Separation issue

Separation issue involving a Boeing 737-377, VH-CZP, 57 km west-south-west of Kalgoorlie VOR, Western Australia, on 23 October 1997

Summary

The aircraft departed two minutes apart from Kalgoorlie enroute to Perth. The first aircraft, BAe 146 VH-NJZ, was cleared by the sector air traffic controller to track via Southern Cross on planned route climbing to FL240. The route followed the 255 degree radial from the Kalgoorlie VOR. When the pilot of the second aircraft, Boeing 737 VH-CZP, contacted the sector controller for a clearance, he advised that the aircraft was avoiding weather and tracking the 240 degree radial from Kalgoorlie VOR. The sector controller subsequently cleared CZP to track via the Nalar Dulya route on climb to FL350.

The pilot of CZP was communicating with the pilot of NJZ on the flight service frequency to ensure separation was maintained between the aircraft during the weather avoidance. The FSO reported to the sector controller that the pilot of CZP advised that he was initially tracking outbound on the 257 degree radial from the Kalgoorlie VOR and was now paralleling track. When queried by the sector controller, the pilot of CZP advised that the aircraft was on approximately the 246 degree radial from the Kalgoorlie VOR and was leaving FL210 on climb. The controller instructed the pilot of CZP to maintain FL210, to which the pilot replied that the aircraft was leaving FL220 on descent to FL210. The pilot of NJZ was immediately queried by the sector controller about his altitude and he reported that his aircraft was leaving FL225 on climb.

The investigation revealed that it was unlikely that a breakdown in separation occurred because the pilots appeared aware of their relative positions and maintained separation. However, the sector controller took action to ensure procedural separation was maintained based upon the information available to him.

Occurrence summary

Investigation number 199703488
Occurrence date 23/10/1997
Location 57 km west-south-west of Kalgoorlie VOR
State Western Australia
Report release date 13/02/1998
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Separation issue
Occurrence class Incident

Aircraft details

Manufacturer The Boeing Company
Model 737-377
Registration VH-CZP
Sector Jet
Operation type Air Transport High Capacity
Departure point Kalgoorlie WA
Destination Perth WA
Damage Nil

Separation issue involving a Beech Aircraft Corp 200, VH-SKN and Beech Aircraft Corp C90, VH-FDM, 96 km north-west of Boulia (ALA), Queensland, on 15 August 1997

Summary

The pilot of VH-SKN reported that, while cruising FL170 some 52NM from Boulia, a VFR aircraft (VH-FDM) reported 49NM from Boulia, on the same track, leaving FL175 on descent. SKN had been advised of several IFR aircraft by Flight Service but had not received any broadcasts from VFR traffic until the descent call from FDM. The pilot of SKN considered that the three mile separation which existed between his aircraft and FDM compromised safety.

FDM departed Mt Isa 5-10 minutes before SKN and thus should have been aware that SKN was tracking for Boulia. Both aircraft were King-Air variants, but had a significant performance margin over FDM and it was this which contributed to SKN catching up to FDM during the flight.

Occurrence summary

Investigation number 199702719
Occurrence date 15/08/1997
Location 96 km north-west of Boulia (ALA)
State Queensland
Report release date 28/08/1997
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Separation issue
Occurrence class Incident

Aircraft details

Manufacturer Beech Aircraft Corp
Model 200
Registration VH-SKN
Sector Turboprop
Operation type Air Transport Low Capacity
Departure point Mount Isa QLD
Destination Boulia QLD
Damage Nil

Aircraft details

Manufacturer Beech Aircraft Corp
Model C90
Registration VH-FDM
Sector Turboprop
Operation type Medical Transport
Destination Boulia QLD
Damage Nil

Separation issue involving a Cessna 402C, VH-UBF and Aero Commander 500-S, VH-TFW, 4 km west of Groote Eylandt Aerodrome, Northern Territory, on 1 August 1997

Summary

An aircraft was approaching to land through a straight-in approach in accordance with the published procedures and criteria. At about 2 NM on final approach, another aircraft reported on base. Although an attempt to contact the aircraft on base by radio was made, it continued and joined final about 500 m in front of the aircraft conducting the straight-in approach. The pilot flying the straight-in approach conducted a go-around and landed off a normal circuit.

