FACTUAL INFORMATION

The pilot had positioned the helicopter at "Fernleigh" homestead on the previous Friday and had not flown the helicopter again until the day of the accident. Flying commenced at 0645, with the helicopter being flown to "Bunburra" property to treat serrated tussocks. Operations ceased there at about 0945, and the helicopter was flown back to "Fernleigh". Further flights were carried out until 1200, when flying stopped for a lunch break. Each treatment flight took approximately 10 minutes, with the helicopter returning to reload with chemical.

After the pilot and loader/driver had finished lunch, they refuelled the helicopter. Two further flights were completed before the helicopter took off again at 1305. This was to have been the last flight in the treatment area before moving to a new location. The pilot had advised the loader/driver that during his return from the treatment area, he would inspect for regrowth another area he had previously treated. Before take-off, the property owner reminded the pilot of the presence of power cables in the area that he was going to inspect. The map location of the cables was not reviewed by the pilot. When the helicopter had not returned by about 1315, the loader/driver and property owner became concerned. Their initial search failed to find the helicopter, but shortly after, the owner of "Belmedie", an adjoining property, advised them that it had crashed.

The helicopter had struck power cables at a height of 26 m whilst tracking in an easterly direction at a calculated airspeed of 45 kts. The power cables were located in the area that the pilot had planned to inspect for regrowth. There were no witnesses to the actual flight path of the helicopter preceding the collision. A witness at "Belmedie" had heard and glimpsed the helicopter near the homestead. Weather conditions at the time of the accident were fine.

The accident site was located on the western side of an open area of rising ground. On both sides of the flight path lay heavily wooded hills. Obstructions to the flight path were two sets of diverging (approximately 46 degrees) 22,000-volt power cables, strung from a pole on the top of a hill to the left of the flight path. The first set, with a span of 224 m, went to the "Belmedie" homestead. The second set, with a span of 428 m, went to a pole on rising ground across and to the right of the flight path.

An engineering examination of the helicopter did not find any anomalies or defects that may have contributed to the accident. Damage to the helicopter structure was consistent with the main and tail rotors having come into contact with power cables. The main rotor blades had initially contacted the power cables, followed by the tail rotor. The cables then passed between the tail-rotor gearbox and the pitch change links around the tail-rotor drive shaft, before breaking. The dynamics of the cable strike resulted in the main rotor slicing off the tail boom forward of the tail-rotor gearbox. Other damage sustained by the helicopter was consistent with severe forces generated during the subsequent ground impact sequence. No emergency locator transmitter (ELT) was fitted.

ANALYSIS

The approach of the helicopter close to the homestead, en route to the inspection site, was consistent with a practice followed by pilots to locate and avoid power cables running to building sites. It would appear that, once having located the power cables to the homestead, the pilot continued towards the area to be inspected. The poles which supported the 428-m cable, which the helicopter struck, were located in heavily wooded areas. The cables could not have been easily seen, due to poor background contrast.

Initial contact with the power cables was by the helicopter main rotor blades, followed by the tail rotor, before the cables broke. The dynamics of the cable impact resulted in the main rotor slicing off the tail boom. As a result, the pilot experienced loss of control as the helicopter was now without directional control, coupled with a significant forward shift of the centre of gravity.

It is likely the pilot either forgot or did not see the second set of cables before colliding with them.

SIGNIFICANT FACTORS

1. The pilot did not adequately establish the location of the power cables prior to the flight.
2. The nature of the terrain in the vicinity of the power cables inhibited the capacity of the pilot to see them.
3. Flight control of the helicopter was lost when the tail boom and tail rotor gear box were severed from the helicopter.

Reports indicated that the pilot had intended to conduct a test flight in his gyrocopter to check the propeller installation. A short time later he was observed flying in an easterly direction at an estimated height of 400 - 500 ft above ground level, when two loud bangs were heard.

A search located the wreckage of the gyrocopter which was mainly intact except that its wooden propeller had separated from the engine crankshaft flange. Pieces of the shattered propeller, a section of rotor blade skin, and the propeller mounting hub/ pre-rotator drum were found along the flight path, within 230 m of the gyrocopters impact point.

Examination of the engine revealed the crankshaft flange had failed at the attachment bolt holes, allowing the propeller and mounting hub to separate and pass up through the rotor system, striking a rotor blade and tearing a large section of skin away from its spar. The gyrocopter then became uncontrollable and descended rapidly to the ground due to loss of rotor speed and aerodynamic lift.

The propeller attachment bolts, although bent, were still attached to the hub/pre-rotator drum. There were no indications that the bolts had been loose, or the propeller had broken prior to the flange failure.

The crankshaft flange was manufactured from a Subaru cast iron flywheel, machined to a thickness of about 6.5 mm, with an associated loss of material integrity. The flange probably failed due to accumulative stresses imposed on it during operations from fluctuating propeller loads, engine RPM changes, and abrupt aircraft manoeuvres.

The crankshaft flange was manufactured from an unsuitable material. No other faults or malfunctions were found with the gyrocopter, or its controls, which may have contributed to the accident.

FACTUAL INFORMATION

History of the flight

A witness heard the aircraft pass King Island aerodrome at 0455 EST at the same time as he noticed the pilot-activated 10/28 runway lights illuminate. The pilot reported to Melbourne Control that he would be completing a runway 10, non-directional beacon (NDB) approach. A short time later he broadcast that the aircraft was at the minimum descent altitude, which is 640 ft above mean sea level (AMSL) for a runway 10 NDB approach. He also broadcast that there was a complete cloud cover. The aircraft did not enter a missed approach procedure but was heard to fly towards the south-east from overhead the NDB, which is located 1.3 km south-south-west of the centre of runway 10/28. A second witness, located near the NDB site, reported observing the aircraft's lights to the south-east. At 0507 a farmer heard the aircraft pass low over his house shortly before it crashed into trees, 3.5 km south-east of the aerodrome. The first responders arrived at the accident site at about 0530. The pilot had not survived.

Damage to aircraft

Parts of the aircraft were torn off by tree and ground impact. However, the fuselage remained substantially intact until it was destroyed by fire after it had come to rest.

Pilot information

The pilot was correctly qualified and endorsed to perform the flight. He held an air transport pilot (aeroplane) licence, a night visual flight rules rating and a current multi-engine command instrument rating.

The pilot's total flying experience included 185 hours at night, of which 36 hours were as pilot in command, 6 hours as dual and the rest as co-pilot in twin turbine-engine regular public transport aircraft. He was approved to fly as pilot in command of charter operations to King Island in Piper PA 31 Chieftain aircraft on 9 May 1995 following company check flights with the chief pilot. The pilot had completed 104 flights to King Island, mostly in daylight, but not all in Chieftain aircraft. He had flown from Moorabbin to King Island at night as pilot in command of Chieftain aircraft on three occasions since 9 January 1996.

