Beech Aircraft Corp 58, VH-NTG

Summary

The Beechcraft Baron aircraft was being operated on a freight charter flight from Groote Eylandt to Darwin.

The pilot said that as the aircraft descended through 5,000 ft the left engine fuel flow gauge reading decreased to zero and the left tachometer indication reduced to about 1,700 RPM. The cylinder head temperature and oil temperature readings also reduced. The pilot advanced the engine control levers to full power and tried to fly the aircraft at the best single engine rate of climb speed. The aircraft continued to lose altitude and the pilot realised there was not enough height remaining to reach an aerodrome. As the left engine tachometer was still indicating about 1,700 RPM, the pilot, believing the engine was still developing power, did not feather the left propeller.

The pilot landed on a two-lane highway. The aircraft was substantially damaged during the landing roll when it slid off the roadway and entered a ditch. The pilot, who was the sole occupant, was not injured.

The pilot had about 1450 hours aeronautical experience and 105 hours on the aircraft type.

Examination of the left engine found the fuel mixture control cable had failed near the fuel control unit control lever. This allowed the lever to move downward under its own weight into the fuel cut-off position. No other pre-existing damage or fault was found that may have contributed to the failure of the engine.

Both engines were only slightly damaged in the forced landing. They were fitted to an engine test cell where they operated in accordance with the manufacturer's standards.

The aircraft's maintenance records showed that the fuel mixture control cable was fitted to the aircraft about 230 hours previously. Specialist metallurgical examination of the cable, which was constructed of one central strand surrounded by six smaller diameter strands, showed it had broken because of fatigue cracking. The fatigue cracking showed significant alternating stresses had been applied to the cable during aircraft operation. The examination also found sliding contact wear close to the break, caused by abnormal alternating loads applied to the cable at the point where it was swaged to the fitting. Possible misalignment of the cable during installation may have led to the failure.

The pilot did not realise that the left engine had failed and the unfeathered propeller was driving the engine, because the RPM indication was higher than he had expected. He therefore was not aware that the unfeathered propeller was causing excessive drag preventing the aircraft from maintaining height.

Occurrence summary

Investigation number 200000624
Occurrence date 18/02/2000
Location Humpty Doo, 37 km SE Darwin, Aero.
State Northern Territory
Report release date 22/12/2000
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Forced/precautionary landing
Occurrence class Accident
Highest injury level None

Aircraft details

Manufacturer Beech Aircraft Corp
Model 58
Registration VH-NTG
Sector Piston
Operation type Charter
Departure point Groote Eylandt, NT
Destination Darwin, NT
Damage Substantial

Lockheed L382G, ZS-JIY

Safety Action

The aircraft operator reported that:

  1. quick release fittings for the universal couplings on the ball screw assemblies have been ordered,
  2. in the interim, a hammer and chisel have been included in each of the L382 aircraft tool kits to enable the crew, if required, to hammer off the bolts that secure the ball screw universal couplings in the event of a landing gear emergency,
  3. the L-382 crew training now includes practical training in emergency landing gear procedures using aircraft that are undergoing hangar checks,
  4. a notice has been issued to L-382 crews that provides further guidance on actions required following landing gear malfunctions, and
  5. the L-382 aircraft have been fitted with satellite capable telephones to allow easier communication with the maintenance organisation.

Analysis

Engineering Aspects

Although the aircraft was about 50 flying hours beyond the 600 hourly block check, it was operating within the approved ten percent servicing extension. It was due to undergo the block check in Singapore immediately after the Dili to Darwin flight. The block check would have included a more in-depth examination of the ball screw assemblies and, in this case, the planned replacement of the subsequently discovered damaged assembly. The preliminary inspection conducted after the accident in Singapore did not detect the damage to the ball screw assembly. The damage was discovered only after the removal and dismantling of the assembly. It was therefore questionable that any developing damage would have been noticed during prior maintenance checks or during the inspection conducted by the flight engineer in Dili.

Both the operator and aircraft manufacturer reported that this was the first reported failure of this type of ball screw assembly. In the absence of other reports or evidence of a developing problem with the ball screw assembly fitted to the aircraft, the probability of recurrence of this type of failure was considered low.

Crew Actions

After the aircraft was shutdown in Dili, the flight engineer performed an on-ground check during which he found no fault with the landing gear. As a result, the pilot in command decided to continue operating the aircraft for the flight to Darwin the next day. The aircraft manufacturer reported that the failure of the main landing gear to lower normally at Dili should have been subjected to a maintenance investigation, and this may have occurred if the operator's maintenance organisation was aware of the problem. There was no published guidance, however, by either the manufacturer or the operator that was readily available to the crew that provided assessment criteria about the continued serviceability of the landing gear. Additionally, the operator had experienced spurious landing gear indication problems that cleared with the reselection of the landing gear position. The crew were aware of these occurrences and without any landing gear system faults being evident, their actions in recycling the gear position several times and decisions about the potential cause of the landing gear fault were probably influenced by the operator's previous experiences.

The operator's prior experience with spurious indications, associated with the air traffic controller's observation made during the fly past in Dili, the failure to find a fault with the landing gear after landing, and the lack of published guidance probably contributed to the crew believing that the problem was a result of an indication fault. The lack of readily accessible communications for the crew to talk to the company's maintenance organisation may have further contributed to the crew's decision to continue operating the aircraft.

When the crew attempted to lower the landing gear at Darwin, the damage within the left main rear landing gear ball screw assembly caused the ball nut to jam on the screw jack. Consequently, due to the interconnection of the gearboxes by the torque shafts, the complete left main gear was jammed. It could not be lowered normally or using any emergency method except by disconnection of the universal joint mounted on top of the left forward main gear ball screw. By the time the flight engineer and loadmaster had managed to undo some of the nuts on universal joint bolts of the forward left landing gear ball screw assembly, the aircraft only had about 20 minutes endurance. The pilot in command assessed that the crew probably did not have enough time to release the remaining two bolts before the aircraft ran out of fuel. Landing the L-382 with just the right main landing gear and nose gear down would have probably made directional control of the aircraft after touchdown difficult. The consequences of the aircraft running out of fuel while airborne were far greater than those associated with landing the aircraft with the landing gear up.