Occurrence summary

Investigation number 199702718
Occurrence date 01/08/1997
Location 4 km west of Groote Eylandt Aerodrome
State Northern Territory
Report release date 02/09/1997
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Separation issue
Occurrence class Incident

Aircraft details

Manufacturer Aero Commander
Model 500-S
Registration VH-TFW
Sector Piston
Operation type Air Transport Low Capacity

Aircraft details

Manufacturer Cessna Aircraft Company
Model 402C
Registration VH-UBF
Sector Piston
Operation type Air Transport Low Capacity
Departure point Numbulwar NT
Destination Groote Eylandt NT
Damage Nil

Separation issue involving a Fairchild SA227-DC, VH-ANY and Cessna 210K, VH-NLB, 26 km north-west of Tennant Creek Aerodrome, Northern Territory, on 20 August 1997

Summary

The pilot reported that at 25 DME inbound to Tennant Creek, the appropriate inbound call was made on the CTAF frequency. No traffic responded to this call, nor were any other calls heard until, approaching 5,000 feet, there was an excited call from an unidentified aircraft to "aircraft inbound to Tennant Creek". VH-ANY levelled at 4,500 feet and called the other aircraft. The pilot of VH-NLB responded, saying that he had left 5,000 feet on climb. VH-ANY then continued descent to Tennant Creek.

The pilot of VH-NLB later said that he had made taxy, airborne and departure calls on departing Tennant Creek. He estimated the minimum separation with VH-ANY to have been about 1NM. The crew of VH-ANY did not see the other aircraft.

Occurrence summary

Investigation number 199702663
Occurrence date 20/08/1997
Location 26 km north-west of Tennant Creek Aerodrome
State Northern Territory
Report release date 23/09/1997
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Separation issue
Occurrence class Incident

Aircraft details

Manufacturer Cessna Aircraft Company
Model 210K
Registration VH-NLB
Sector Piston
Operation type Air Transport Low Capacity

Aircraft details

Manufacturer Fairchild Industries Inc
Model SA227-DC
Registration VH-ANY
Sector Turboprop
Operation type Air Transport Low Capacity
Departure point Tindal NT
Destination Tennant Creek NT
Damage Nil

Separation issue involving a Short Bros Pty Ltd SD360-300, VH-SUR, Hervey Bay Aerodrome, Queensland, on 6 July 1997

Summary

When approaching the aerodrome, the crew made the appropriate CTAF calls, with no response. At 1,500 ft, just before turning crosswind, a single engined Cessna aircraft was observed about 800 m to the right and about 200 ft below. No response was heard after further calls on CTAF. The crew was unable to identify the aircraft.

The pilot suggested that the Hervey Bay / Maryborough area be made an MBZ due to the number of airline flights into the area each day, and the traffic density associated with the two aerodromes.

Advice of a safety deficiency has been raised and is being considered. The situation is common to other aerodromes subject to frequent airline operations.

Occurrence summary

Investigation number 199702266
Occurrence date 06/07/1997
Location Hervey Bay Aerodrome
State Queensland
Report release date 08/09/1997
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Separation issue
Occurrence class Incident

Aircraft details

Manufacturer Short Bros Pty Ltd
Model SD360-300
Registration VH-SUR
Sector Turboprop
Operation type Air Transport Low Capacity
Departure point Maryborough QLD
Destination Hervey Bay QLD
Damage Nil

Separation issue involving a British Aerospace PLC BAe 146-200, VH-JJU and Cessna 207, VH-UBX, 24 km west-south-west of Kununurra Aerodrome, Western Australia, on 10 December 1996

Summary

The BAe146 was inbound to Kununurra from Curtin and the crew had been listening on both the area and the MBZ frequencies. They heard the pilot of the C207 make contact with Perth and discuss SARTIME arrangements and give his destination as Broome. This information indicated the C207 might be conflicting traffic for their arrival. They assumed the C207 was still on the ground at that time. As nothing further was heard from the pilot of the C207, the crew of the BAe146 made several attempts to contact him. When contact was established the C207 was 12 NM from Kununurra on the 242-degree radial at 5,500 ft. The BAe146 was 14 NM from Kununurra on the 250-degree radial at 3,800 ft, on descent.