The pilot flew for the King Island operator on a part-time basis. His normal full-time employment involved flying Metroliner aircraft (a twin-engine turboprop aircraft with a maximum weight exceeding 5,700 kg) as co-pilot for a domestic airline. As co-pilot, he had accrued 1,837 hours. The pilot was on annual leave from his full-time employer at the time of the accident.

To be promoted to pilot in command of a Metroliner the pilot had to first accrue 500 hours as pilot in command of multi-engine aircraft operating under instrument flight rules. This was to comply with Civil Aviation Order 82.3. To meet this requirement, the pilot's full-time employer gave him permission to work part-time for the smaller regular public transport / charter operator. At the time of the accident, he still needed to accrue a further 247 hours.

It was reported that the pilot was well rested prior to the accident flight. The tape recordings of the pilot's radio calls, made shortly before the accident, do not indicate he was suffering any significant stress.

The pilot passed his last aviation medical examination on 23 February 1995. There were no restrictions on his medical certificate. He was not known to be suffering from any ailment.

No evidence was found to indicate that the pilot had ever experienced the combined conditions of flying an NDB approach to the minimum descent altitude, with the cloud cover at or near that altitude, and at night in very dark conditions with no ground lighting apart from runway lights. No evidence was found that he had flown circling approaches in simulators under simulated dark night conditions. However, during his experience as a co-pilot on turboprop aircraft, he had flown at night to aerodromes which had a low level of ambient light.

Meteorological information

The pilot received an AVFAX of relevant weather forecasts prior to the flight. He discussed the AVFAX contents with another company pilot who was also planning an early morning flight to King Island in a Chieftain. The AVFAX included the aerodrome forecast for Moorabbin, the relevant area forecast, and the aerodrome forecast for King Island.

At hourly intervals, the automatic weather station at King Island aerodrome measured and recorded wind velocity, air temperature, dew point temperature, QNH, and rainfall. These readings were transmitted electronically to the Melbourne control operator within one minute of their recording. Also, a trained weather observer estimated and recorded the cloud amounts and heights at three-hourly intervals.

At 0500 the King Island aviation special weather report was wind 320 degrees at 5 kts, temperature 15 degrees, dew point 15 and QNH 1003. No evidence was found that the pilot received the 0500 weather report. The 0300 and 0600 observations included a report of a complete cloud cover. No cloud base was reported at 0300. At 0600 the base was reported as 1,000 ft above ground level.

A post-accident Bureau of Meteorology assessment indicated that the meteorological situation at King Island at 0507 on 8 February 1996 would have included complete cloud cover with a base at 1,000 ft above ground level, or possibly lower, with the possibility of fog or mist.

A ground witness at King Island aerodrome reported that he did not see the aircraft or its lights when he heard it fly near the aerodrome at the beginning of the NDB approach. A policeman who drove to the accident site from Currie, about 20 minutes after the accident, advised that conditions were very misty and very dark.

A second pilot from the same company flew a Chieftain to King Island, arriving shortly after the accident. At 0525, he commenced the runway 10 NDB missed approach from 1.6 km west-north-west of the runway 10 threshold. He conducted the missed approach because the runway lights were intermittently obscured by cloud below 640 ft AMSL and there was fog in the area. The aircraft returned to Moorabbin.

Aids to navigation

The only ground-based approach aid for aircraft arriving or departing from King Island aerodrome is the NDB. Several other NDB approaches were conducted at King Island on the day of the accident. No problems were reported concerning the serviceability of the King Island NDB.

Communications

Communications between Melbourne Control and VH-KIJ en route to King Island were excellent. At 0445 the pilot reported that he was changing to the King Island mandatory broadcast zone frequency. At 0451 he reported to

Melbourne Control that he was going to conduct an NDB approach. At 0502 he advised that he would call Melbourne Control again by 0505. At 0506, the controller asked the pilot to confirm that operations were normal. When there was no reply, he attempted to contact the aircraft several times until 0510. After that he requested the pilot of the second Chieftain, estimating overhead King Island at 0510, to try to ascertain if KIJ had landed safely. No radio transmissions were recorded from the pilot of KIJ after 0502.

The last comment by the pilot of KIJ, made on the mandatory broadcast zone frequency and recorded on the King

Island aerodrome aircraft movement recording tape, was for another party to stand by. The operator's agent at King Island aerodrome, reported that he had attempted to contact the pilot by radio but was unsuccessful. The pilot's comment was probably a response to this transmission. It was not possible to determine the time that the comment was made. At no stage did the pilot advise of an in-flight problem.

Aerodrome information

King Island aerodrome had three runways. Only runway 10/28 was equipped with runway lights. The lights were pilot-activated and standby power was available. The runway 10/28 lights were activated when KIJ first passed the aerodrome and remained on until after the accident. Runway 10/28 was 1585 m long and 30 m wide. No visual approach slope indicator system was installed. Three unlit obstacles were clearly depicted on the Civil Aviation Safety Authority's aerodrome chart but only the NDB was marked on the Jeppesen charts used by the pilot. These were the NDB mast at 238 ft AMSL, a second mast at 173 ft AMSL, and third mast at 152 ft AMSL.

A mandatory broadcast zone with a radius of 15 NM was centred on King Island aerodrome.

During the investigation pilots reported that the area around King Island aerodrome had low ambient lighting at night. In hazy or misty conditions or when there was extensive cloud cover there was often no visible horizon and no lighting other than the runway lights to provide a visual reference point.

Terrain/obstacles

King Island aerodrome elevation was 132 ft AMSL at its reference point. The highest obstacle within the prescribed 2.66 NM circling area was the NDB mast at 238 ft AMSL. From the air by day, the terrain within the prescribed circling area looked quite flat. However, the tops of the trees involved in the initial impact were estimated to be 227 ft AMSL.

Runway 10 NDB instrument approach

The minimum sector altitude for a radius of 25 NM was 1,800 ft AMSL. The outbound track for category B aircraft (which includes the Chieftain) was 325 degrees for 2.5 minutes. Aircraft were required to be established on the inbound track of 130 degrees not below 1,300 ft AMSL. Minimum descent altitude was 640 ft AMSL. Circling minimum was 740 ft AMSL. A missed approach required a climb, from overhead the NDB, on 130 degrees to 1,800 ft AMSL.

The pilot used Jeppesen charts which showed the minimum descent altitude for the runway 10 NDB approach as 540 ft AMSL with actual aerodrome QNH set on the altimeter sub-scale, and 640 ft AMSL with forecast QNH set.

Emergency locator transmitter

The aircraft was not fitted, nor was it required to be fitted, with an emergency locator transmitter.