The pilot in command's actions including directing the copilot to fly while he worked through the problem with the flight engineer probably assisted him in remaining situationally aware and making valid assessments about the options available. The cockpit voice recording revealed that the crew used appropriate crew management principles, extensively discussing their options and helping the pilot in command make informed and appropriate decisions.

The pilot in command's request for the laying of a foam path was based on a common misconception that such a path would be effective in reducing the chances of a fire during landing. The nature of the foam agent used in Australia, however, meant that the laying a foam path would have been ineffective in reducing the chance of fire after landing.

CONCLUSION

The aircraft's left rear main landing gear ball screw assembly had failed internally. The resultant damage required the crew to reselect the landing gear during the approach to Dili and prevented the crew lowering the landing gear normally during the later approach to Darwin. The left main forward landing gear universal joint bolts and nuts were damaged, preventing the crew from lowering the landing gear using either normal or emergency lowering methods within the time available. The pilot in command assessed that the left landing gear could not be lowered before the aircraft's fuel was exhausted.

Summary

History of Flight

The day before the accident, the Lockheed L-382G Hercules was being used to conduct a United Nations charter flight from Darwin in the Northern Territory to Dili in East Timor. During the approach for landing, when the landing gear was selected down, the main gear indication showed that the left main gear had not fully lowered. The crew checked the electrical and hydraulic systems but no fault was found. They also reported that after a fly-past of the control tower, the air traffic controller advised that the gear appeared down and locked. The crew then cycled the gear up then down and it lowered normally with the indication showing the gear down and locked. The landing at Dili was made without further incident. The flight engineer reported that he inspected the landing gear after landing at Dili and found no faults in the landing gear system. He said that he suspected that a micro switch might have been the cause of the indication. The aircraft operator did not have any maintenance personnel stationed at Dili and the crew did not report the problem to the operator's maintenance organisation.

The aircraft returned to Darwin the next day. At about 1000 (CST), while the aircraft was on approach to Darwin airport, the crew lowered the landing gear. The nose and right main gear indicators showed that the respective gear was down and locked but the left main gear position indicator showed unsafe. Still suspecting an indication problem, the crew raised and lowered the landing gear several times, but the left main gear indicator continued to show an unsafe condition. The crew conducted a fly-past of the control tower and the controller confirmed that the left main gear was not down. Having confirmed that the nose and right main landing gear operated correctly and that the left main landing gear would not move, the pilot in command allocated flying duties to the copilot. The pilot in command and flight engineer conducted the checklist actions and attempted to lower the gear using the emergency procedures. The attempt to lower the gear hydraulically by using the landing gear override selector valve was unsuccessful. An attempt to lower the gear using the manual drive failed because the emergency engaging handle could not be moved. The flight engineer unsuccessfuly attempted to manually move the shift lever on the forward gearbox of the left landing gear from "power" to "manual" and the loadmaster then attempted to lower the gear by disconnecting the universal joints on the vertical torque shafts of the left landing gear. However, the castellated nuts on the bolts of both wheel vertical torque shaft universal joints could not be undone without using a spanner. Even using a spanner, only two of the four nuts had been undone after about 30 minutes.

At about 1020, the crew of a C5 Galaxy military cargo aircraft also inbound to Darwin advised air traffic control that their aircraft was experiencing a hydraulic problem. Twenty minutes later, the crew of the L-382 informed air traffic control that the aircraft would be making a gear-up landing. The pilot in command requested that the airport's Rescue and Fire Fighting Service (RFFS) lay a foam path along the last two thirds of Runway 36. The air traffic controller informed the crew that a landing on Runway 29 was preferred, and that the L-382 was number two in the "emergency landing sequence". Air traffic control intended that the Galaxy land first followed by the L-382.

The air traffic controller later informed the L-382 crew that the airport RFFS advised that laying foam was not standard procedure. The controller also advised that if foam was laid, no foam would be available to attend the aircraft after it landed. The pilot in command was concerned about the potential for fire caused by sparks during the landing and he requested a clearance from air traffic control to perform the landing on the grass alongside the runway.

By the time two of the nuts on each of the universal joints had been undone, the fuel state of the L-382 was approaching 1,500 lbs or about 20 minutes endurance. The pilot in command decided that due to the low fuel state, there was insufficient time to undo the remaining nuts before a landing was required and he advised the controller of the aircraft's low fuel state. Concerned at the chances of the aircraft slewing off the runway after touchdown, the pilot in command also decided that the nose and right main landing gear would be raised for the landing. The L-382 was cleared to track for final approach Runway 29. The Galaxy diverted to the Royal Australian Air Force Base at Tindal.

The pilot in command subsequently decided that it would be more prudent to land on the runway because of possible obstructions on the grass area. After briefing the passengers, the crew conducted their own emergency briefing, including actions after touchdown, shutdown actions, and evacuation routes. The pilot in command assumed control of the aircraft during final approach and conducted the gear up landing.

At 1104, the L-382 landed on Runway 29. Touchdown was made at approximately 90 kts and the aircraft slid about 300 metres before stopping adjacent to Taxiway D. The aircraft remained straight on the runway and none of the crew or passengers were injured. They evacuated the aircraft soon after it came to rest. Although a flash fire erupted at the rear lower fuselage area while the aircraft slid along the runway, the fire did not spread. The RFFS applied foam to the area around the aircraft after it came to a halt.

Damage to the Aircraft

The aircraft sustained extensive lower fuselage structural damage due to the scraping along the runway. All rib lower end-caps aft of the nose-wheel bay were damaged and there was evidence of a flash fire in the rear section of the lower fuselage. Some damage to the electrical wiring located in the lower fuselage area had also been sustained.

Weight and Balance

The aircraft remained within the published centre of gravity and weight envelopes throughout the flight.

