On 8 June 1998, at 0855 EST, the pilot of a Boeing 737 air transport aircraft reported receiving an emergency locator transmitter (ELT) signal about 25 NM west of Melbourne. The pilots of several other aircraft also reported hearing the emergency beacon signal on 121.5 MHZ. At 0949 the Australian search and rescue centre received the distress signal via a satellite and had a possible location in the Mount Macedon area. At 1012, VH-SAR, a dedicated search aircraft, departed Moorabbin tasked with locating the beacon using a homing device. The pilot of SAR reported that the cloud tops over Mount Macedon were about 4,500 ft. By about 1245, Cessna 210, UNH, was assessed to be the missing aircraft. UNH had been conducting a no search and rescue (NOSAR), visual flight rules (VFR) flight from Bendigo to Moorabbin. At 1302 a ground party discovered the wreckage of UNH on the north western slope of the Mount Macedon feature at a ground elevation of about 2,840 ft above mean sea level (AMSL). The aircraft had cut a 100 metre swath through tall trees in the direction of 060 degrees magnetic. Both wings and the tail plane were torn off before the fuselage impacted sloping ground.

Melbourne radar recorded only one minute 35 seconds of UNH's flight path. UNH had maintained a steady track of about 160 degrees magnetic at 122 kts groundspeed from Kyneton before turning east in the Woodend area. Shortly thereafter the aircraft turned onto an east north easterly heading before disappearing off radar. Briefly during the recorded easterly turn, the radar recorded a groundspeed of 153 kts. The groundspeed then decreased to 77 kts just before the aircraft disappeared off the radar screen. The forecast wind at the time was 180 deg (true) at 20 kts at 2,000 ft AMSL, and 170/20 kts at 5,000 ft. There was no altitude recorded for UNH on the radar tape.

A few minutes before the accident a qualified pilot, on the ground 6.5 km S of Kyneton, witnessed an aircraft meeting the description of UNH. This aircraft was flying SE at about 500 ft above ground level (AGL) just below the cloud. The weather to the north of Kyneton was clear sunshine. The cloud line was from Kyneton to the northern edge of Woodend. The Mount Macedon feature was obscured by cloud. The aircraft maintained a steady track towards Gisborne. He reported that the aircraft's engine sounded normal. He lost sight of the aircraft as it neared Woodend. At 0829 two other people heard an aircraft flying very low over their house near Woodend but they did not see it. They described the weather conditions as heavy fog to below the tops of tall trees. Another qualified pilot witnessed the weather from the ground in the Woodend area at about the time of the accident. He described the cloud as low stratus in the form of fog. He also said that Mount Macedon was not visible due to cloud coverage.

The ground level at Kyneton was about 1700 ft AMSL and at Woodend about 1900 ft, compared to about 2,840 ft at the accident site.

The Bureau of Meteorology described the weather conditions as: "Rain showers and drizzle accompanied by patchy low cloud, generally widespread on and south of the Great Dividing Range mainly east of 144 deg E, while conditions to the north were quite clear due to the drying out of the airstream". There was no cloud and excellent visibility at Bendigo and visual meteorological conditions (VMC) prevailed at Moorabbin. At Melbourne airport, 30 minutes after the accident, there were three OKTAS of cloud at 300 ft AGL, seven OKTAS at 800 ft, plus drizzle.

The 37-year-old pilot held a private pilot's licence, issued in August 1982. He was qualified to fly the Cessna 210, UNH, which he owned. He held a valid class two medical certificate with a restriction of needing vision correction to meet the near vision standard. No evidence was found that the pilot was suffering from any medical condition which could have contributed to the accident. Vision correction spectacles were found at the accident site and a taxi driver, who drove the pilot to Bendigo airport on the morning of the accident, stated that the pilot was wearing spectacles. The pilot had logged total flight time of 340 hours, comprised of 120 hours dual and 220 hours as pilot-in-command by day. He had never qualified for an instrument rating. He had logged only eight hours of simulated instrument flight time but was reported to have gained more simulated instrument flight rules (IFR) experience by practising with a safety pilot in accordance with the provisions of Civil Aviation Regulation 153. He was reported to have accrued 1.5 hours simulated IFR flight time as recently as 30 May 1998 between Mildura and Leigh Creek. His last biennial flight review was conducted on 28 May 1998. From 29 May 1998 until 8 June 1998, the pilot had logged 17 hours as pilot-in-command of UNH. He had shared the flying with another private pilot from Moorabbin to the Northern Territory to Bendigo. He was on the last leg of the return flight from the Northern Territory to Moorabbin when the accident occurred.

