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 pilot of the Cessna 210 was to be accompanied by five passengers on a flight from Merimbula to Albury. A flight notification was submitted by telephone to the Airservices Australia regional briefing office which indicated that the aircraft would be operating under the instrument flight rules and would track to Albury via Cooma and Corryong at 10,000 ft. The pilot obtained a pre-flight briefing from the Airservices Australia automated pilot briefing system (AVFAX) and selected a product code that provided weather forecasts and operational information for aviation meteorological forecast Area 21.

The Area 21 forecast was applicable for the sector of the flight from Merimbula to approximately 30 NM east of Corryong. At that point the aircraft would enter the eastern part of the adjoining Area 30. The pilot did not order any briefing products for Area 30 from the AVFAX system, which would have included information for his destination aerodrome. No information was requested from the briefing officer during the telephone submission of the flight plan and it was not possible to establish if the pilot had obtained an Area 30 or destination aerodrome forecast from alternative briefing sources. It was reported however, that prior to departing Merimbula the pilot had telephoned a family member to inquire about the prevailing weather conditions in Albury.

The forecast for Area 21 indicated that there would be significant cloud extending up to 8,000 ft over the Snowy Mountain ranges, with some isolated tops to 11,000 ft in the far south of the area. Moderate icing was forecast in the tops of cumulus cloud. The freezing level was forecast to be at 6,000 ft in the south. A hazard alert had been issued for occasional severe turbulence below 10,000 ft over, and to the east of, the ranges. A westerly wind of 30 knots was forecast at the pilot's intended cruise level.

The conditions forecast for Area 30 were similar to those for Area 21. Broken cumulus cloud tops were forecast to extend to 10,000 ft with broken altocumulus/altostratus from 8,000 to 20,000 ft in the east of the area. Moderate icing was forecast in cloud above the freezing level and areas of isolated severe turbulence near the ranges below 10,000 ft. The cloud forecast for Area 30 indicated that flight along the proposed route could possibly require flight in cloud, above the forecast freezing level. The aircraft was not equipped for flight in known icing conditions.

The aircraft departed Merimbula at 1200 Eastern Standard Time and the pilot reported to flight service that he was tracking for Cooma and was on climb to 10,000 ft. Although the aircraft would not enter controlled airspace until just before Albury, an en-route radar controller would provide the pilot with a flight information service from 30 NM south-east of Cooma. The pilot was issued with a transponder code for radar identification and was given frequency change instructions. Flight service also passed information to the pilot on a hazard alert that had been issued for Albury aerodrome, due to cloud at 1,200 ft above ground level, which had not cleared as had been forecast.

As the aircraft approached top of climb it appeared on the en-route controller's radar display. The radar return from the aircraft's transponder indicated that the aircraft had levelled off at 10,100 ft and its ground speed was observed to steadily increase from 78 knots and then stabilise for a short period at approximately 140 knots. The ground speed was then observed to commence a gradual reduction, which was accompanied by some minor variations in the radar-recorded transponder altitude.

At 1233 the pilot reported overhead the Cooma non-directional beacon at an altitude of 10,000 ft. The radar-derived groundspeed was reducing through 110 knots at this time and continued to reduce at a constant rate, before stabilising at approximately 95 knots.

When the aircraft was 8 NM northwest of Cooma the controller observed the pilot to be conducting what appeared to be a descending turn to the right. The controller requested that the pilot confirm that aircraft operations were normal and the pilot responded that "operations are not normal" and indicated that he was diverting to Cooma for a landing. The recorded radar data indicated that the initial stage of the descent was uneven, with erratic rates of descent and some increases in altitude. The final part of the descent was conducted at a stable rate.

A short time later, the pilot advised the controller that he was tracking 310 degrees at an altitude of 7,500 ft and that the descent had been necessary due to an accumulation of airframe ice. The pilot indicated that he had "unloaded" the ice and commented that he was able to get over the cloud at Kosciusko without going "to that height". The investigation was unable to determine what the comment "to that height" meant.