Fuel

The aircraft taxied at Dili with about 17,600 lbs of fuel, for the flight to Darwin. The departure fuel load was estimated to be 800 lbs more than the amount needed for the flight and required reserves. The aircraft arrived at Darwin with over 8,000 lbs of fuel and landed with about 1,500 lbs of fuel remaining.

Personnel Information

The pilot in command had accumulated 9611 hours of flying experience and had about 4428 hours on the Hercules series of aircraft including the military C-130 and civilian L-382. The copilot had about 2,300 hours flying experience of which nearly 600 had been gained on the L-382. The flight engineer had 1,224 hours operating experience of which about 484 hours were in the L-382. The flight engineer reported that he had not conducted, nor had he witnessed, a practice emergency lowering of the landing gear. There was no regulatory requirement for him to conduct or witness a practice emergency lowering of the landing gear.

Operator Information

The operator conducted freight and passenger flights in several countries including remote areas of Africa, South America and Antarctica.

The operator reported that because many of its operations were in remote areas, crews were expected to assess aircraft serviceability according to the company operations manuals, Aircraft Flight Manuals (AFMs) and Minimum Equipment Lists. There was no published guidance available to the crew regarding the maintenance requirements following landing gear incidents such as the one they encountered during the approach to Dili.

Meteorological Information

The weather conditions were clear with a 10 kt breeze from the north-west.

The Main Landing Gear

The main landing gear of the L-382 comprises a main assembly on each side of the aircraft. Each assembly has two shock struts each equipped with a brake assembly, wheel and tyre assembly, torque strut, and ball screw retracting mechanism. The brake, wheel, and tyre assemblies are mounted on the bottom of each shock strut. The two shock struts are mounted in tandem and connected to each other by a torque strut.

Each main landing gear retracting mechanism has horizontal and vertical torque shafts, three gearboxes, a hydraulic motor, ball screws, and strut vertical guide tracks. An emergency manual drive is provided for extension and retraction of the main landing gear following a hydraulic system failure.

The left main landing gear gearboxes are mounted on the left wheel well structure over the forward and aft shock struts, and connected to each other by a horizontal torque shaft. A hydraulic motor and a manual gearbox are mounted forward of the drive assembly. A vertical torque shaft extends down from each of the two gearboxes to a universal joint mounted on top of each of the ball screws. Each ball screw is anchored through a ball bearing pillow block at the upper end, and through a trunnion in the shelf bracket at the lower end. A ball nut on the ball screw is connected to the strut lower flange. The vertical ball screw assembly is installed on each of the two main landing gear struts. Each screw is centred between the strut guide tracks, and mounted to the inboard wheel well wall through its upper pillow block and trunnion assembly at the lower end of the ball screw shaft. Consequently, rotation of the screw by the vertical torque shaft causes the ball nut attached to the landing gear strut lower mounting flange to travel up or down, directly raising, or lowering the landing gear.

Main Landing Gear Operation

When the landing gear selector in the cockpit is positioned either up or down, an electrical signal commands the selector valve to direct hydraulic pressure to the hydraulic motor mounted on the front of each forward gearbox. Each of the forward gearboxes rotate the attached vertical torque shaft and screw assembly while also driving the horizontal torque shaft to drive the associated rear gearbox. The rear gearbox turns the rear vertical torque shaft and attached ball screw assembly.

Lowering of the landing gear can also be achieved by several alternative methods, depending on the type of failure encountered. Following a failure of the selector valve, over-ride buttons on the landing gear selector valve can be used to manually direct hydraulic power to the hydraulic motors of the main landing gear. The main landing gear can also be lowered using the manual shift on the forward gearbox. Pulling the emergency engaging handle moves the shift lever on the forward gearbox from power to manual thereby engaging the manual gearbox and releasing a spring-loaded brake. The main gear should then free-fall. If the gear fails to free-fall, a hand-crank is available to wind the gear down into position. A malfunction that locks any component of the system could prevent the main gear from moving. Consequently, the AFM advises that the universal joints mounted on top of each of the ball screws be disconnected. The gear should then free-fall under its own weight. A wrench is provided to wind down the landing gear should it not free-fall once the universal joints were disconnected. The universal joints are connected to the torque shaft by bolts and secured with castellated nuts. The nuts and their associated bolts should be tightened during installation to a torque of 25 to 30 inch pounds.

The aircraft manufacturer reported that it was possible, though undesirable, to land the L-382 model Hercules with one landing gear leg down on one side and both gear legs down on the other.

Engineering Investigation

A field structural repair was carried out in Darwin before the aircraft was flown to Singapore for final rectification of the damage. The landing gear was secured in the down position for the flight. The engineers conducting the repairs visually inspected the landing gear and found no abnormalities. The aircraft was then jacked clear of the ground, and functionally tested the landing gear. They found that the left main gear failed to extend normally. When the engineers attempted to hand crank the gear down, they noted that there was a high resistance within the system and the left main gear would not lower. When the universal joints were disconnected on the left main landing gear assembly, the forward strut lowered freely but the rear strut remained up. On closer inspection and disassembly, the left rear main gear ball screw assembly was found to have excessive backlash and the grease on the ball screw was found contaminated with accumulated debris. The engineers also reported finding several defects within the disassembled ball screw assembly including; excessively worn ball inserts and numerous chipped and distorted bearing balls in the ball nut assembly. Three circular scores with deep gouges were found on the internal surface of the ball nut assembly return sleeve and the scores coincided with the positions of the bearing balls. The ball screw was also bowed. The engineering organisation concluded that the damage was consistent with the bearing balls not riding normally or freely along the sleeve, with the greatest resistance probably occurring when the bearing balls rode across the gouges. The examination found no faults in the left landing gear hydraulic motor or associated gearboxes. The operator and aircraft manufacturer reported that there had been no previous failures of the type of ballscrew fitted to the accident aircraft.

