Interim factual report released 3 December 2008

On 17 October 2007, the pilot of a Cessna Aircraft Company C210M, registered VH-WXC, was fatally injured when his aircraft impacted terrain about 257 km south-west of Warburton, WA.

The pilot had delivered an item of general freight at Warburton and was returning to Kalgoorlie when the accident occurred. The aircraft was being operated at night under the visual flight rules.

Preliminary report released 12 December 2007

On 18 October 2007, the pilot of a Cessna Aircraft Company C404 Titan aircraft was conducting a charter flight from Adelaide Airport, SA to Parafield Airport, Beverley airstrip, and return to Adelaide. The pilot had commenced descent into Adelaide on the final sector of the flight when the right engine lost power. There were no apparent anomalies, and the fuel quantity gauges were showing adequate fuel in each tank. After securing the right engine, the pilot continued to Adelaide Airport and landed without further incident.

Aircraft maintenance engineers who inspected the aircraft reported that 3 L of fuel was drained from the right tank and 90 L was drained from the left tank. The fuel quantity gauge was indicating 150 lbs (95 L) in the right tank. An engineer found that one of the electrical circuits in the right fuel quantity indicating system had a high resistance. After wiring in the circuit was repaired, the fuel quantity gauge correctly indicated zero fuel in the right tank. Calibration of the fuel quantity indicating system was carried out and during that process, the left and right signal conditioners were found to be unreliable and were replaced or repaired.

The operator amended its fuel documentation and fuel planning procedures to include a secondary means of verification of fuel on board to cross-check the electric fuel indication system.

Preliminary Report released 21 November 2007

On 25 September 2007, a Robinson Helicopter Company R22 Beta II helicopter was conducting a stock survey flight in the vicinity of Doongan Station, WA. On board the helicopter were the pilot and one passenger.

After about 5 to 10 minutes into the flight, the passenger notified the pilot that he detected a strong burning smell. The pilot landed in a clear area adjacent to a nearby road to inspect the helicopter and elected to keep the helicopter engine running. Both the pilot and passenger visually inspected the helicopter, focussing on the two rubber drive belts that transfer power to the rotor system.

Following the inspection and discussion of the drive belt serviceability, the pilot elected to continue the flight to Doongan Station, while the passenger elected to walk along the road towards the station, until met by a vehicle which was to be sent back by the pilot for him.

After walking about 11 km along the road in the direction of the station, the passenger saw smoke and flames and, upon reaching the source of the smoke, discovered the wreckage of the helicopter adjacent to the road. The helicopter had been destroyed by impact forces and a post-impact fire. The pilot was fatally injured. The post-impact fire started a bushfire which continued for several days. The investigation is continuing.

On 21 September 2007, a SAAB Aircraft AB, SF-340B (SAAB) registered VH-EKX was inbound to Sydney, NSW on a scheduled passenger service from Wagga Wagga, NSW. The crew was cleared by air traffic control to track direct to short final runway 16R at Sydney Airport. The last assigned altitude issued to the SAAB crew was 2,500 ft. A Eurocopter EC120 helicopter registered VH-CKO had departed Sydney Airport on a Georges River 1 departure and, when identified on radar by air traffic control, was cleared to track direct to Kingsgrove at 1,500 ft for aerial work. Air traffic control had coordinated the positions and intended tracks of both aircraft and established a 1,000 ft vertical separation standard.

At 1058.08 Eastern Standard Time, the short-term conflict alert activated on the display consoles of the air traffic controllers. Two seconds later, the copilot of the SAAB reported that they were responding to a resolution advisory from the aircraft's traffic advisory and collision avoidance system (TCAS). Radar analysis indicated that the separation between the two aircraft reduced to 200 ft vertically and 0.5 NM horizontally. There was an infringement of the vertical separation standard of 1,000 ft.

The helicopter pilot had climbed to 2,000 ft and later reported that he had been distracted from monitoring his assigned altitude by a focus on meeting the client's photographic requirements. The pilot in command and the copilot of the SAAB both reported that they believed that they had been cleared by air traffic control to make a visual approach and had descended their aircraft to 2,000 ft.

The investigation established that there was a safety issue in that there is no requirement for a controller to confirm that descent below a previously assigned altitude has not been given in a clearance to a circuit position that does not include a visual approach clearance. Airservices Australia is examining options to address this safety issue.

Preliminary report released 30 October 2007

This preliminary report details factual information established in the investigation’s early evidence collection phase and has been prepared to provide timely information to the industry and public. Preliminary reports contain no analysis or findings, which will be detailed in the investigation’s final report. The information contained in this preliminary report is released in accordance with section 25 of the Transport Safety Investigation Act 2003.

History of the flight 

On 21 July 2007, an Airbus A320-232 aircraft, registered VH-VQT, was being operated on a scheduled international regular public transport service between Christchurch, New Zealand and Melbourne, Australia.

