmaster then lost sight of the student and an observer on the ground reported that she did not attempt to deploy the reserve until about five seconds before impacting the ground. The reserve parachute became entangled with the lines, bag and pilot chute of the main parachute and did not inflate. A subsequent inspection of the equipment used by the student did not find any defect or inconsistency in its operation. Students on the course indicated that most parts of the course provided adequate training for the jump. However, adverse comments were received concerning the number of students on the course and the written examination. In general, it was felt that 21 was too large a group for the organisation to train given the amount of equipment available and the necessary time restraints caused by the need for all students to complete the jump, from the one aircraft in the one day, before dark. They believed that the written examination was poorly administered and inadequate. The investigator's opinion is that the examination lacked objectivity. .

At 1810 Eastern Standard Time on 30 August 2004, a Fairchild Industries Inc. SA226-T Merlin III aircraft, registered VH-SSL, departed Bankstown, NSW on a charter flight to Glen Innes, NSW with the pilot and seven passengers on board.

The pilot reported that he manually flew the aircraft in instrument meteorological conditions during the climb to flight level (FL)160. On levelling at the cruise level, he noticed that the aircraft was flying in a slightly right-wing low attitude. The pilot said that he applied left rudder trim to level the wings and engaged the autopilot. About 2 ½ minutes later, the autopilot suddenly disengaged without warning. The aircraft then rolled rapidly to the right and entered a steep spiral descent. A review of air traffic control radar data indicated that about 50 seconds later, the aircraft levelled at 5,200 ft. After the pilot regained control of the aircraft, he reported that he noticed that the right fuel tank gauge reading was 350 kg (437.5 L) greater than the left fuel tank gauge reading, and that the aircraft was ‘very heavy on the right-hand side’. The pilot then climbed the aircraft to FL130 and diverted to Tamworth, NSW without further incident. There were no reported injuries to any of the aircraft’s occupants.

The aircraft’s fuel system included a cross-flow valve that allowed pilots to balance the fuel between the aircraft’s fuel tanks if needed. The Merlin III Aircraft Flight Manual contained the aircraft operating checklists. The BEFORE STARTING ENGINES and DESCENT checklists required that the fuel system cross-flow valve switch be closed. The pilot reported that during the diversion to Tamworth he used the cross-flow valve to reduce the fuel imbalance. A subsequent engineering examination revealed no defects in the aircraft’s fuel tanks, fuel vent systems, the cross-flow system, and the cross-flow valve.

The pilot reported that he conducted the last flight in the aircraft a few days before the occurrence flight. The fuel remaining on board the aircraft after that flight was 500 L, and the right fuel tank contained about 150 L less than the left fuel tank. The pilot believed that he might have used the fuel cross-flow valve during that flight. When the aircraft was refuelled before the occurrence flight, 700 L of fuel was added to the right tank and 550 L to the left tank to give a total fuel load of 1,750 L. The pilot reported that after the refuelling ‘the gauges were pretty well reading the same’.

The pilot of a Cessna 340 departed Bankstown, NSW at 1223 ESuT, for Townsville, Qld via Walgett, St George, Roma, Emerald and Clermont. He reported that he climbed the aircraft to 16,000 ft and adopted a long range power setting of about 49% which equated to a true air speed (TAS) of 168 kts and a fuel burn of 141 lbs per hour.

As the pilot approached the ‘OLDER’ waypoint north of Clermont, he reviewed his fuel situation and, because of a strong tailwind decided to continue on to Cairns. He informed an enroute controller of his decision and requested, for fuel planning purposes, a clearance to allow him to track in the opposite direction on a one-way air route. The controller was unable to approve his request but offered the pilot a direct track to Biboohra, a navigation aid 20 NM west of Cairns. The pilot accepted the amended track with the intention of later requesting a more direct route to Cairns.