Late on the afternoon of 7 June 1998, the pilot, his companion pilot and two passengers had arrived at Bendigo in UNH. They refuelled the aircraft with 243 litres of AVGAS. Their intention was to continue the flight to Moorabbin that day but as there was some doubt about reaching Moorabbin before last light, the pilot elected to remain overnight at Bendigo and to continue the flight on 8 June 1998, weather permitting. For reasons unrelated to the accident, the companion pilot and one of the passengers elected to be driven by road to Melbourne on the night of 7 August 1998.

At 0644 on the morning of 8 June 1998, the pilot telephoned an Airservices Australia briefing officer and was given weather details for the proposed flight from Bendigo to Moorabbin. He did not submit a flight plan or a search and rescue time (SARTIME) to the briefing office for the flight. A flight log sheet, found in the aircraft after the accident, confirmed that the pilot had planned the flight from Bendigo to Moorabbin via Kyneton, Mount Cottrell and Point Ormond. On the recent flight legs from Victoria to the Northern Territory and return the pilot had nominated SARTIMEs to Airservices Australia.

For the trip to the Northern Territory and return to Victoria, the pilot had used his portable Garmin 195 global positioning system (GPS) to assist with navigation. He was reported to have been quite competent with its use. Another pilot, who had flown UNH in the past, using a similar portable GPS, reported experiencing erratic GPS tracking in the Mount Macedon area. However, on 30 June 1998 Airservices conducted flight test trials in the Mount Macedon area using a Gulfstream Commander 1000 test aircraft fitted with five GPS receivers. One GPS was a handheld Garmin GPS 90 with an external antenna, comparable to the GPS used in UNH. No fault was found with GPS tracking in the Mount Macedon area at the time of the trials.

The aircraft was examined at the accident site before being retrieved to Moorabbin airport where it was subjected to detailed examination. Evidence was found at the accident site that there was fuel on board the aircraft at impact. Damage sustained by the engine crankshaft confirmed that the engine was producing power at impact. No fault was found with the airframe or engine which may have contributed to the accident. Damage sustained by instruments and avionics was consistent with impact forces.

A Piper Archer and a Piper Tomahawk collided at an altitude of about 1,200 ft as the Archer was tracking to enter the crosswind leg for a landing on runway 34 at Hoxton Park aerodrome. The collision occurred in fine and clear conditions, about 0.5 NM east of the upwind end of the runway. Both aircraft were being flown under the visual flight rules (VFR). The pilot of the Archer was able to maintain control of his aircraft and make a successful approach and landing on runway 34, although the nose landing gear had been substantially damaged in the collision. The aircraft was stopped on the runway, resting on the collapsed nose landing gear.

The collision was observed by witnesses who reported that the Tomahawk immediately spiralled down and crashed into an unoccupied house in a suburban housing area. Both occupants were fatally injured. There was no fire and there were no injuries to persons on the ground.

Operations at Hoxton Park are not directed by air traffic control services and rely on pilots seeing and avoiding other aircraft. The aerodrome is located within a common traffic advisory frequency (CTAF) area, extending to a 2 NM radius from the aerodrome and to a height of 1,700 ft. Pilots of radio-equipped aircraft intending to operate within that area are required to make a radio broadcast when approaching the CTAF boundary. That broadcast must include aircraft callsign and type, position, level, and intentions. No other radio report is required prior to landing.