The aircraft was observed on radar to be flying a steady north westerly ground track, at a constant altitude of 7,600 ft. The groundspeed stabilised at approximately 145 knots before radar contact with the aircraft was lost at 1243. The controller informed the pilot that radar contact with his aircraft had been lost and nominated a time for the pilot to make an operations normal report.

At 1248 the pilot reported that he was tracking direct to Corryong and had commenced a climb to 10,000 ft. The pilot confirmed that he was tracking north of his original track and again stated that the ice had been "unloaded". He also indicated that the cloud conditions looked much better about 5 or 10 miles north of his planned track.

An unidentified person made several incomplete transmissions, which appeared to be inter-cabin type conversation, on the area VHF frequency. The background noise from these transmissions very closely matched the background noise contained in other reports made by the pilot. At 1252 the person was heard to say, "... you have a standing wave? Well, it's ...".

The aircraft reappeared on the controller's radar display at 1253 flying a south-westerly track, climbing through a transponder-indicated altitude of 8,400 ft with a ground speed of approximately 45 knots. At 1254, as the aircraft climbed through 8,800 ft, the climb performance appeared to reduce significantly. The transponder return stabilised at an altitude of 9,000 ft, although the ground speed did not increase as would normally be expected if the aircraft had levelled out at this altitude. The aircraft was then observed to take up a more westerly track and appeared to be tracking direct for Corryong.

The aircraft disappeared from the controller's radar display at 1257. The last return received from the transponder indicated an altitude of 8,800 ft with a radar-derived ground speed of 47 knots. During the last 20 seconds of recorded data, the transponder indicated a descent of approximately 200 ft, without any significant increase in groundspeed.

Prior to disappearing from radar the aircraft was flying directly towards Mt Jagungal (6,760 ft AMSL) and was operating downwind of the mountain. Meteorological conditions were conducive to the formation of mountain waves and this type of activity was evident on meteorological satellite imagery that had been taken a short time before the accident. Mountain waves, also known as standing waves are characterised by "waves" of ascending and descending air in the lee of a mountain range, and can be associated with moderate to severe turbulence. These waves can extend for significant distances downwind of the range and can pose a serious hazard to the safety of light aircraft.

Several witnesses had seen or heard the aircraft shortly before the accident. One witness saw the aircraft fly overhead, making slow progress towards Mount Jagungal. The engine sounded as if it was operating normally and could still be heard even after visual contact with the aircraft was lost. The witnesses described a low layer of broken cloud close to the ground, with the aircraft apparently flying in clear air above this cloud. Several persons on the ground reported that the aircraft noise increased in pitch, as if in a dive, shortly before the sound of an impact. This account of engine operation to the point of impact indicates that there was no significant reduction in engine power during the final stages of the flight.

The following morning the aircraft wreckage was located at a position that was consistent with the last recorded radar data. It had impacted the ground at high speed, in a near vertical attitude, and in an apparent left turn. Impact forces had destroyed the aircraft, and all six persons on board sustained fatal injuries. The accident site was located 3.4 NM directly east of Mt Jagungal, approximately 5,700 ft above mean sea level.

The impact crater contained the engine and the forward section of the fuselage. The remainder of the wreckage was located a short distance away. Examination of the wreckage did not reveal any defect that could have affected the operation of the aircraft prior to impact.

The pilot held a valid single-engine command instrument rating. He had satisfactorily completed the requirements for the renewal of his rating on 11 April 1997. The pilot had logged a total of 2904.4 hours aeronautical experience, of which approximately 580 hours had been flown in Cessna 210 type aircraft. He had regularly operated his aircraft as pilot in command during the previous 12 months and had frequently flown between Albury and Merimbula under instrument flight rules. The passenger who was believed to have been in the co-pilot's seat held a private pilot licence, which was valid for flight under the visual flight rules.

Colleagues of the pilot reported that he was familiar with the use of the systems on-board the aircraft and would normally use the autopilot during cruise. They stated that his usual habit was to hand fly the aircraft during climb/descent and when operating in turbulent conditions.