An inspection of the universal joint castellated nuts and associated bolts found that none of the nuts could be fully unwound without the use of a spanner. A subsequent materials analysis of one of the castellated nut and bolt units revealed that the thread of both the nut and bolt had been deformed by the imposition of a load or loads along the axis of the bolt. Excessive tensile loads being applied during the tightening of the bolts or a load caused, for example, by abnormal operation of the landing gear could cause the damage. The reason why the threads of the nuts and bolts deformed could not be determined.

The aircraft manufacturer reported that no records could be found specifically stating that difficulty was experienced in removing the nuts from the bolts in the flanged connection.

The manufacturer had, however, introduced a torque shaft with a quick release feature that replaced the nuts and bolts. The manufacturer reported that the feature was introduced as a product improvement to make it easier and safer to disconnect the torque shaft from the ball screw.

Maintenance

A review of the aircraft maintenance documentation revealed no precursory event or events that may have indicated to the operator or the flight crew that there was an impending problem with the left main gear. No landing gear system faults were recorded during the previous block check. The manufacturer advised that the inspection requirements of the L-382 included a daily, a "B" check (the earlier of every 6 months or 600 flying hours), and a "C" check (the earlier of 2 years or every 2,400 flying hours). The daily and "B" checks required the checking of ball screws for general condition, cleanliness and lubrication. The "C" Check required a more detailed examination. The aircraft operator reported that the approved company maintenance schedule for the L-382 aircraft utilised block checks that occurred every 600 hours flying time. The block checks incorporated the "B" and one quarter of the "C" checks. Consequently, the aircraft would complete the manufacturer maintenance requirements every four block checks. The aircraft underwent a block check 647 hours before the incident at Dili. The aircraft was operating on an approved ten percent extension to the servicing schedule and was due to be flown to Singapore after the return flight to Darwin to undergo the block check.

The damage found within the ball screw assembly could be identified only when the unit was dismantled. There was no maintenance requirement to disassemble the unit for an in-service inspection. The ball screw assembly was installed as a new component and the aircraft operator approved documentation indicated that life of the component was 6 years or 6,300 flying hours. The ball screw assembly involved in the accident had been in service for 5,506 hours and 65 months and was due for replacement during the next block check. The ball screws were cleaned every 50 flying hours and were due for cleaning within six flying hours after the flight to Dili.

The aircraft manufacturer reported that the failure of the main landing gear to lower properly during the approach to Dili should have been subject to a maintenance investigation using the trouble-shooting procedures detailed in the aircraft maintenance manual. According to the manufacturer, the main landing gear system should have undergone an extensive maintenance inspection including extension and retraction testing before the aircraft was released for continued operation.

Operating Procedures

The AFM, in part, stated, "If the main and nose landing gears fail to extend after normal actuation of the landing gear lever, attempt to identify the malfunction before making further attempts to lower the gear". The operator's standard operating procedures provided the procedure for emergency lowering the landing gear but did not provide any further elaboration on the AFM requirements.

The aircraft operator reported that landing gear indication problems had occurred on other occasions; mainly due to spurious electrical signals that cleared with the reselection of the landing gear position.

The crew had been provided with a mobile telephone but the mobile service in Dili at the time was reported as being unreliable.

Passenger Evacuation

One of the loadmasters in the crew gave a pre-flight briefing to the passengers before the departure from Dili. Once the decision was made to make an emergency landing at Darwin, the senior loadmaster briefed the passengers on emergency procedures for the landing. The loadmasters reported that procedures were conducted in accordance with the operator's loadmaster training manual and drill cards carried by each loadmaster.

Before landing, the passengers were briefed that the front (crew) door and left emergency exit number two would be used. They were told to move towards the nose of the aircraft after exiting and to remain clear of the aircraft propellers. The passenger next to the exit was briefed about operating the emergency door and only to exit after the propellers had stopped. The passengers complied with the evacuation briefings and no injuries were reported.

Rescue Fire-fighting Services

The Airport Services Manual provided a discussion and guidance on the technique of foaming runways for an aircraft emergency including gear-up landings. It noted that, "Flouroprotein foam, film forming flouroprotein foam and aqueous film forming foam are not considered suitable for runway foaming operations due to their short drainage time". The Civil Aviation Safety Authority (CASA) reported that all the Airport Fire Services in Australia audited by CASA use Aqueous Film Forming Foam. Consequently, Airservices Australia and the Civil Aviation Safety Authority had an agreed policy that foam paths would not be laid at Australian airports. This decision was due, in part, to the poor persistence qualities of the foam agent (the foam path would only exist for a short period) and because aircraft frequently missed the foam path during landing. Both factors reduced the effectiveness of laying foam paths. The investigation was also advised that an attempt to lay a foam path for the aircraft probably would have exhausted the total stocks of foam agent held by Darwin RFFS, leaving none to use on the aircraft after it had landed.

Occurrence summary

Investigation number 200000618
Occurrence date 18/02/2000
Location Darwin, Aero.
State Northern Territory
Report release date 02/01/2001
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 Lockheed Aircraft Corp
Model L-100
Registration ZS-JIY
Serial number 4691
Sector Turboprop
Operation type Charter
Departure point Dili, EAST TIMOR
Destination Darwin, NT
Damage Substantial

Beech Aircraft Corp 1900D, VH-NTL

Summary

On 13 February 2000 a Beech 1900D Airliner, VH-NTL, was on a local training flight. The pilot in command simulated a failure of the left engine shortly after take-off by retarding the left power lever to the 'FLIGHT IDLE' position. The handling pilot applied full right rudder and right aileron to counter the resultant yaw to the left, but the yaw continued until power was restored to the left engine to regain directional control. In the 21 seconds following take-off, the aircraft did not climb above 160 ft above ground level, and at one stage had descended to 108 ft.

The aircraft was then climbed to a height of 2,000 ft where the pilot in command simulated another failure of the left engine by retarding its power lever to the 'FLIGHT IDLE' power setting. The aircraft again lost controllability. Power was restored to the left engine, and the aircraft landed without further incident.

There was no evidence that any aircraft or systems malfunctions contributed to the controllability problems experienced by the crew during the occurrence flight.