Following an uneventful flight from New Zealand, the crew were conducting an instrument landing system (ILS) approach to runway 27 at Melbourne. Weather conditions were forecast to include fog, which had subsequently eventuated and was likely to necessitate an instrument approach to the minimum altitude on the approach. The likelihood of the crew having to conduct a missed approach was high, as aircraft ahead of VQT had already conducted missed approaches because of the low visibility and fog. The crew had been aware of these conditions prior to departure and had flight planned accordingly. They had also conducted a briefing on the likelihood of having to conduct a missed approach prior to commencing the descent into Melbourne.

At the decision height on the ILS approach, the crew did not have the prescribed visual reference and commenced a missed approach. During the initial part of the missed approach, the crew were not aware that the aircraft had not transitioned to the expected flight guidance modes1 for the missed approach. When the aircraft did not respond as expected, the crew took manual control of the aircraft. The crew were subsequently processed by air traffic control (ATC) for another approach to Melbourne Airport. This second approach also resulted in the crew conducting a missed approach and the aircraft was subsequently diverted to Avalon Airport, where it landed uneventfully. During the second missed approach, the aircraft systems functioned correctly.

During cruise at 9,000 ft, the aircraft encountered severe turbulence, and the electrical system failed. The pilot unintentionally lost control of the aircraft when he leaned forward on the control column yoke and used both hands to search in the dark for a torch on the cockpit floor.

After recovering the hand-held torch, the pilot was able to light the instrument panel and return the aircraft to the required heading and altitude. When the battery master switch was turned off, the electrical system returned to full operation on alternators.

Maintenance personnel found that an internal electrical short in one of the 12-volt batteries had contributed to the electrical failure. After replacement of the faulty battery and completion of satisfactory electrical system checks, the aircraft was returned to service.

The pilot of the aircraft now secures his torch to his shirt with a strap to enable him to use both hands to keep control of the aircraft should a similar situation arise.

The aircraft operator now secures torches in all its aircraft with the addition of a quick release strap on the torch container.

At about 1717 Eastern Standard Time on 27 August 2007, a student pilot and an instructor in a Cessna Aircraft Company C172 (172), registered VH-TIX, were operating in the circuit area as the crew of a Boeing Company B737-838 (737), registered VH- VYC, was conducting a runway 01 instrument landing system (ILS) approach at Townsville Airport, Qld. The pilot of the 172 was cleared for take-off and to make a right circuit on runway 07 from a position about 700 m along the runway. The 737 was about 1.2 NM from the runway 01 threshold and descending through 400 ft at that time.

The 737 landed on runway 01 and, as it crossed the extended centreline of runway 07, the pilot observed the 172 to pass in close proximity. Radar data and pilot estimates indicated that the 172 passed about 150 m behind the 737 at an altitude of about 100 ft. There was no separation assurance.

As a result of this incident, the local procedures at Townsville were amended to require the application of the Manual of Air Traffic Services (MATS) 4.8.9 Take-off Behind Landing or Departing Aircraft on Intersecting Runways separation standard between aircraft departing runway 07 and aircraft landing or departing runway 01/19 at Townsville. In addition, the Royal Australian Air Force (RAAF) implemented an audit project to examine the compliance of Australian Defence Force (ADF) air traffic services, instructions and procedures with civil requirements.

On 27 August 2007, a Piper PA-31P Navajo aircraft, registered VH-SGA, with a pilot and a survey equipment operator on board, was being operated on an aerial survey 21 NM west of Mildura, NSW. At 5,000 ft altitude and operating under the visual flight rules, the pilot noticed an electrical burning smell, which was confirmed by the survey equipment operator.

The pilot, although affected by the fumes, was able to conduct a successful landing at Mildura aerodrome and reported to Air Traffic Services when safely on the ground. The aircraft was examined by a Licensed Aircraft Maintenance Engineer at Mildura. The right engine alternator 'inoperative' sensor was replaced.

As a result of this occurrence, the aircraft operator initiated safety actions to prevent a recurrence.

Preliminary report released 11 October 2007

The aircraft was reported missing and was subsequently discovered to have collided with terrain.

Preliminary report released 11 October 2007

On 11 August 2007, a Boeing 737-476 aircraft, registered VH-TJE, was being operated on a scheduled passenger service between Perth, WA to Sydney, NSW. The flight crew consisted of a pilot in command, who was the pilot flying, and a copilot. The aircraft took off from Perth at 0544 Western Standard Time. About 2 hours 40 minutes later, the master caution light illuminated associated with low output pressure of the aircraft's main tank fuel pumps. The pilot in command observed that the centre tank fuel pump switches on the forward overhead panel were selected to the OFF position and he immediately selected them to the ON position.

The main fuel tanks were low on fuel and the investigation estimated that there was about 100 kg in each of the main tanks. The centre fuel tank contained about 4,700 kg of fuel when the master caution occurred. The flight continued on the flight planned route and landed at Sydney 51 minutes after the initial illumination of the master caution light.