The pilot of the C207 reported that his aircraft was fitted with one VHF set. After making his departure report on the MBZ frequency he changed to the area frequency and became engaged in a discussion with Perth flight service about his SARTIME. The discussion took longer than expected and during that time he could not hear any transmissions from the BAe146 on the MBZ frequency. When he changed back to the MBZ frequency he heard the transmission from the BAe146, and he answered immediately. He had tracked south of the Kununurra - Broome track to remain clear of cloud. He does not believe he came close to the BAe146.

It is likely that the discussion between the pilot of the C207 and Perth flight service, which the crew of the BAe146 assumed had taken place whilst the C207 was still on the ground, was the one that occurred after the C207 had departed. Consequently, the BAe146 crew did not hear the taxi and departure transmissions that preceded that discussion. The fitment of only one VHF set prevented the pilot of the C207 from adequately monitoring the MBZ frequency and, as a result, separation between the two aircraft could not be arranged in a timely fashion.

Occurrence summary

Investigation number 199604066
Occurrence date 10/12/1996
Location 24 km west-south-west of Kununurra Aerodrome
State Western Australia
Report release date 17/12/1996
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Separation issue
Occurrence class Incident

Aircraft details

Manufacturer British Aerospace
Model BAe 146-200
Registration VH-JJU
Sector Jet
Operation type Air Transport High Capacity
Departure point Broome WA
Destination Kununurra WA
Damage Nil

Aircraft details

Manufacturer Cessna Aircraft Company
Model 207
Registration VH-UBX
Sector Piston
Operation type Business
Departure point Kununurra WA
Destination Broome WA
Damage Nil

Separation issue involving a de Havilland Canada DHC-6 Series 320, VH-KZQ and Cessna 500, VH-ICN, Sydney Aerodrome, New South Wales, on 25 July 1996

Summary

A handwritten flight plan for a Cessna Citation to fly from Bankstown to Coolangatta was received by facsimile at the Melbourne Briefing Office at about 1040 EST.  Personnel involved with the processing of the flight plan details interpreted the estimated time of departure as 2130 UTC (0730 EST) and presumed that the flight was planned for the following day. It was the intention of the crew of the Citation, however, to depart at 0230 UTC (1230 EST), about two hours after the flight plan had been submitted.

Details of the flight were forwarded to Bankstown Tower, and both Sydney and Brisbane Air Traffic Control centres.  As the plan was considered to be for the following day, it was held at the Aviation Data System Operators' desks in the two centres, and flight progress strips were not issued to the appropriate sector controllers. 

Consequently, when the crew requested a clearance there was a delay of about 40 minutes to the planned departure as time was spent locating the plan and flight progress strips.  Due to this delay, the crew elected to depart visually from Bankstown, via the lane of entry at 2,000 ft, outside controlled airspace.

The Bankstown tower coordinator controller notified Sydney Flight Service of the aircraft callsign, time of departure, tracking details and altitude.  As the flight had been originally planned to remain within controlled airspace, this was the first time that the Flight Service officer was provided with information about the Citation. The officer annotated a flight progress strip for the aircraft with the details provided.

The crew of a Twin Otter reported departure from Aeropelican aerodrome and indicated that the aircraft was tracking 215 degrees M, on climb to 6,000 ft. The Flight Service officer did not pass mutual traffic information to the crews of the Citation or Twin Otter, as the nominated altitudes of the aircraft provided vertical separation and ensured the aircraft were not in conflict.  When the Citation was north of the lane of entry, the pilot in command initiated a climb outside controlled airspace, anticipating that a clearance would become available which would allow the aircraft to continue climbing to the planned level of Flight Level 330. Recorded radio communications indicated that the Citation crew did not report climbing above 2,000 ft.