Wreckage, flight path and impact information

Within the limitations created by the post-impact fire, no evidence was found that aircraft components or systems were factors in the accident. The landing gear was down, and the flaps were estimated to have been extended to 15 degrees at impact. A ground witness reported that the engines sounded as if they were normal and producing power immediately prior to impact. Post-accident inspection indicated that the engines should have been capable of normal operation and that they were producing power at impact.

Witness information and post-accident flight tests indicated that the aircraft probably tracked 135 degrees from the NDB for 3 km before commencing a 30-45 degree banked left turn towards the threshold of runway 28. The aircraft was left wing low and heading 360 degrees when it collided with trees during the turn. The aircraft had descended from 640 ft AMSL to 227 ft AMSL prior to impact.

Altimeters

The aircraft was equipped with two barometric altimeters which were severely burnt during the accident. It was not equipped, nor was it required to be equipped, with a radar altimeter. One altimeter retained a sub-scale setting of 1007 hectopascals. The other altimeter was too damaged for the altimeter setting to be ascertained. Forecast QNH for departure Moorabbin was 1007 hectopascals. On the AVFAX received by the pilot prior to departure, the forecast local QNH for his arrival at King Island was 1005. At 0415, Melbourne Control advised the pilot that area QNH was 1007. In contrast, the QNH recorded by the King Island automatic weather station, seven minutes before the accident, was 1003. This reading was passed to the Melbourne Control operator within one minute of its recording. Had the pilot requested an updated QNH from Melbourne Control shortly after 0500 he would have been given 1003.

The sub-scale setting on the altimeter being referenced by the pilot could not be determined. The company chief pilot reported that both altimeters in KIJ had been accurate to within plus or minus 20 ft during flights prior to the accident. The allowable instrument flight rules tolerance was plus or minus 60 ft with an accurate QNH set. A sub-scale error of +4 hectopascals (1007 instead of 1003) could result in the aircraft flying 120 ft lower than expected.

Medical information

The post-mortem and toxicology tests performed on the pilot revealed no medical problem which may have contributed to the accident.

Fire

No evidence was found of in-flight fire. There was a post-impact fire which destroyed most of the aircraft.

Survival aspects

The accident might have been survivable except for the post-impact fire.

Possible misinterpretation of visual circling criteria

No evidence was found to indicate that the pilot would have deliberately descended the aircraft below the circling minima prior to becoming visual.

After discussions with several very experienced instrument-rated pilots, approved testing officers, chief flying instructors, chief pilots and flying operations inspectors, it became apparent that many instrument-rated pilots continued to misinterpret the departure and approach procedures set out in Airservices Australia's Instrument Approach and Landing Charts, page 2, paragraph 1.5, and in particular note 1.

The following extract from Aeronautical Information Publications - Visual circling is relevant to the accident:

"When visual reference has been established within the circling area at or above the minimum descent altitude, further descent below the minimum descent altitude may occur provided that: a. the aircraft is maintained within the circling area; b. visual reference can be maintained; c. the approach threshold or approach lights or other markings identifiable with the approach end of the runway to be used are visible during the subsequent visual flight; and d. obstacle clearance of at least 300 ft (category B) is maintained along the flight path until the aircraft is aligned with the runway, strip or landing direction to be used.

"Note 1: For the purpose of this paragraph visual reference means clear of cloud, in sight of ground or water along the flight path, and with a flight visibility not less than the minimum specified for circling."

The aircraft crashed within the prescribed circling area. Whether the pilot maintained at least the 2.4-km minimum visibility specified for visual circling is unknown.

This investigation determined that many pilots misinterpret the words "in sight of ground or water" to mean no cloud is anticipated between the aircraft and the ground or water along the flight path, whether by day or night, despite not being able to see the ground, water or obstacles. Some pilots believe it acceptable to have 4/8 of cloud below the aircraft at night during a 300-ft obstacle clearance circling approach in very dark conditions. Other interpretations were also evident.

Research has indicated that many pilots in their training have been taught a wrong interpretation of the meaning of "in sight of ground or water along the flight path."

The authoritative interpretation from the Civil Aviation Safety Authority is that "in sight of ground or water along the flight path" means that pilots must be able to physically see the ground, water, and obstacles along the flight path before descending below the minimum descent altitude to apply a 300 ft obstacle clearance buffer.

Previous action on misinterpretations of visual circling criteria

In the Bureau's report 9301743 of the accident involving Piper PA-31-350 Chieftain VH-NDU at Young NSW on 11 June 1993, BASI interim recommendation IR930231 recommended that the Civil Aviation Authority review:

"(a) the adequacy of instructions to flight crew for maintaining a safe height above terrain at night, and

"(b) the phraseology used in aeronautical information publications, departure and approach procedures, instrument and approach and landing charts, paragraph 1.5 with a view to making it less susceptible to misinterpretation".

As a result of this recommendation the Civil Aviation Authority modified the words in the Aeronautical Information Publications to read as follows: "visual reference means clear of cloud, in sight of ground or water along the flight path".

From the same report BASI interim recommendation IR9300234 recommended that the Civil Aviation Authority review the obstacle terrain guidance information provided for flight crew in other than high-capacity regular public transport operations. This review was intended to ensure that flight crew have an adequate knowledge of terrain associated with the route flown, including obstacle terrain information for non-precision and circling approaches. The following is part of the Authority's response:

"The requirement to avoid obstacles by 300 feet is to be complied with using visual reference only, i.e. the pilot must be able to ensure all obstacles lit or unlit are avoided visually. At night this may not be possible. Thus the pilot may only be able to descend when he is aligned with the landing runway and able to use the documented obstacle limitation surface, and, the Civil Aviation Authority will review the practices of other authorities in respect to the provision of terrain information on instrument approach charts with a view to determining whether the current practices need to be changed".

BASI investigation report 9302851 of an accident involving Piper PA-31-350 Chieftain, VH-WGI, in Tasmania, was produced after report 9301743. Report 9302851 identified that the visual circling criteria continued to be misinterpreted despite the fact that the Civil Aviation Safety Authority had amended information on visual circling contained in Aeronautical Information Publications.

Night visual approaches

During a visual approach, a pilot relies on a combination of visual cues and instrument indications to judge the flight path, rate of descent and closure rate. However, clearance from the ground is maintained by visual reference only. During an instrument approach, ground clearance is maintained by reference to a set instrument flight path and an established minimum altitude until the ground is in sight.

When conducting night visual approaches where there are overcast conditions, low levels of ambient light and no visual cues on the ground prior to the runway lights, pilots are less able to adequately judge rates of descent and closure rates appropriately. In many previous accident investigations and research studies using simulators, these "black hole" conditions have been associated with pilots flying low approaches and impacting the ground before the runway threshold. However, the same conditions can also produce high approaches. The black hole conditions in this accident were also exacerbated by the lack of a defined horizon or other visual cue information on the ground beyond the runway lights.