The pilot of the Archer reported that he had made a broadcast on the CTAF when 3 NM inbound to Hoxton Park. He then descended to 1,200 ft and tracked to join the crosswind leg for runway 34, making a "joining crosswind" broadcast while still approaching the upwind end of the runway. He saw another aircraft turning onto crosswind after taking off from runway 34, and a second aircraft on the downwind leg. At about that time, he saw to his left the underside of an aircraft turning to the left, about 50 m away, but skidding towards him at about the same altitude. The pilot of the Archer said he started to turn to the right to avoid a collision, but there was a bang just moments after he first saw the aircraft. He briefly glanced back and saw the aircraft spiralling down to the left. It appeared to him that the outboard end of the right wing of the other aircraft was bent upward at about 45 degrees and that the aircraft appeared to be totally out of control. As he was concerned for the safety of his own aircraft, he concentrated on landing as soon as possible. At no stage prior to the accident was he aware of the presence of the Tomahawk.

Investigation of the wreckage of the Tomahawk indicated that the engine had been torn out during the impact with the house. There was major disruption to the aircraft structure and cockpit area. Small sections from the right wing were scattered about the immediate neighbourhood. The cockpit instruments and controls were too severely damaged to provide any useful information. The very high frequency radio was selected to the CTAF frequency. There was no evidence of any pre-existing defects or abnormalities with either aircraft that may have contributed to the accident.

A metallurgical examination of a section of the right outboard wing from the Tomahawk revealed that a propeller blade of the Archer had first cut through the wing-tip plastic moulding near the trailing edge. The propeller had then cut through the wing at about the mid-chord area before finally striking the leading edge. The action of the propeller blades striking the wing resulted in disruption of the wing structure, with an associated upward bending of the outer section of the wing.

Sydney airport and associated airspace was being operated in accordance with Mode 9 of the Long-Term Operating Plan. A Boeing 737 (B737) departed runway 34R for Melbourne and was cleared initially to 5,000 ft on a MARUB ONE standard instrument departure (SID), with a Wollongong transition. The SID required the crew to intercept and track via the 075 Sydney VOR radial to 15 NM (waypoint MARUB), and to then turn right and track 144 degrees until passing 9,000 ft.

At the same time, another B737 inbound to Sydney on a CHEZA THREE standard arrival route (STAR) for a landing on runway 34R had passed waypoint WHALE, located 20 NM east of Sydney, and was maintaining 7,000 ft in accordance with its clearance.

The Departures South controller cancelled the 5,000 ft altitude restriction for the departing B737 and issued a clearance for the aircraft to climb to Flight Level 280. The 5,000 ft restriction would have assured separation with the inbound B737. When the altitude restriction was removed, the controller relied on monitoring the flight paths of both aircraft and intervening, if necessary, to maintain separation.

When the departing B737 turned right to track 144 degrees in accordance with the SID, there was a breakdown in separation between the two aircraft. Separation was reduced to 2.5 NM horizontally and 500 ft vertically, whereas the required standard was either 3 NM or 1,000 ft. Traffic information was passed to the crew of the departing B737, who sighted the other B737 while passing behind it.

The Departures South controller was relatively inexperienced, having held a control rating in the Sydney Terminal Control Unit for only three weeks. The controller was distracted from the monitoring role by coordination activities with Bankstown control tower, and by radio transmissions to other aircraft. The controller also considered himself to have been fatigued as a result of local rostering practices.

A Boeing 737 (B737) departed runway 34R on an ENTRA ONE standard instrument departure (SID), on climb to 5,000 ft. Immediately after departure, the crew established communication with the Departures North (DN) controller.

A Metro, inbound to Sydney from the north, was being radar vectored for a wide downwind leg to runway 34R, maintaining 7,000 ft, having earlier been diverted to the east for sequencing with preceding slower traffic. Although this track placed the aircraft in DN airspace, the Metro crew, as instructed, remained in communication with the Approach North (AN) controller. On request, the AN controller had been granted approval by the DN controller for the Metro to transit through the DN controller's airspace. The weather conditions were fine, and runway 34 parallel operations had been in progress for 18 minutes.

The DN controller had elected to provide vertical separation between the two aircraft by issuing instructions that would enable the B737 to climb above the Metro. This plan was coordinated with the AN controller. A clearance to climb to flight level 280 was issued to the crew of the B737, with a request to expedite climb through 8,000 ft. As this transmission was being made by the DN controller, the AN controller instructed the crew of the Metro to turn right onto a heading of 170 degrees for the downwind leg.