The pilot had completed a Class 1 flight crew medical examination on 18 November 1997, which had included a requirement for completion of a stress electrocardiogram (ECG). Although this testing did not return an abnormal result, post-mortem examination of the pilot did reveal that he was suffering severe coronary artery disease. The examining pathologist commented that the stress associated with operating the aircraft in difficult weather conditions could have precipitated a sudden deterioration in his cardiac condition, possibly resulting in a sudden medical incapacitation.

Prior to departing from Albury on the outbound leg of the flight, the aircraft had been fuelled with 200 litres of avgas. It was not possible to determine how much fuel was on board the aircraft prior to the commencement of the fuelling operation. Based on a minimum fuel quantity of 200 litres for departure from Albury, at least 70 litres of fuel is estimated to have be on board the aircraft at the time of the accident.

The aircraft departed Merimbula with sufficient fuel to complete the flight to Albury, with the recommended IFR reserves intact. As it has not been established that the pilot had obtained an aerodrome forecast for his destination, the extent to which he may have made provision for holding fuel or flight to a suitable alternate aerodrome was not determined.

The seating position of the passengers could not be positively determined due to the extent of the destruction of the cabin. Estimated pilot and passenger weights and their assumed seating positions were used to calculate the aircraft operating weight and centre of gravity position. The passenger-seating configuration to provide the optimum centre of gravity position was used in the investigation estimation. Based on these assumptions, at the time of the accident the aircraft was operating below its maximum take-off weight, with the centre of gravity in the vicinity of the published rear limit.

The pilot had regularly operated the aircraft when similarly loaded and would have been familiar with its handling characteristics. The published stalling speed (wings-level) for the aircraft at the estimated load configuration was approximately 64 knots indicated air speed (IAS). The published best rate of climb speed was 92 knots IAS.

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.

The pilot of the Lancair 320 aircraft planned to fly, with a passenger, from Archerfield to Rockhampton and return. The aircraft was refuelled at Rockhampton and after an hour's stopover, they departed for Archerfield, on climb to the planned cruise altitude of 5,500 ft above mean sea level. The aircraft left controlled airspace at 1403 Eastern Standard Time. At 1428 Brisbane Flight Service received a Mayday transmission from the aircraft. The pilot indicated that the engine had lost all oil pressure, and that she intended to land on a road. This was the last recorded transmission from the aircraft. The crews of searching aircraft did not hear any transmissions from the missing aircraft's emergency locator transmitter (ELT). The crew of a search aircraft sighted the wreckage at 1815.

The pilot held a commercial pilot licence, and a medical certificate limited to private operations. She had been taught to fly the aircraft type in July 1994, and up to December 1997 had gained 104 hours experience on type. The pilot met the 90-day recency requirement specified in the Civil Aviation Regulations pertaining to the carriage of passengers. However, with the exception of a 30-minute flight on 13 December 1997, the only flying experience gained by the pilot in the last 90-days was the 3 hours flown on the day of the accident. The passenger held a private pilot licence but was not experienced on the aircraft type.

The wreckage was located about 380 m south of a dirt road aligned 080/260 degrees M. The road was new and unusually wide due to the recently constructed clearway through the coastal forest. it had a natural surface and was suitable for an emergency landing. The surface wind at the time of the accident was an easterly at about 15 kts.

Examination of the accident site revealed that the aircraft struck the ground at an angle of 45-50 degrees nose-down and banked approximately 90 degrees left. The left wingtip struck the ground first. The aircraft then cartwheeled, traversed a windrow of felled trees, and came to rest inverted, aligned approximately 345 degrees M, 22 m from the initial impact point. The engine, firewall and instrument panel had separated from the fuselage in one piece. The empennage had separated in a whiplash action and had come to rest 8 m beyond the fuselage, also aligned approximately 345 degrees M. The landing gear was locked in the extended position and the wing flaps were retracted. A significant quantity of oil had escaped from the engine during flight, as evidenced by oil along the lower fuselage. A search of the area where the aircraft was parked at Rockhampton found a small pool of fresh oil consistent with engine oil dripping from the engine cowling during the stopover. It could not be established if oil had been added to the engine at Rockhampton.