Previous Bureau investigations of night take-off and landing accidents have determined that pilots often have difficulty accepting that operating conditions do not meet the requirements for visual flight, particularly when they can see the runway or helipad lights and there appears to be adequate visibility. However, in black hole conditions a pilot must revert to instrument approach procedures to ensure an adequate level of safety. At many aerodromes this is not an option as there is no precise approach aid. Consequently, pilots often persist with a visual approach despite the conditions.

Automatic weather stations

An automatic weather station was installed at King Island. This provided information electronically to the air traffic service operators in Melbourne. This information was available to the pilot on request.

Automatic weather information broadcast facilities have been established at a number of airports throughout Australia. More automatic weather information broadcast facility installations are planned. The automatic weather information equipment, which is linked with the automatic weather station, normally transmits weather information on the airport navigation aid frequency. Information from Airservices Australia suggests that the locations of automatic weather information broadcast facilities are determined by the aviation industry and the Bureau of Meteorology.

King Island is currently serviced by four airlines and a number of charter operators. At present Airservices Australia has no plans for an automatic weather information broadcast facility to be installed at King Island.

Statistics of similar accidents

During the investigation, a search of Bureau of Air Safety Investigation and National Transportation Safety Board (USA) records for similar occurrences was completed.

Recent Australian accidents identified were:

• BASI investigation report 8802354, Piper PA-31-350 Chieftain, VH-HOX, Coffs Harbour NSW, 7 April 1988; fatal accident at night within the circling area in marginal weather.
• BASI investigation report 9301743, Piper PA-31-50, VH-NDU, Young NSW, 11 June 1993; fatal accident at night within the circling area in marginal weather.
• BASI investigation report 9302851, Piper PA-31-350 Chieftain, VH-WGI, Tasmania, 17 September 1993; fatal accident at night within the circling area in marginal weather.

A computer search of US accident records since 1991 disclosed 17 accidents in which aircraft flew into the ground within the circling area in dark-night conditions. Most of these accidents involved instrument flight rules flights and marginal weather.

ANALYSIS

Accident location

The accident site and aircraft configuration were consistent with the aircraft being on a left base turn for runway 28. Wind conditions were suitable for a landing on runway 10 or 28. Had the pilot intended to land on runway 10, there was no reason for the aircraft to fly so far south-east of the NDB before turning towards the north.

Obstacle clearance

After 104 flights to King Island, the pilot was probably confident that he could avoid the obstacles within the circling area. However, it was possible that the pilot was unaware that the terrain/obstacles to the south-east were about 100 ft higher than the aerodrome reference elevation.

Final flight path

The evidence provided about the misinterpretation of the visual circling criteria may be relevant to the pilot's actions. Information from the witness who reported seeing the aircraft's lights indicates the aircraft had probably descended below the cloud base prior to or during the final turn. Despite this, the reported weather conditions of a dark and misty night with no defined horizon and no ambient lighting made it unlikely that the pilot could maintain visual contact with the ground or obstacles as required by the circling criteria. He would, however, have been able to see the runway lights. If the pilot was not aware of the correct meaning of the criteria, he probably assumed that having only the runway lights in sight was acceptable. Consequently, he continued a visual approach in conditions that were not suitable for visual flight.

Accident investigation and anecdotal evidence indicate that pilots are reluctant to accept that conditions do not always meet visual requirements when they can see the runway or helipad lights during an approach, especially in marginal weather conditions on a dark night. This lack of acceptance often leads to misjudgement of the aircraft's performance during the approach which, in turn, can lead to unexpected ground impact.

Because the pilot did not request updated QNH information, it is probable that he did not have the King Island QNH of 1003 hectopascals set. This would have resulted in the aircraft being closer to the obstacles than the pilot realised.

As the pilot had few visual cues during the turn, he would have relied on the altimeter and vertical speed indicator to help judge his descent rate. At the same time, he would have needed to check the aircraft's position in relation to the runway by reference to the runway lights. This regular transition between visual and instrument flight, in what were instrument flying conditions, probably distracted the pilot to the point where he was unaware of the proximity of the trees until it was too late to prevent the impact.

The evidence indicates that it is unlikely that the pilot had encountered a similar combination of conditions in either his flying or training experience.

The combination of a misunderstanding of the circling criteria, lack of adequate visual conditions, lack of recognition that adequate visual conditions did not exist, the black-hole effect, incorrect QNH, distraction and lack of experience probably caused the pilot to misjudge the descent rate during the approach to runway 28.

The Bureau believes that AIP/DAPS IAL-2, 1.5 should be amended to clarify the instruction and differentiate between day and night circling approaches due to the apparent misunderstandings of the circling requirement. The difficulties of maintaining visual reference with the ground or water at night should also be considered. Clear visual sighting of ground obstacles is almost impossible at night. Therefore, a different limitation may be appropriate.

The Bureau is also concerned that the obstacle clearance heights of 300 ft for category A and B aircraft, and 400 ft for category C and D aircraft, leave very little margin for height deviation. During the high workload of circling approaches, as the aircraft configuration changes with flap and landing gear extension, an inadvertent height loss of 200-300 ft could occur. Pilots are not required to demonstrate a visual circling approach at minimum obstacle clearance height as part of the initial instrument rating test and renewals.

SIGNIFICANT FACTORS

1. The pilot continued a visual approach in conditions which prevented him from maintaining adequate visual clearance from the ground or obstacles and which made visual judgement of the approach difficult.
2. The pilot probably did not recognise that the conditions were not suitable for a visual approach.

SAFETY ACTION

As a result of the investigation, the Bureau of Air safety Investigation issued interim recommendation IR960027 to the Civil Aviation safety authority on 28 August 1996.

"IR960027

"The Bureau of Air Safety Investigation recommends that the Civil Aviation Safety Authority:

"(i) amend AIP/DAPS IAL-2, 1.5 to clarify the intent of the instruction and differentiate between visual circling approaches conducted during the day and at night;

"(ii) critically review the obstacle clearance height to assess whether these minimum heights are appropriate from an operational viewpoint; and

"(iii) require pilots to demonstrate a visual circling approach at the minimum obstacle clearance height during the test for their instrument rating and at subsequent renewals."

The Civil Aviation Safety Authority responded on 12 November 1996 as follows:

"I refer to your interim recommendation IR960027 concerning the accident involving PA31-350, VH-KIJ at King Island on 8 February 1996.

"(i) AIP amendment List 17, effective 5 December 1996, includes a revision of DAPS IAL 2, para 1.5. The revision clarifies requirements for visual circling which are: applicable by night or day, and applicable only during daylight.

"An AIP SUP addressing the AIP changes has been produced with an effective date of 7 November 1996.