Subsequently, it was perceived by the DN controller that the effective climb performance of the B737 would be insufficient to ensure that the required separation standard of 1,000 ft vertically or 3 NM horizontally between the two aircraft would be maintained. The controller amended the clearance and instructed the crew of the B737 to maintain 6,000 ft. However, because the B737 was climbing at 4,500 ft/min, it had climbed to 7,000 ft before the crew were able to stop the climb and commence descent. As there was now less than 3 NM between the aircraft, both controllers passed traffic information to the crew of their respective aircraft. The crew of the B737 sighted the Metro, passing beneath that aircraft with approximately 600 ft of vertical separation. The crew of the Metro did not sight the B737.

During the two years since the AN controller had been rated, the system in which he was working had changed significantly due to noise-sharing arrangements at Sydney (Kingsford-Smith) Airport. The controller's training and endorsement had been undertaken and achieved in a less complex environment. The unpredictability of the more complex arrangements required a high degree of coordination for which the controller had not been adequately trained.

Conversely, the DN controller had gained his initial rating in the days when air traffic control was more reactive and dynamic than the present more regulated system. In the previous, less structured air traffic control environment that the controller had been trained in, there had been undocumented procedures that everyone was aware of. Those procedures were passed on from controller to controller as skills were developed and refined. The DN controller expected that his intentions and plan would be readily interpreted by the AN controller.

A Boeing 747, while en-route from Kansai to Brisbane at Flight Level 370, encountered unforecast clear air turbulence, which lasted for about 10 seconds. One flight attendant and 16 passengers suffered minor injuries. The aircraft sustained minor damage to internal ceiling panels in the rear cabin. A number of panels which contained the passenger overhead lighting and air vent controls were dislodged. However, the overhead cabin baggage lockers remained intact during the event.

An examination of the aircraft flight data recorder indicated that the turbulence had been preceded by a period of smooth air, which lasted for 40 seconds. The data revealed that during the event, the aircraft had sustained a positive G-loading of about 1.55, and a negative loading of about 0.21. The aircraft also deviated 250 ft above, and 30 ft below, its assigned flight level. No anomalies were recorded that might have suggested a malfunction of the aircraft systems.

A forecast for the area indicated no significant weather, although a subsequent analysis of relevant satellite images revealed isolated cumulo-nimbus clouds. A report by the Bureau of Meteorology suggested that turbulence above those clouds may have been responsible for the occurrence.

During the flight, the pilot in command had recommended that the passengers, when seated, should keep their seatbelts fastened. The pilot in command subsequently advised that prior to the turbulence, flight conditions had been smooth. The night was dark, and the aircraft weather radar did not indicate adverse weather. Consequently, the crew did not illuminate the seatbelt signs.

A flight attendant reported that, at the time of the occurrence, a number of passengers did not have their seatbelts fastened and were injured when they were thrown from their seats. Some of those passengers had refused to fasten their seatbelts when seated. One of the passengers was injured when a piece of ceiling panel fell on him. A flight attendant was injured when she was thrown to the ceiling and then to the floor. Five passengers admitted to hospital were later released the same day.

In order to alert other crews in the area, the airline's standard operating procedures required the crew to report severe turbulence to air traffic services. However, flight service records indicated that this did not occur.

Earlier on the day of the accident the pilot had flown the aircraft to Stanthorpe before returning to Casino at about 1100 EST. He had refuelled the aircraft with approximately 60 litres of Mogas (automotive fuel) immediately prior to departure at about 1250. The aircraft was approved to operate on Mogas.

The last confirmed radio transmission from the pilot after he departed Casino was at 1332 when he reported to Air Traffic Services (ATS) that he was 62 NM from Archerfield, maintaining 4,500 ft. A search was mounted for the aircraft after it was reported overdue on the flight to Archerfield. The following two days of the search were hampered by low dense cloud in the area. Several pilots of overflying aircraft reported hearing transmissions from an emergency locator transmitter in the area of Mt Chingee, near the Queensland-New South Wales border.

Searchers located the wreckage of the aircraft early on the third day of the search, at approximately 2,500 ft AMSL, in densely wooded terrain on the slopes of Mt Chingee. The pilot did not survive the accident. The area where the wreckage was located was known to be a popular poor weather route for VFR traffic through the area.