Since 1992, it was the practice of the operator's check pilots to simulate one-engine inoperative by retarding the power lever of the 'failed' engine to 'FLIGHT IDLE'. That was contrary to the procedure prescribed in the Federal Aviation Authority-approved Beech 1900D Airplane Flight Manual, and also to that specified in the operator's Civil Aviation Safety Authority-approved Training and Checking Manual. Reducing power to 'FLIGHT IDLE' also had the effect of simulating a simultaneous failure of the engine and its propeller auto-feather system. The simulation of simultaneous inflight failures was contrary to the provisions of the CASA-approved Training and Checking Manual. During each of the simulated one-engine inoperative sequences, control of the aircraft was not regained until the power on the 'failed' engine was advanced to the manufacturer's prescribed one-engine inoperative thrust power setting.

The operator's training and checking organisation and its check pilots were aware that the likely consequences of simulating an engine failure by retarding its power to less than zero thrust were reduced aircraft climb performance and increased air minimum control speed (VMCA). They were also aware that risk increased when inflight training exercises involved the simulation of multiple failures. The prescribed procedures were therefore necessary defences to minimise those risks. The circumvention of those defences significantly increased the risks associated with the operator's training and checking procedures, and was a safety-significant concern. This occurrence demonstrated the potentially serious consequences of degraded aircraft performance by setting 'FLIGHT IDLE' to simulate one-engine inoperative. The practice has the potential to jeopardise the safety of flight and should be strongly discouraged.

The ATSB's investigation established that the failure to achieve predicted performance during take-off and subsequent climb was the result of an incorrect procedure. As a result of this serious occurrence, the ATSB recommended that the Civil Aviation Safety Authority (CASA) publish information for the guidance of operators and pilots regarding the correct procedures for simulating engine failures in turbo-propeller aircraft. CASA advised that it will publish an amendment to Civil Aviation Advisory Publication 5.23-1(0) to highlight appropriate engine-out training procedures in turbo-propeller aircraft. CASA also advised that it would ensure that operators' manuals contained appropriate procedures for the conduct of multi-engine training, and that it would draw attention to those procedures during forthcoming safety promotion activities. The operator advised that it had instructed its check pilots that an engine's power lever must not be retarded below the zero thrust torque setting when simulating an engine failure on take-off, and that those simulations were not be carried out until the aircraft had reached 250 ft above ground level.

Occurrence summary

Investigation number 200000492
Occurrence date 13/02/2000
Location Williamtown, Aero.
State New South Wales
Report release date 21/12/2001
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Control - Other
Occurrence class Serious Incident
Highest injury level None

Aircraft details

Manufacturer Beech Aircraft Corp
Model 1900
Registration VH-NTL
Serial number UE-117
Sector Turboprop
Operation type Air Transport Low Capacity
Departure point Williamtown, NSW
Destination Williamtown, NSW
Damage Nil

Boeing 767-338ER, VH-OGN

Safety Action

LOCAL SAFETY ACTION

Following this and other similar occurrences, Airservices Australia has changed the TAAATS system to reduce the possibility of similar false radar couplings. This change consisted of adding an additional longitudinal check that limits the size of the Coupling Corridor to within a defined Variable System Parameter (minutes) ahead and behind the estimated position of the aircraft based on FDP time estimates. Initially this parameter was set to 12 minutes. This additional longitudinal check was only to be applied for Flight plans that were "Active" or "Inhibited".

The software carrying this fix was installed in the ML FIR on the night of January 17th, 2001, and in the BN FIR on the night of May 10th, 2001.

Analysis

In the TAAATS Eurocat Radar Data Processor, coupling between Radar tracks and Flight Plans was limited to a corridor around the flight plan route - ahead of the last overflown position. This significantly restricted the chances of false coupling to aircraft squawking incorrect SSR codes.

In geographically small systems with relatively saturated radar coverage, this was very effective and anomalies are usually easily determined and rectified. However, with the geographical extent of TAAATS en-route system, and the reliance in TAAATS on Flight Plan tracks for separation purposes, the possibility and ramifications of false couplings assumes greater significance.

A solution was to longitudinally restrict the coupling corridor to a time/distance ahead and behind the estimated position of the aircraft based on Flight Data Processor (FDP) time estimates.

Unless the non-radar controller observed the flight plan track and jurisdiction strip deletion, no cues other than the controllers memory or scratch pad notes existed of the presence of the flight and the controllers situational awareness was severely compromised.

The radar controllers in Sydney may not have noticed the newly coupled radar track and if they did, it may have been disregarded as a false coupling.

Summary

The flight plan track, which was an on-screen indication showing the location of the Boeing 767 (B767) aircraft while outside radar coverage, disappeared from the air situation display while the crew was receiving an air traffic control service. This loss of display resulted in the controller loosing situational awareness and no separation or SAR alerting service being provided to the aircraft.

The controller observed the aircraft's flight plan track overhead Oodnadatta at 1727 Central Summer Time. At 1736 the crew reported their position overhead AGAGO, the controller had no on-screen indication of the B767 as the flight data record for the aircraft no longer existed. All indications of the aircraft had been removed from the controller's screen.

An investigation carried out by Airservices Australia revealed that the crew of an aircraft close to Sydney was cycling through SSR codes on its transponder and momentarily squawked the code that was assigned to the flight data record of the aircraft near Oodnadatta. The received transponder return was a valid code within the coupling corridor associated with that aircraft's track. That scenario caused a false radar coupling that resulted in The Australian Advanced Air Traffic System (TAAATS) automatically modifying the flight data record, which resulted in the deletion of the flight plan track and the controller's jurisdiction strip. That sequence of events displayed a coupled radar track for 10 seconds. However, the track was outside of the controllers displayed range.