"(ii) 300 feet minimum obstacle clearance is the internationally accepted requirement for visual circling for

Category A and B performance aircraft as published in ICAO PANS OPS Doc 8168. The Civil Aviation Safety Authority does not have any evidence to indicate that a trained and recent pilot who is attempting to comply with the obstacle clearance requirements specified for visual circling is placing his or her aircraft in an unsafe situation. The revised text of AIP DAP IAL 2 para 1.5 will further promote safety in this regard by clarifying the requirements for visual circling at night and advising pilots to maintain the maximum practical obstacle clearance during visual circling.

"(iii) Appendix 1 of CAO 40.2.1 specifies the flight test requirements for the initial issue and renewal of instrument ratings. Para 2.1 (f) of the Appendix specifies that the applicant shall demonstrate proficiency conducting a circling approach. However, the present flight test form for the conduct of an instrument rating test does not list a circling approach as a test item. This shortcoming in the flight test form is being addressed in the course of a review of all flight test forms commenced several months ago. It is anticipated that a new instrument rating flight test form will be promulgated and distributed to industry early in 1997."

The Civil Aviation Safety Authority responded again on 13 January 1997 as follows:

"I refer to BASI draft Air Safety Occurrence Report 9600399 concerning the accident involving Piper PA31-350, VH-KIJ, near Moorabbin Victoria on 8 February 1996. The following comments are forwarded for your consideration.

"The Authority agrees with the recommendations contained in the subject draft ASOR. Also, in regards to IR960027:

"(1) AIP DAPS IAL 2 paragraph 1.5 has been amended, with effect 5 December 1996, to clarify the intent of the instruction. The revised text provides requirements for visual circling at night and by day.

"(2) The obstacle clearance heights required for visual circling are those included in the procedures of ICAO Doc 8168 OPS/611 Volume 1 which have been adopted by Australia. These procedures are accepted and are used worldwide. The Civil Aviation Safety Authority considers that the minimum obstacle clearance heights specified in the PANS OPS procedures provide an appropriate safety margin for visual circling operations."

Classification of response: OPEN (The Bureau considers that the response does not meet some or all of the criteria for acceptability for a recommendation that the Bureau considers to be significant for safety. The Bureau will initiate further correspondence.)

The Bureau issued interim recommendation IR960054 to Airservices Australia on 27 August 1996 as follows:

"IR960054

"The Bureau of Air Safety Investigation recommends that Airservices Australia review the criteria used for the installation of AWIBs, taking into account the types of operations at the airport, the frequency of RPT operations, the geographic location and prevailing meteorological conditions."

Airservices Australia responded on 15 November 1996 as follows:

"Re: Occurrence 9600399 generating Interim Recommendation: IR960054

"The Bureau of Meteorology has been installing Automatic Weather Stations (AWS) at aerodromes around Australia for a number of years. AWS are now a vital component of the weather observation network and make a significant contribution to aviation weather products, in addition to other services provided by the Bureau.

"AWS transmit to both the Bureau and to Airservices Australia the basic elements of wind direction and speed, pressure (QNH), air temperature, dew point, relative humidity and ten-minute rainfall. The AWS observations are distributed to Air Traffic Service units and are also stored in the AIS/MET database. In essence, the AWS observations form part of the preflight and inflight information service and, as such, are available on request.

"At the 1994 consultative meeting, industry endorsed a Bureau proposal to make AWS information available via telephone; this being facilitated by means of a Bureau developed device (known as Aerodrome Weather Information Broadcast [AWIB]) connected to each AWS. Industry also endorsed a proposal to make the AWIB information available on navigation aids which were collocated with Bureau AWS.

"With respect to installation and priorities, industry endorsed the proposition that any installation to support telephone (Bureau) or navigation aid (Airservices) access would form part of the normal equipment (AWS and navigation aid) maintenance programmes of the respective organisations. This endorsement was based on the understanding of AWIB connection issues at that time. It is on this basis that the Bureau is progressively implementing a national AWIB installation programme, providing industry with access to the broadcast information via telephone. The Bureau is currently planning to introduce some 20 AWIB per year. However, this installation programme is rather flexible as it depends largely on Bureau Regional Office priorities as to when and where it is carried out. Funding of the Bureau's installations was an integral part of the proposal endorsed by industry.

"Airservices Australia's involvement with such facilities to date has been limited to:

"(a) permitting AWIB to be connected to the Mount Gambier VOR for the initial proof-of-concept trial;

"(b) the use of AWIB (connected to a local navigation aid) as a replacement for obsolete ATIS facilities at four other non-towered locations; and

"(c) introducing AWIB at Canberra as an out-of-hours ATIS supplement which eliminates the need for costly ATC support of out-of-hours RAAF flights, while at the same time directly assists industry to meet Canberra's new Noise Abatement Procedures (ATIS ZULU retained on NDB, AWIB on VOR).

"The only criteria applied in the selection of these sites was that of cost benefit to Airservices. Each of these installations was progressed as an individual requirement and not as part of any programme.

"Whereas the Bureau's costs were not high, were readily defined and were therefore endorsed as a part of the proposal, Airservices is still in the process of identifying the cost of AWIB/navigation aid connection at other locations. It is intended that this costing information form part of a proposal to industry seeking funding for an installation programme. As you might appreciate, the cost of these connections varies considerably from site to site, and as they may involve several kilometres of new cabling work can be quite significant. Airservices' technical staff estimate the average cost of new cabling works at over $23,000 per kilometre.

"The other component of this Airservices proposal will be a prioritised installation schedule. The priorities are expected to be derived from work currently being undertaken by a group (chaired by the Bureau) which is determining a programme for AWS upgrades/enhancements. The remainder of this group is made up of representatives from Airservices, CASA, industry, and the aerodrome owners. The criteria being used by the group specifically includes consideration of the rate of aerodrome utilisation by RPT and other IFR aircraft, critical weather locations and the availability of alternates.

"In the meantime, Airservices will continue to make AWS-derived observations available as part of the preflight and inflight information services."

Classification of Response: CLOSED - ACCEPTED

The aircraft departed Wee Waa at about 1755 EST with a load of 1450 litres of Endosulphan and Delphin spray mixture, to spray a cotton property 5 km east of Walgett. At about 1900 the aircraft was noticed by a witness in the adjoining property making a spray run from the north towards south. At the end of the run the aircraft pulled up and commenced a turn initially to the right then reversed the turn to the left. The left turn continued and the aircraft flew into the ground. The aircraft appeared to be operating normally up until the accident.

This accident was not subject to on-site investigation.

FACTUAL INFORMATION

The aircraft had been hired in Victoria by the pilot for an extended private business trip to south-east Queensland.

The aircraft disappeared on a NOSAR (no search and rescue watch) flight from Caloundra to Kooralbyn via Jacobs Well. The aircraft had not been reported missing and there was no evidence that the pilot had made any arrangements for a private SARWATCH. The pilot was not rated for flight in instrument flying conditions.