The Bureau of Meteorology analysed the weather conditions in the area of Mt Chingee on the day of the accident. The analysis indicated that low cloud and probably precipitation would have prevailed at the time of the accident. Residents in the area reported weather conditions consistent with the Bureau of Meteorology analysis.

The Bureau did not conduct an on-site examination for this investigation. An assessment of the aircraft wreckage was carried out using police photographs and video footage. The following assessment is based on the photographic and documented evidence. The aircraft attitude at impact and the damage sustained by the airframe and propeller suggest that the aircraft was in near level flight when it first struck trees. This suggests it was probably under control. The majority of the airframe was severely disrupted by impact forces. The type of torque twisting of both propeller blades and the manner in which the propeller hub separated from the engine, indicate that the engine was developing significant power at impact. The aircraft had a current Maintenance Release that showed no outstanding maintenance requirements.

The last altitude and position report given by the pilot, placed the aircraft at 4,500 ft, approximately 7 NM or about 3 minutes flight time from the accident site. The site was approximately 2,500 ft AMSL.

The pilot usually kept his personal logbook and the aircraft records in the aircraft. None of these records were recovered for examination. Records held by the Civil Aviation Authority show that he held a Private Pilot Licence. He did not hold an instrument rating. His total aeronautical experience was approximately 650 hours. He held a night VMC rating however, it could not be established if the pilot ever exercised the privileges of the rating.

The investigation established that the pilot commonly worked long hours in demanding employment. A Human Factors specialist assessed the pilot's known workload. The specialist advised that the pilot was likely to have experienced sleep deprivation and high workload in the two days preceding the accident. When these factors are combined, fatigue, whether of an acute or a chronic nature, will eventually be experienced. The effects of fatigue on performance vary from individual to individual and may include poor judgement and decision making, increased reaction times, mental haziness or lethargy, and a general decrement in psychomotor performance.

The investigation sought the assistance of a specialist in Aviation Medicine for the interpretation and analysis of the pilot's post-mortem report toxicological results which indicated the presence of prescription drugs. This was done to determine the possible effects these drugs would have on the pilot's ability to safely operate an aircraft. Prescription drugs used alone or in combination may seriously interfere with an individual's ability to safely operate an aircraft, particularly as a single pilot in bad weather. The pilot should have been aware of the potentially serious hazards of using these medications in the flight environment. A review of the CASA aircrew medical examinations of this pilot could find no evidence of any recorded medical problems warranting the use of the drugs described in the toxicology report.

The Boeing 747 (B747) was on descent for an arrival at Sydney. The crew was being radar vectored to runway 16R for sequencing behind a SAAB 340 that was being radar vectored to runway 16L. Procedures at Sydney had different air traffic controllers responsible for directing the traffic to each of the parallel runways. The Director West controller positioned aircraft on final for runway 16R and the Director East for runway 16L.

The Director West controller was sequencing the B747 and assigned a heading of 060 degrees magnetic with an instruction to report when the crew had the field in sight.

The crew of the B747 reported the field in sight and the Director West controller told the crew to expect to go right up to the localiser, with a right turn to intercept from the eastern side. The crew acknowledged with a partly unintelligible transmission that included the words "roger" (unintelligible) "localiser into".

Almost immediately, the crew of the B747 turned their aircraft away from the assigned heading onto a heading of 110 degrees to intercept the runway 16R localiser. They advised air traffic control that they were now right heading 110. This particular heading placed the aircraft in potential conflict with the SAAB. The Director West controller instructed the crew of the B747 to maintain a heading of 060 degrees to ensure that the aircraft passed behind the SAAB. The Director East controller passed traffic information regarding the B747 to the crew of the SAAB.

Although the crew of the SAAB reported that they had the B747 sighted, radar separation between the two aircraft was reduced to 2.5 NM during the manoeuvre. The separation standard required was either 3 NM horizontally or 1,000 ft vertically. Analysis of the radar data indicated that vertical separation between the two aircraft was reduced to approximately 800 ft when the 3-NM radar separation standard was infringed.