A flight data record may couple on either the Previous SSR code (PSSR) or Assigned SSR code (ASSR), there was no indication to the controller on which of these codes the flight data record had coupled unless the controller selected "SSR ALL" to determine the squawked code. The PSSR is the code assigned by the previous control authority, in the receiving control authority TAAATS attempts to retain this code. The aircraft PSSR was the code assigned by the Singapore Control Authority and was retained by Brisbane and Melbourne TAAATS. This code was one normally used for code allocations to Visual Flight Rules flight data records.

Occurrence summary

Investigation number 200000520
Occurrence date 09/02/2000
Location AGAGO, (IFR)
Report release date 05/09/2001
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Incident
Highest injury level None

Aircraft details

Manufacturer The Boeing Company
Model 767
Registration VH-OGN
Serial number 25576
Sector Jet
Operation type Air Transport High Capacity
Departure point SINGAPORE
Destination Sydney, NSW
Damage Nil

Piper PA-38-112, VH-ZWG

Summary

The Piper Tomahawk aircraft was being used to conduct a series of touch-and-go landings during a dual instructional flight. During the climb after the second take-off, and when the aircraft was at a height of about 200 ft, the engine failed without warning. The instructor manoeuvred the aircraft to avoid landing in a lake located just beyond the end of the runway and landed in an adjacent paddock. Although the aircraft hit some low bushes during the landing roll, the pilots were not injured, and the aircraft was not damaged.

The aircraft was moved to a maintenance facility and, prior to conducting any maintenance or inspections, the engine was started and ground-run without any obvious problems. The maintenance inspection revealed a contact mark had been worn through the Teflon coating of the wear area of the carburettor float needle. When the carburettor was reassembled and tested, it was found that the carburettor float needle would stick in the valve seat and prevent fuel flowing into the carburettor bowl. The float needle and seat were replaced, and the aircraft test-flown without further incident.

Occurrence summary

Investigation number 200000313
Occurrence date 31/01/2000
Location Point Cook, Aero.
State Victoria
Report release date 01/08/2000
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Fuel starvation
Occurrence class Incident
Highest injury level None

Aircraft details

Manufacturer Piper Aircraft Corp
Model PA-38
Registration VH-ZWG
Serial number 38-78A0234
Sector Piston
Operation type Flying Training
Departure point Essendon, VIC
Destination Essendon, VIC
Damage Nil

Cessna 182Q, VH-LMH

Summary

The pilot reported that while in cruise flight over water, the C182 aircraft was subjected to a strong downdraft. The pilot immediately reduced engine power to slow the aircraft in anticipation of further turbulence. Having established the desired airspeed, the pilot attempted to re-apply power but the engine did not respond. He selected carburettor heat and attempted several times to start the engine.

As there was no suitable landing area on nearby Huon Island, the pilot ditched the aircraft 1 km from the mainland shore. Three of the four occupants exited the aircraft unassisted; the fourth had to be pulled free by the pilot. All then made their way to the shoreline.

Subsequent salvage attempts were unable to locate the wreckage. Consequently, to assess the airworthiness of the aircraft, the investigation could examine only the aircraft documentation. No deficiencies that might have contributed to the accident were identified.

Information provided by the Bureau of Meteorology indicated that atmospheric conditions at the time of the engine failure were conducive to the formation of moderate to severe carburettor icing. The formation of ice in the carburettor venturi can result in partial or complete loss of power. Contamination of the fuel system was also considered. However, the aircraft operator said that the aircraft had not been fuelled from known contaminated batches.

The investigation could not determine why the engine failed. However, it is possible that carburettor icing formed after the pilot reduced power in response to the turbulent conditions.

Occurrence summary

Investigation number 200000190
Occurrence date 21/01/2000
Location 1 km S Verona Sands
State Tasmania
Report release date 01/08/2000
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Ditching
Occurrence class Incident
Highest injury level Minor

Aircraft details

Manufacturer Cessna Aircraft Company
Model 182
Registration VH-LMH
Serial number 18266830
Sector Piston
Operation type Charter
Departure point Cambridge, TAS
Destination Melaleuca, TAS
Damage Destroyed

British Aerospace Plc BAe 146-300, VH-NJL

Summary

While en route from Darwin to Gove, the master warning system of the BAe 146 chimed and the crew noticed that the engine vibration indication for the number four engine was fluctuating between 0.6 and 2.0 inches per second. All other engine indications appeared normal. The pilot in command switched off the thrust management system, retarded the number four engine power lever to idle and switched off the associated bleed air. At the same time, a loud series of thuds were heard and the master warning system again chimed, alerting the crew to low oil pressure indications for this engine. The pilot in command and the first officer then noticed smoke in the cabin when they looked back through the flight deck door. The crew donned oxygen masks and completed the "smoke or fire in cabin" and "engine fire or severe damage" checklists. ATC was notified and a return to Darwin requested. With the diversion approved and a distress phase declared, the subsequent return and one-engine-inoperative landing were uneventful. Company maintenance inspection found the number four-engine could not be rotated and had incurred severe internal damage.

The manufacturer inspected the engine and found that the number 1 bearing pack had failed. The pinion gear retention nut backed off, and had misaligned the gears, causing metal contamination in the oil supply from the improperly meshed gear teeth. The failure of the bearing pack in turn caused major internal damage to other parts of the engine as the high-pressure compressor shaft was allowed to orbit within the engine. The reason the pinion gear nut lost tension could not be determined.

The manufacturer indicated that the incidence of failure of the pinion gear retention nut is very low, with a mean time between failure of 2.9 million fleet hours. As a result, the ATSB does not believe further safety action is necessary.

The company investigation also identified several other issues associated with this occurrence that are being addressed:

  1. The quality of communications between cabin crew and cockpit crew using the dedicated emergency-in-cabin (EIC) call facility;
  2. The clarity of audio when the crew were wearing oxygen masks; and
  3. Formalising procedures for medical examinations and counselling after the event.

The operator will advise the ATSB if any safety action is taken.

The cabin crew reported minor and temporary eye irritation and sinus discomfort from the smoke during the incident. The medical examinations the following week did not find anything notable. The pilot in command and first officer did not seek medical attention after the incident.