On 8 January 1996, a body, later identified as that of a passenger in the aircraft, was washed up on a beach near Caloundra and some aircraft wreckage was found on a beach at the south-eastern end of Bribie Island. The pilot's body was found in the same area the following day. Later, a member of the public handed to police additional pieces of wreckage which he had found in the area on 5 January.

Recorded data from the Brisbane Terminal Area radar (TAR) revealed that the aircraft tracked along the Bribie Island coast to a point three kilometres north-north-west of Woorim near the ocean beach. It disappeared from radar at the completion of a 180-degree left turn at 1456 EST. The aircraft was outside controlled airspace at the time and its transponder was not operating. The Bureau of Meteorology weather radar information showed a large rain squall at the southern end of Bribie Island between 1440 and 1520.  Correlation with the TAR-recorded information showed that the aircraft entered the area of the rain squall. Another pilot, who was conducting a scenic flight near the Glass House Mountains, confirmed that the southern end of Bribie Island was obscured by a heavy rain squall at the time of the disappearance.

The aircraft was fitted with an ELT which complied with TSO C91. No reports were received that indicated that the ELT operated during the accident sequence.

The aircraft has not been recovered.

ANALYSIS

Radar plots showed that the aircraft entered a heavy rain squall. The 180-degree turn may have been an attempt by the pilot to regain visual flight, but during the turn, control of the aircraft was probably lost.

SIGNIFICANT FACTORS

1. The pilot did not hold an instrument rating.
2. The aircraft entered a rain squall.

At a result of the investigation into this occurrence, the Bureau of Air Safety Investigation forwarded the following interim recommendation to the Civil Aviation Safety Authority on 4 November 1996:

IR960127

The Bureau of Air Safety Investigation recommends that the Civil Aviation Safety Authority:

1. review the Aviation Safety Surveillance Program to ensure that new commercial operators are adequately monitored and inspected until a demonstrated history of safe operation is known;
2. align the scheduled surveillance period of the Aviation Safety Surveillance Program to that of the validity period of the air operators certificate;
3. reconsider the flight review requirements for Chief Pilots with the view of bringing them into line with the current situation for Chief Flying Instructors, as an additional method of surveillance;
4. review the adequacy of the approval and assessment requirements for Chief Pilots who do not have a demonstrated history in flight operations with a commercial operator;
5. review the current situation regarding Aeroplane Flight Reviews, to allow for appropriate notification to the Civil Aviation Safety Authority and recording of the results.'

FACTUAL INFORMATION

Sequence of events

The occupants of the Piper Lance aircraft had planned an overnight stop at a farmhouse near the proposed landing area. The pilot in command spoke to his contact (another pilot) at Boddington by telephone at least three times on matters related to the landing area. Landing area details were discussed in depth and the contact indicated that the pilot in command should land towards the east in the paddock he recommended. It was also recommended that he complete a right circuit at 1,800 ft above mean sea level (1,000 ft above ground level) to remain clear of the surrounding terrain. Immediately prior to departure the pilot in command was told that the wind at the landing area was a north-westerly at 15 kts. During one conversation the pilot in command indicated that he would land at Narrogin if the landing area at Boddington was unacceptable.

The aircraft circled Boddington for 15 minutes before it made an apparent approach to land. During this time, it made a low pass alongside the proposed landing area.

The pilot in command did not follow instructions. He completed a left circuit at 500 ft above ground level and approached from the north-west at 45 degrees to the proposed landing direction. The aircraft descended to within 3 m of the ground, with landing gear and full flap extended. Power was then applied and a go-around commenced. The aircraft turned slightly left, passed between trees and continued to climb over rising ground. It was observed to veer towards the right during the climb.

Evidence indicates that the landing gear and flap remained extended during the climb.  The aircraft collided with a tree 900 m from the go-around point. The collision occurred 25 m above the ground and 3 m below the top of the tree. The aircraft was extensively damaged by the collision. It then crashed in a dam 50 m beyond the tree and to the right of the original flight path.

Damage to the aircraft

Damage to the aircraft indicated that its flying characteristics were adversely affected by the tree collision. Tree impact had severely damaged both wings and destroyed the control system located in the aircraft's lower fuselage. The pilot in command could not have exercised any control after that point.

Weight and balance

The aircraft's weight at the time of the accident was estimated at 1450 kg. Maximum weight was 1633 kg.

Personnel information

Despite the pilot in command's considerable flying experience, information provided by his associates indicates that he had always flown into and out of landing areas that were marked as flight strips. As a result, the pilot in command had not previously been confronted with the complexities of assessing whether a farm paddock met terrain clearance and aircraft performance requirements.

Post-mortem examinations did not disclose any medical condition that might have contributed to the accident.

Meteorological information

The weather conditions were recorded as fine, temperature 28 degrees Celsius with a wind from the north-west at approximately 8 kts.

Proposed landing area information

The paddock chosen for the landing was aligned east-west across a valley and included a grassed area 1,200 m long and 100 m wide. There were no other suitable paddocks in the immediate area. The grassed area was clear of obstructions but was not marked out as a landing strip. The proposed landing area sloped up from a river, towards the east and was contained within the grassed area. The slope was two degrees (3.4%) for the first 900 m, increasing to four degrees (6.8%) at the eastern end. There were ridges, 35-45 m higher than the surrounding terrain, at each end of the landing area. A displaced threshold, to assist the pilot in command during his approach over the high ground and trees, was marked by a car parked 300 m in from the western edge of the paddock. The car was also parked facing into wind, as arranged with the pilot in command, to indicate the wind direction. It was expected by the ground party that the pilot in command would make an approach for a landing towards the east (uphill). This direction meant the aircraft would land downwind.

A post-accident inspection of the paddock and an assessment using the approved landing weight chart indicates the proposed landing area did not meet the specifications contained in Civil Aviation Advisory Publication No. 92-1(1), Guidelines for Aeroplane Landing Areas. The average longitudinal slope was 5%. This exceeded the maximum of 2%. The landing distance available, after object clearance requirements were considered, was 530 m. This was 190 m less that the minimum distance calculated from the landing weight chart for the prevailing conditions. The pilot in command did not attempt to use the proposed landing area although it had been recommended to him by another pilot.

The approach direction used by the pilot in command was along the valley rather than across it. This allowed the pilot in command to fly a shallower approach than would have been the case had he used the direction recommended. It also provided a better climb-out route in the event of a go-around. However, fences and a dry watercourse reduced the actual landing distance available in this direction to 300 m, much less than the distance required.

Wreckage information

The wreckage was examined at the accident site and after removal to storage. The inspection of the airframe did not disclose any defects that may have contributed to the accident sequence.

Witnesses reported that the engine sounded normal during the climb-out after the go-around. Inspection of the engine indicated it was capable of normal operation and was developing power at the time of impact with the water.