About 15 minutes later, the pilot requested a more direct track, but was told to call the approach controller for a possible clearance. He contacted the approach controller and told the controller that he had minimum fuel. The controller asked the pilot if he was declaring an emergency, to which he replied affirmative. The pilot later commented that he did this in the hope of expediting his arrival. He was instructed to descend to 6,500 ft and track direct to Cairns. The controller asked the pilot if he preferred to join the runway 15 circuit via a left downwind or right downwind, to which the pilot requested to join a left downwind. The pilot later commented that the aircraft fuel flow gauges were indicating a total flow of 140 lbs per hour and the fuel quantity gauges for the selected main tanks, although wandering somewhat, were ‘displaying a healthy amount’ considering that he was about 12 NM from his destination. As the pilot approached 6,500 ft, he requested a clearance for further descent, to which the controller instructed the pilot to descend to 4,000 ft.

As the aircraft descended to 4,000 ft, the pilot saw Cairns City, but could not see the runway at Cairns airport. The aircraft's distance measuring equipment (DME) indicated 9 NM to the DME navigation aid at Cairns Airport. The pilot reported that at about this time, he observed one of the fuel flow gauges indicating zero, while at the same time, one or both engines began to surge and run roughly. He immediately informed the controller of the situation. The controller asked the pilot if he was familiar with a local airstrip (Greenhill which is 10 NM to the southeast of Cairns airport), to which the pilot replied that he wasn't. The controller indicated to the pilot that the strip was situated in his two o'clock position at a range of about two miles and to be aware of power lines and the sugar cane. The pilot was unsure of what to look for and was unable to see the strip, but after conducting a number of steep turns, saw a cleared strip in a field. He decided that he had to land. He extended the landing gear, but realised that the aircraft was too high and attempted a 360-degree steep turn onto final to reposition the aircraft. However, the airspeed was rapidly decreasing and there was insufficient height to complete the approach. At 1729 EST, the aircraft impacted the ground short of the strip and slid for about 20 metres. The pilot was seriously injured and the passengers received minor injuries.

The ATSB did not conduct an onsite investigation. Witnesses reported that the aircraft's engines were operating just prior to the crash.

The aircraft’s fuel system included main, auxiliary and locker tanks on each wing. During normal operation each engine used fuel from either the main or auxiliary tanks on the corresponding wing. Access to the locker tank fuel was by pilot-activated transfer of the fuel from the locker tank to the same side main tank. Fuel not required by the engine was returned to the main tank regardless of which tank was selected. It was possible for fuel to vent overboard when the main tank was full and fuel was being drawn from the auxiliary tank and/or transferred from the locker tank. Each main tank contained an auxiliary fuel pump that provided fuel pressure for starting and in the event of an engine driven fuel pump failure. A transfer pump was also fitted to each main tank to continuously transfer fuel from the nose section of the tank to the centre sump area of the tank. A function of the pump was to permit steep descents with a low main tank fuel quantity. Pump operation could only be deactivated by pulling a circuit breaker.

The pilot later commented that he had checked the fuel tanks before departure and could confirm that they were full. The pilot had recently flown the aircraft from the USA to Australia.

The pilot later reported that the fuel flow indicator, that had indicated zero, had been repaired about nine months prior to the accident and although initially erratic had operated flawlessly for the last three months. He went on to say that he now has no recollection of what occurred after he descended below 4,000 ft and cannot recall the engines surging.

A number of flight plans, using reported winds from the Bureau of Meteorology, were prepared by the ATSB to consider a number of possible scenarios. These calculations included a greater fuel burn than planned by the pilot, departing with less than full tanks, incorrect fuel tank usage which could result in fuel being vented overboard or remaining in the auxiliary or locker tanks, or a different TAS and groundspeed because of power settings. The ATSB calculations indicated that the aircraft should have arrived, after a descent and straight-in approach from 16,000 ft, with about 95-100 minutes of fuel on board, if fuel management and flight planning were as reported.