Occurrence summary

Investigation number 200000176
Occurrence date 21/01/2000
Location 241 km E Darwin, (NDB)
State Northern Territory
Report release date 30/04/2000
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Abnormal engine indications
Occurrence class Incident
Highest injury level None

Aircraft details

Manufacturer British Aerospace
Model BAe 146
Registration VH-NJL
Serial number E3213
Sector Jet
Operation type Air Transport High Capacity
Departure point Darwin, NT
Destination Gove, NT
Damage Nil

Cessna 210M, VH-NOK

Summary

On the morning of the accident, the pilot woke at 0530 Central Summer Time (CSuT) and started duty at 0630. The pilot had undertaken an Instrument Flight Rules (IFR) Regular Public Transport (RPT) check flight in a Cessna 402 for 2.3 hours during the mid-morning on the day of the occurrence. The pilot's performance during the check flight was considered above average. The pilot was then tasked by the company for a Visual Flight Rules (VFR) charter flight in a Cessna 210. Towards the end of this substantial tour of duty, the pilot entered the Croker Island circuit for an approach to runway 31 at about 1806. During final approach, the pilot did not recall any auditory landing gear warnings, nor did he recall the status of the landing gear indicator lights. The pilot proceeded to land the aircraft with the landing gear retracted. This event occurred at approximately 1813 (CSuT). The pilot and five passengers were unharmed and evacuated the aircraft.

The pilot reported that he was fatigued during the flight and that the landing gear pump circuit breaker had popped on the final leg to Croker Island. The pilot recycled the landing gear pump circuit breaker and realised that the electric motor was still running. The pilot subsequently elected to pull the circuit breaker to prevent damage to the electric motor. This procedure was executed in accordance with the Cessna 210 Information Manual recommendation that when the hydraulic pump continues to run after gear cycle completion (up or down), the gear pump circuit breaker should be pulled out to shut off the hydraulic pump motor, thereby preventing damage to the pump and motor. The circuit breaker must be re-engaged prior to landing so that the landing gear can been extended (sections 3-20 & 7-12 of Cessna 210 Information Manual). On approach to Croker Island, the pilot selected the landing gear down but forgot to re-engage the landing gear pump circuit breaker. Consequently, the wheels did not deploy.

The pilot reported that the aircraft had sustained damage to the propeller and the underside of the aircraft. An initial engineering inspection revealed no apparent damage to the engine crankshaft or other engine components. A maintenance engineer from the company's contracted maintenance organisation found the landing gear handle in the fully extended position and the landing gear pump circuit breaker disengaged.

The pilot had accrued 2286.9 hours of flight time, of which 785.0 hours were on the Cessna 210. The pilot was considered as above average and very capable by both the chief pilot and the check-and-training officer. The pilot had flown five aircraft types in the week preceding the occurrence.

The maintenance release indicated no problems with the landing gear. The pilot reported that the Cessna 210 was well maintained and serviceable prior to flight.

The company did not have a documented procedure for the actions required when the landing gear hydraulic pump continues to run when the landing gear has been retracted. The Cessna 210 Information Manual recommends that when the hydraulic pump continues to run after gear cycle completion (up or down), the gear pump circuit breaker should be pulled out to shut off the hydraulic pump motor, thereby preventing damage to the pump and motor. The circuit breaker must be re-engaged prior to landing so that the landing gear can been extended (sections 3-20 & 7-12 of Cessna 210 Information Manual). The pilot reported that he was familiar with this procedure as annotated in the Cessna 210 Information Manual. The pilot also reported that the landing gear warning systems were tested and found to be fully functional prior to flight. These systems include the landing gear intermittent warning tone and gear indicator lights.

The pilot did not recall hearing any audio warning indicating that the gear had not extended until the aircraft was on the ground. In addition, the pilot did not recall the status of the landing gear indicator lights prior to landing. Finally, the pilot did not visually confirm the extension of the landing gear.

The pilot reported that he was very tired on the day of the occurrence and that he had been tired for some time leading up to the accident. The pilot's work/rest history for the 14 weeks before the accident was examined using a computerised fatigue algorithm developed by the Centre for Sleep Research, University of South Australia. The results indicated that the pilot was probably not suffering severely from cumulative fatigue on the day of the accident. On the day of the occurrence, however, the pilot reported feeling tired and he had been on duty for almost 12 hours before the accident. Moreover, he had been awake for almost 14 hours before the accident.

The pilot probably suffered from a transient fatigue related memory lapse where he forgot to re-engage the landing gear pump circuit breaker before landing and failed to visually check that the landing gear was down and locked.

Occurrence summary

Investigation number 200000148
Occurrence date 17/01/2000
Location Croker Island, Aero.
State Northern Territory
Report release date 09/08/2000
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-NOK
Serial number 210-62063
Sector Piston
Operation type Charter
Departure point Smith Point, NT
Destination Croker Island, NT
Damage Substantial

Robinson R22 Beta, VH-JHZ

Summary

The helicopter was being used to conduct basic helicopter training at Jandakot. There was an accumulation of raindrops on the helicopter's canopy due to showers that had recently passed through the area. The instructor reported that both he and the student were getting hot from prolonged hovering and that he decided that a short flight was needed to cool the cockpit. The instructor took control of the helicopter from the student and transitioned into forward flight, climbing at about 35 kts to approximately 50 ft before commencing a continuous left turn to return to the hover. The instructor reported that while he was looking out to his left at the area where he intended arriving, he realised that the helicopter was too low to the ground. The helicopter's left skid hit the ground then the helicopter rolled right and the main rotor blades hit the ground. The helicopter then cartwheeled two or three times before skidding and coming to rest on its right side. The fuel tanks ruptured and the helicopter caught fire. Just after both pilots escaped through the front of the shattered canopy, the wreckage exploded. The student sustained minor injuries while the instructor suffered burns to his right arm and head. The pilots were not wearing helmets. The pilots reported that the helicopter was operating normally before it hit the ground. The investigation could not determine if the raindrops that had accumulated on the canopy had affected the instructor's visual perception.