An anomaly was found with the rear wing spar attachment points that might have affected the structural integrity of the aircraft. Post-accident inspection of the wreckage disclosed that the rear wing spar attachment points had been modified some time prior to the accident. The attachments had been cut to turn bolt holes into slots. The aircraft manufacturer has not approved this type of modification. There were indications that one attachment had been loose prior to the accident. No records were found relating to the modification. Discussion with one of the aircraft's owners indicated that the modification had not affected the aircraft's performance. It compared favourably with other PA32s also flown by the owner of the accident aircraft.

Aircraft performance

Performance calculations based on flight manual and manufacturer's information, indicate that the aircraft should have been capable of climbing clear of the terrain and trees following the go-around with the landing gear and flaps extended.

ANALYSIS

Proposed landing area

The recommendation by the ground contact and the acceptance by the pilot in command that the proposed landing site was suitable, indicates that neither had an adequate understanding of the parameters for an acceptable aeroplane landing area as set out in GAAP 92-1(1).

The pilot in command did not attempt to land in the paddock recommended by his ground contact at Boddington. This was probably because a later assessment from the air indicated that it was unsuitable.

The investigation could not determine why the pilot in command was not aware of the landing distance limitation on his actual approach path. It is possible that the obstructions did not become apparent until late in the approach as the fences and the dried watercourse would have blended into the surrounding dry grass. The attempted go-around probably indicates that the pilot in command realised the area was unsuitable during the latter part of the approach.

Go-around and climb performance

During the go-around the pilot in command did not retract either the flaps or the landing gear. The investigation could not determine the reason for this.

Performance calculations indicate that the aircraft should have been capable of climbing clear of the terrain and trees following the go-around. Why it did not could not be determined. Nor could it be determined why the pilot in command did not turn the aircraft further right, away from the trees and towards lower ground. The Piper Lance has an extended forward fuselage, restricting forward and downward visibility during a climb. It is possible that the pilot in command was not aware of the aircraft's proximity to the tree and that the collision was completely unexpected.

Wing spar attachment modification

It was not possible to determine when or why the holes in the wing rear spar attachments had been modified. It could not be determined what effect the modification and/or the loose wing spar attachment might have had on the structural integrity of the aircraft, particularly during the collision.

SIGNIFICANT FACTORS

1. A landing was planned and attempted in an area where there were no suitable landing sites.
2. The aircraft's climb performance was less than it should have been during the climb-out from the go-around.

SAFETY ACTION

As a result of the investigation into this occurrence, the Bureau of Air Safety Investigation advised the Civil Aviation Safety Authority of the details of the wing spar attachment modification.

Summary

Shortly after 0900 on Saturday, 2 December 1995, the Singapore registered bulk carrier Sea Crane, while bound for the port of Wallaroo to load a part cargo of barley, grounded off Tiparra Reef in the Spencer Gulf, South Australia. The water ballast in the upper wing tanks was dumped and the vessel refloated after about 1 hours under its own power. Inspection by divers on 3 December revealed that only minor damage had been sustained, the hull plating not having been penetrated.

Originally the vessel had orders to load at Portland and Geelong, in Victoria, and the Master obtained the necessary navigation charts at the previous voyage discharge port of Yokkaichi, Japan. However, after sailing from Japan the Master received a change of orders, initially directing him to load at Ardrossan and Port Giles in South Australia, but this was then changed to Wallaroo and Port Giles. Although the Master requested that the necessary navigation charts be supplied at the Gladstone anchorage, Queensland, where the vessel was to take on bunkers, he did not receive them.

To assist him in navigating from Cape Nelson, Victoria, to Wallaroo, the Master constructed a chart on a celestial navigation plotting chart, taking details from the small-scale chart Aus 4709, "Southern Ocean -Australia South Coast". However, this chart did not show details of lights and shoals within Spencer Gulf.

Conclusions

These conclusions identify the factors contributing to the incident and should not be taken as apportioning either blame or liability.

The main contributing factors to the grounding of Sea Crane on Tiparra Reef are considered to be:

1. The Master was not provided with the necessary navigation charts for the safe conduct of the voyage beyond Cape Martin, eastern South Australia and for the approach to Wallaroo in particular.
2. The lack of co-ordination between the owner and the charterer, resulting in charts not being provided at Gladstone on 26 November 1995.
3. The apparent lack of appreciation by the owner of the importance for the charts to be supplied to the ship before it arrived in South Australian waters and, therefore, the fact that the owner did not arrange for the ship to divert to another port en route for this purpose.
4. The Master accepted the non-delivery of the charts and did not request the owner to arrange their delivery at another port en route.
5. In compiling his own chart, the Master did not utilise all the relevant information available to him in the Admiralty publications.
6. Having observed a structure and a number of fishing craft in proximity to it, the Master did not maintain a sufficiently safe passing distance.
7. The echo sounder was not used to check the depth of water and the trend of the seabed, particularly while approaching the structure.

Summary

The 135,000-tonne deadweight bulk carrier Goonzaran anchored four miles off the Port of Newcastle, New South Wales, at 2200 on 20 November 1995, to load a cargo of coal. The vessel was scheduled to berth on 25 November.

The 38,305 tonne deadweight bulk carrier New Noble anchored about four miles off Newcastle, at 0955 on 22 November, about 1.2 miles south of the Goonzaran. New Noble was also to load coal and was due to berth about midday on 24 November.

At 0000 on 23 November, the wind speed and direction recorded at Nobbys Head signal station was from the south-east at eight knots (force 2). At 0700, the wind speed had increased to 16 knots, veering to the south-south-east and increasing to 30 knots by 0800. At 1000, the wind speed had risen to 38 knots from the south-south-west.

With the increasing wind speed and heightening sea and swell, the New Noble's Master ordered the engine should be ready for immediate use, but the ship reportedly maintained its position throughout the morning. At about 1400 on 23 November, the Master became concerned that the vessel was dragging anchor to the north. The bulk carrier, Goonzaran, was the closest ship, lying to the north and in the line of drift of New Noble.

At about 1420, the Mate was sent forward with three crew members to weigh anchor. At about this time the Masters of Goonzaran and New Noble made contact on channel 6 VHF and the Master of New Noble informed Goonzaran that he was weighing anchor. New Noble's engine was used to try and take the weight off the anchor cable and five and a half shackles (150 m) was recovered, but the windlass could not recover the final three shackles.

At approximately 1448, New Noble had closed to about 3 cables (550 m) from the bow of Goonzaran and New Noble continued to drag anchor towards the larger ship. On board Goonzaran the engine had been put on stand-by and the Mate and three crew were forward by the windlass. At about 1450, Goonzaran paid out a further 90 m of anchor cable, to 12 shackles. However at about 1458, New Noble's anchor fouled Goonzaran's anchor cable drawing the ships together, before clearing itself a few minutes later.