The ELT was mounted in the rear of the fuselage but was disconnected from its aerial due to impact forces. The unit was turned off 42 hours after the accident. Later specialist examination found that the near-new batteries were almost depleted, indicating that the unit had been operating but not radiating effectively without its aerial.

The engine was removed to an engineering workshop and dismantled under the supervision of BASI investigators. Approximately 1 L of oil was recovered from the engine and there was no sign of seizure damage to any engine component. Specialist engineering opinion was that the engine was serviceable before impact. Destruction dynamics of the wooden-bladed, variable-pitch propeller assembly indicated that the engine was producing power at impact. During removal of the engine ancillary components, a high-pressure oil hose was found to be holed. The braided steel, rubber-lined hose had been resting on the Number 1 cylinder exhaust pipe and had worn through due to vibration and heat.

The oil hose had been fitted to replace the engine manufacturer's stainless-steel line between the propeller hub and the propeller governor at the rear of the engine crankcase. Replacement of the stainless-steel line with a braided steel hose was authorised by Civil Aviation Safety Authority (CASA) Airworthiness Directive (AD) AD/LYC/86 Amdt. 1 issued on 12 July 1990. The AD referred to Textron Lycoming Service Instruction 1435, which specified a Type D, teflon hose with steel braiding/fire-sleeving, and instructions on clamping/routing. The item fitted to the aircraft was a Type A, steel-braided, rubber hose of lower specifications than the Type D hose and was clamped/routed incorrectly. The aircraft was amateur-built by its previous owner. The hose had been installed before the aircraft's initial airworthiness inspection prior to being placed on the Australian Aircraft Register.

Forty flight-hours before the accident, the engine's cylinders had been removed/refitted during unscheduled maintenance. The aircraft had also undergone a periodic inspection at the same maintenance organisation 19.4 flight hours before the accident.

Although the engine did not show any signs of seizure and some oil remained, the length of time that the engine may have continued to operate could not be determined. Bundaberg aerodrome, 72 km from the accident site, was the nearest suitable aerodrome. Considering the loss of oil pressure, the pilot's decision to carry out a precautionary landing on a road in an area devoid of other suitable landing sites was appropriate. The circumstances of the approach could not be determined. Although the wing flaps had not been configured for landing, the disposition of the wreckage was consistent with a right-base position for landing into wind. The attitude of the aircraft at impact was consistent with a loss of control at a height from which recovery was not possible.

Comparison of limitation data contained in the aircraft flight manual and the flight test results contained in the aircraft files held by CASA revealed a discrepancy in the documented aerodynamic stalling speeds. The stall speeds specified in the aircraft flight manual were lower by 2 kt when compared with the relevant flight test power-off stalling speeds.

Although not implicated in the accident sequence, two other discrepancies were found which involved the fitment of an automotive engine oil filter to the engine, and a right-angle drive adaptor for the rear mounted propeller governor. Neither was covered under an Australian Engineering Order or Supplemental Type Certificate for the Textron Lycoming engine.

During the course of the investigation, it was reported that maintenance by unqualified personnel had been performed on the propeller system following the last periodic inspection. This could not be substantiated.

The Airbus A320 on a flight from Hobart to Melbourne had commenced descent from flight level (FL) 350 to FL210 when the aircraft cabin altitude began to rise rapidly. The co-pilot was unable to control the cabin pressurisation manually.

The flight crew donned oxygen masks, and the pilot in command requested and was given a clearance by air traffic control for an immediate descent to 10,000 ft. During the descent, the passenger oxygen masks deployed. The aircraft subsequently made an uneventful approach and landing at Melbourne Airport.

The operator found that the electronic control of the pressurisation outflow control-valve had failed, allowing the valve to remain in the fully open position. The valve was changed and the aircraft returned to service. The valve has been returned to the manufacturer in France for further evaluation.