Occurrence summary

Investigation number 200000125
Occurrence date 17/01/2000
Location Jandakot, Aero.
State Western Australia
Report release date 08/08/2000
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Collision with terrain
Occurrence class Accident
Highest injury level Serious

Aircraft details

Manufacturer Robinson Helicopter Co
Model R22
Registration VH-JHZ
Sector Helicopter
Operation type Flying Training
Departure point Jandakot, WA
Destination Jandakot, WA
Damage Destroyed

Steering gear failure on the Australian flag motor Warden Point

Final report

Summary

On 9 November 1999, the Australian flag bulk carrier Warden Point was southbound off the north coast of New South Wales, en route to Melbourne, with a cargo of fly ash. At about 0230, the weather changed due to an intense low-pressure system approximately 300 nautical miles to the south. By 0800 the vessel was experiencing near gale force winds from the south. The vessel was pitching heavily in large seas submerging the lower poop deck, at times, under 2-3 m of water.

At 1400, the duty engineer reported that the rope locker hatch lid, on the lower poop deck, was leaking and that water had entered the rope locker and adjoining steering flat. The crew subsequently managed to reseal the hatch lid after some problems due to waves that were periodically sweeping the deck and running over the hatch.

At 2330, Australian Eastern Standard Time (EST), the second mate came on the bridge to take the watch. After the watch was handed over, he instructed the 12-4 integrated rating (IR) to go through the accommodation and advance the clocks 1 hour, he also instructed the IR to check the rope locker and steering flat. The IR rang back a short time later to report that the rope locker and steering flat were awash and that the water was running over the steering motors. The second mate started the stand-by steering motor and called the duty engineer. Just as he put the phone down one steering motor failed, followed by the other motor about 10 seconds later. The second mate stopped the ship and called the master. The time was 0115, Australian Eastern Summer Time (EDT), 10 November 1999, with the vessel east of Sugarloaf Point, north of Newcastle. Once the vessel lost headway it became beam-on to the large sea and rolled heavily.

All the engineers and integrated ratings were called to the engine room to work on restoring the steering and pumping the steering flat and rope locker dry. Both steering motors were dismantled and found to be damaged beyond repair. There was no spare motor so the lower rated stand-by main engine jacket cooling water pump motor was used to make an emergency repair. While the crew were completing the emergency repairs to the steering the cargo shifted, causing a port list of 2-3° and a noticeable trim by the head.

At 0852 on 10 November 1999, with the steering finally restored, the vessel headed for Newcastle, the nearest port of refuge, to effect permanent repairs. However, Newcastle Port closed at 1526 on 10 November 1999, due to the bad weather, and the decision was made to divert Warden Point to Port Kembla.

Warden Point arrived at the Port Kembla pilot boarding ground at 1000 on 11 November 1999 by which time the list had increased to over 5°. The steering was limited to a maximum of 15° helm and the vessel was berthed using two tugs. At 1236, the vessel was finally made fast alongside no.1 coal berth. The ships engineers and shore contractors worked into the night on the steering gear and rope locker hatch lid. The cargo was inspected and found to have moved in both holds. The list was corrected by re-trimming the cargo in no.1 hold.

Warden Point departed Port Kembla at 0830 on 12 November 1999 and completed the voyage to Melbourne without further incident.

Conclusions

These conclusions identify the different factors contributing to the incident and should not be read as apportioning blame or liability to any particular organisation or individual.

On 9,10, 11 November 1999 Warden Point experienced a series of events in which the ship suffered significant damage and which endangered the vessel and crew.

1. The initial failure of Warden Point's steering gear was a result of the steering pump motors failing after contact with seawater.

2. The seawater gained access to the steering gear flat via the two lowest penetrations in the bulkhead between the steering flat and the adjacent rope locker, which had been flooded as a result of its leaking hatch lid.

3. The rope locker hatch lid leaked as a result of seawater over the lower poop deck, and the poor seal between the hatch lid and the hatch coaming. The rope locker hatch lid had not been maintained in a watertight condition in that the worn dogs and wedges were not exerting sufficient clamping pressure to secure the hatch lid given the recent fitment of soft new sealing rubber.

4. The seawater contamination of the fuel service tanks was a result of poorly maintained breather vents and the weight of seawater over the vents in the poor weather conditions.

5. The vessel's initial list to port was a result of the fly ash cargo shifting. The shift of cargo was the direct result of the movement of the vessel when lying starboard beam-on to the large sea.

Although not contributing factors, it is further considered that:

6. The initial stability conditions for the vessel should have been calculated after completion of loading at Gladstone. Some assessment of the vessel's stability should also have been made after the cargo had shifted.

7. Safety harnesses and lifelines would have minimized the risk of crew members being swept overboard when working on resealing the rope locker hatch while the lower poop deck was being regularly swamped by waves.

8. The absence of a bilge alarm fitted in either the rope locker or steering flat prevented the crew being alerted to the water ingress in sufficient time to avert the failure of the steering motors.

9. The knowledge of the transportation properties of the Gladstone power station fly ash is insufficient; an accurate stowage factor needs to be ascertained and the 'cohesive' categorisation of the cargo reviewed. Adequate measures also need to be prescribed to minimise the risk of cargo shifting in adverse conditions.

10. The decision to divert the vessel to Port Kembla, rather than a closer port of refuge, may have unnecessarily endangered the vessel and crew with the continued movement of the cargo.

11. The efforts of the crew on the days of 9,10, 11 November, in resealing the rope locker hatch, restoring the steering and navigating Warden Point safely to port in such adverse conditions, were commendable.

Occurrence summary

Investigation number 152
Occurrence date 10/11/1999
Location Off east coast, Australia
State New South Wales
Report release date 04/06/2001
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Marine
Marine occurrence category Equipment
Occurrence class Incident
Highest injury level None

Ship details

Name Warden Point (formerly Red Sea)
IMO number 7636822
Ship type Bulk carrier
Flag Australia
Departure point Port Kembla, NSW
Destination Melbourne, Vic