At 1500 New Noble collided with Goonzaran in way of number three hold and then passed down Goonzaran's side making two further contacts.

Once clear of Goonzaran, New Noble recovered its anchor and after checking for ingress of water put out to sea to await port entry.

Goonzaran suffered significant damage to the hull and deck plating. New Noble suffered relatively minor damage to the bow at the forecastle head level and an indentation in its bulbous bow. Nobody was hurt as a result of the collision.

On 24 November, both ships were brought into port for inspection and necessary repair.

Conclusions

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

The following factors are considered to have contributed to the collision between New Noble and Goonzaran:

1. The Master and watchkeeping deck officers aboard New Noble did not appreciate that the ship had dragged anchor from its original position, indicating that the combination of the depth of water, holding ground and ship's freeboard combined to make the anchorage insecure and alert them to the increased risk of dragging anchor in deteriorating weather.
2. The Master and watchkeeping deck officers aboard New Noble did not detect the early signs of dragging and increased the risk of an accident by not reacting sufficiently early to the dragging of the ship's anchor.
3. The need to monitor the ship's position from a consistent set of reference marks was not fully appreciated by the Master and officers on board New Noble.
4. The limitations of the anchors was not fully appreciated by New Noble's Master.
5. Inadequate communications between the two ships meant that Goonzaran's Master was unaware that New Noble's anchor could not be recovered before the collision occurred.
6. New Noble's Master was preoccupied with the recovery of the anchor and did not drive the ship ahead, either dragging the anchor or releasing the bitter end and allowing it to pay out, while the opportunity existed.
7. New Noble's Master undertook no contingency planning regarding recovery of the anchor, nor did he think through his intended action or make any realistic assessment of how long it would take to recover the anchor.
8. New Noble's position relative to the most imminent danger, Goonzaran, was not monitored while trying to weigh anchor.

The Inspector also concludes that:

1. The decision by New Noble's Master not to drop the port anchor was sensible in the circumstances.
2. Goonzaran's Master had the option of slipping his ship's anchor cable and this may have avoided the collision.

Summary

The 46,265 deadweight tonne livestock carrier Mawashi Al Gasseem arrived in the port of Adelaide on 7 September 1995 to load fodder and water. The vessel was on a ballast voyage from Jeddah, in Saudi Arabia, to Napier, New Zealand, where it was to load a cargo of sheep for the Middle East.

Mawashi Al Gasseem was built as a tanker in 1973 and converted to a livestock carrier in 1983. At sea, steam for fuel heating, deck machinery and hotel services is provided by an exhaust gas economiser unit, while in port it was provided by a single Hitachi Zosen two-drum, water-tube, oil-fired auxiliary boiler.

On the morning of 9 September 1995, Mawashi Al Gasseem was at No.1 berth, Outer Harbour, Adelaide, with the auxiliary boiler in use supplying steam for the auxiliary services. The oiler on watch had joined the ship, for the first time, the previous evening. Shortly after coming on watch, he began to encounter problems maintaining steam pressure and water level in the boiler. At about 0920, when he was asked to supply steam to the deck machinery, he called for the assistance of the Fourth Engineer, who, when he saw the low water level in the boiler, immediately shut off the fuel to the burner.

Five or ten minutes later, the Fourth Engineer saw what he believed was still a fire in the furnace, but was, most probably, the boiler internals glowing white hot. He shut off all the valves in the fuel system, but the fire appeared to continue burning and the boiler casing around the aft end of the side water-wall began to glow red hot and give off smoke.

The ship's staff used a number of foam and CO2 extinguishers in an attempt to cool the casing. Hoses were then rigged and used to cool the casing more effectively. At 0950, the fire brigade was called and arrived at 0957, by which time the apparent fire in the furnace seemed to burn itself out and the furnace was cooling down. The fire brigade took over from the ship's staff and continued for the next hour to cool down the boiler casing.

After some inspection doors in the casing had been removed, a cursory inspection of the boiler gave the impression that, apart from some distorted tubes, it had suffered no damage. However, when the Chief Engineer went into the furnace that evening, he found that the boiler had been severely and extensively damaged. The side water-wall and refractory had collapsed, the rear water-wall was burned out and most of the screen tubes were burned out. Most of the furnace tubes in way of the radiant heat from the burner showed signs of having reached white heat and had begun to melt.

The evidence indicates that the damage to the boiler was caused primarily by the burner being fired without water in the tubes. Accumulations of soot, oil and scale on the boiler tube surfaces, caused by poor operating and maintenance procedures, may have contributed to the apparent fire.

The incident was investigated by the Marine Incident Investigation Unit under the provisions of the Navigation (Marine Casualty) Regulations.

Conclusions

These conclusions identify the different factors which contributed to the circumstances and causes of the incident and should not be read as apportioning blame or liability to any particular organisation or individual.

It is concluded that:

1. The extensive damage to the boiler water-walls, refractory and screen tubes in the auxiliary boiler of Mawashi Al Gasseem was caused by firing the oil burner after the water level had been lost, following a failure of one or more boiler tubes. Indications of a tube failure were present 1 hours or more before the apparent fire.
2. The subsequent symptoms of fire were caused by overheating of the port side boiler casings by intense radiant heat from the furnace, after a collapse of the refractory behind the water-wall on the port side of the furnace.
3. A build-up of soot and oil on the tubes and water-walls may have contributed to the incident, these deposits occurring due to poor operating and maintenance procedures.
4. The boiler water level, observed by the watchkeeper, in the gauge glasses may have borne no relation to the actual level in the boiler on account of the steam cocks on the gauge glasses having been shut and no gauge glass drill was carried out to check the accuracy of the level shown in the glasses.
5. The main factor leading to the failure of the first tube, causing loss of water level, was progressive tube wastage, due in turn to the age of the boiler, lack of maintenance, poor combustion control and insufficient control of the chemical parameters of the boiler water.
6. The investigation revealed, among those of the crew who were interviewed, a considerable lack of knowledge and experience in the operation and maintenance of steam plant.
7. Had the automatic control systems on the boiler been in good working order, the incident would probably have been prevented, as the fuel trip valve would have shut off fuel to the burner as soon as the water level dropped.
8. The ship's crew successfully contained the heat from the furnace until the fire brigade arrived by which time the furnace had begun to cool down, however, there was an unnecessary delay before hoses were used to cool the boiler casing.
9. The initial reaction to the fire by the Master and crew was not in accordance with the prescribed and practised procedures in as much as the Master did not take control of the situation from the bridge and there seems to have been some confusion and a degree of panic in the response by the crew.
10. There was a delay in calling the fire brigade, exacerbated by the absence of a telephone on board the vessel and the Inspector considers that a more immediate and reliable means of contacting the emergency services should have been used. VHF radio was not used to contact the port authorities to advise them of the situation and they were eventually informed of the incident via a fourth-hand report.