Shortly after the Twin Otter departed Aeropelican, the Flight Service officer handed over duty to another officer, a process which took about two minutes to complete.  The new officer then became engaged in coordinating clearances into controlled airspace for the Citation and another aircraft, and responding to a number of calls from other aircraft in the officer's area of responsibility. The Citation was then instructed to contact Brisbane centre for a clearance. Just after the pilot transferred to the Brisbane frequency, the Flight Service officer was advised by the Sydney Departures radar controller that the aircraft had passed in close proximity to the Twin Otter, while outside controlled airspace. Neither crew were aware of the proximity of the other aircrft.

The Flight Service officer handing over was expecting the pilot of the Citation to receive a clearance with little delay. His impression was that the aircraft would soon enter controlled airspace and would therefore remain in his area of responsibility for only a short period. Consequently, he did not request additional tracking information on the Citation such as the next position and estimated time interval. As a result, the Flight Service officer assuming responsibility for the area had limited information to assist in resolving the conflict. The situation was further compounded by the high speed of the Citation, in comparison to other general aviation aircraft, and the rate of closure with the Twin Otter. As the new officer became distracted by other coordination tasks there was insufficient time to appreciate the lack of positional information on the flight progress strip. Without that information the officer was unable to establish if a traffic conflict was likely to occur.

The Flight Service officer may have been assisted in identifying a conflict if the departure report for the Citation, provided by the Bankstown tower coordinator controller, included details regarding the next reporting point and estimated time interval. Current procedures require Bankstown tower controllers to notify only those details which were provided in this occurrence.

The absence of a report by the crew of the Citation, advising that the aircraft had left 2,000 ft and was climbing, was an important cue not received by the Flight Service officer. Without this cue, the officer continued to assume that the Citation and Twin Otter were vertically separated and not in potential conflict. Consequently, traffic information was not provided to the crews of either aircraft.

Safety Action

The Bureau is researching safety issues highlighted during the course of this investigation concerning aspects of Air Traffic Control coordination.  Any recommendations and responses will be published in the Bureau's Quarterly Safety Deficiency Report.

Occurrence summary

Investigation number 199602327
Occurrence date 25/07/1996
Location Sydney Aerodrome
State New South Wales
Report release date 11/10/1996
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Separation issue
Occurrence class Incident

Aircraft details

Manufacturer Cessna Aircraft Company
Model 500
Registration VH-ICN
Sector Jet
Operation type Charter
Departure point Bankstown NSW
Destination Coolangatta QLD
Damage Nil

Aircraft details

Manufacturer De Havilland Canada/De Havilland Aircraft of Canada
Model DHC-6 SERIES 320
Registration VH-KZQ
Sector Turboprop
Operation type Air Transport Low Capacity
Departure point Aero Pelican, NSW
Destination Sydney NSW
Damage Nil

Separation issue involving a Beech Aircraft Corp A36, VH-PRI, Gatton (ALA), Queensland, on 8 July 1995

Summary

The Beech 36 aircraft flew over the active drop zone at about 2,000 ft and narrowly missed a parachutist. The aircraft passed underneath the parachute and did not respond to repeated warning calls on radio.

The red parachute symbol on the VTC is in the incorrect place (South of the Warrego highway) and would encourage pilots to track north of the highway, which is where the drop zone is located.

As a result of the investigation and subsequent analysis into this and other related incidents at the same location, the Bureau of Air Safety Investigation issued the following interim recommendation to the Civil Aviation Safety Authority and Airservices Australia on 24 November 1995.

"IR950225

"The Bureau of Air Safety Investigation recommends that the Civil Aviation Safety Authority, in conjunction with Airservices Australia, amend both the Brisbane and Oakey Visual Terminal Charts to display a danger area symbol alerting pilots to the location and hazards presented by parachute operations at the Gatton ALA. As an interim measure during the time required to cover the changes, a NOTAM should be issued alerting pilots to the incorrect location of the parachute symbol."

The following response was received from the Civil Aviation Safety Authority on 18 January 1996.

"I refer to your interim recommendation number IR950225 concerning an incident involving Beech A36, VH-PRI on 8 July 1995.

"The Authority is aware that the operator of the parachute drop zone at Glenore Grove, near Gatton QLD, has submitted a number of incident reports concerning aeroplanes tracking over his ALA whilst following the Warrego Highway between Archerfield and Toowoomba.

"As a result of these reports, the Authority requested Airservices to issue a NOTAM on 27 October 1995 to correct the position of the chart symbol depicting this operation, which is incorrect on the Brisbane VTC but correct on the Oakey VTC (both dated 7 December 1995).

"In discussion with the operator it appears that, despite his making the required broadcasts prior to parachutists exiting the drop aeroplane other traffic in the area are not responding to those broadcasts and therefore parachutists are not aware of traffic which will pass below them whilst they are still under canopy some five minutes later. This traffic may be up to 15 miles from the drop zone at the time the drop aircraft broadcasts its advisory message and may not recognise the potential for confliction.

"A further difficulty is that the drop zone is only four miles from the frequency change point which coincides with the Amberley CTR boundary, and so broadcasts are often made on both frequencies. As an additional precaution, the target control officer on the drop zone monitors traffic on a portable VHF transceiver.

"The operator has previously sought the advice of the Queensland RAPAC on the establishment of a formal danger area to provide an enhanced warning to itinerant aircraft of the extent of the hazard posed by their overflying this area. However, the Authority is not convinced that a danger area is necessary in this case.

"Nevertheless, since airspace is now the responsibility of Airservices Australia, your report and recommendation have been passed to them for consideration.

"The questions of re-issuing a safety poster about parachuting activity and publishing an article on ways to minimise risks when flying near a parachute drop zone, have been raised with the Authority's Safety Promotion Section and some further educational material is under consideration."

The following response was received from Airservices Australia on 6 May 1996.

"Subject: BASI IR950225 Gatton

"Reference incorrect location of parachute symbol;

A NOTAM was issued alerting pilots to the parachute symbol location. The symbol appears on the 20 June 1996 charts at the amended position.

"The proposal for a Danger area was referred to the Queensland Regional Air Co-ordinating Sub Committee (RACS) for consideration.

"As part of the "Process 5 for the Origination, Co-ordination, Ratification, Promulgation and Registration of Airspace and Air route Amendment Proposals " the recommendation was considered by the Queensland Regional Airspace Users Advisory Council (RAPAC).

"The RAPAC did not support the establishment of a Danger area. Further action regarding chart symbols, pilot education and consultation with CASA is to be undertaken by the RACS."

The Bureau of Air Safety Investigation has classified these responses as: CLOSED - PARTIALLY ACCEPTED.

Occurrence summary

Investigation number 199502562
Occurrence date 08/07/1995
Location Gatton (ALA)
State Queensland
Report release date 03/03/1997
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Separation issue
Occurrence class Incident

Aircraft details

Manufacturer Beech Aircraft Corp
Model A36
Registration VH-PRI
Sector Piston
Damage Nil

Separation issue involving a Cessna 404, VH-TTZ and Unknown Glider, 25 km south of Ballarat, Victoria, on 25 February 1995

Summary

At the completion of a fire spotting exercise VH-TTZ was passing 9000 feet on descent in controlled airspace (CTA) when a glider was sighted at the same altitude.  Air traffic control had no knowledge of glider operations in the area, for which the lower level of CTA was 6,000 feet. The glider was not identified.

Investigation disclosed that a gliding competition was being conducted from Bacchus Marsh airfield and the glider was most probably one of those taking part. The competition task was a triangular cross-country flight departing from Bacchus Marsh, tracking southwest to Derrinallum, then north west to Buangor, then returning to Bacchus Marsh.

Bacchus March is situated under the 2,000 foot step of Melbourne CTA. On the day of the competition "Area Alpha", a specially released block of airspace over Bacchus Marsh with a 4,000 foot ceiling, gave pilots a higher start level over the airfield.  The south-eastern boundary of the 4,000 foot CTA step is located one mile to the west of the airfield. The competition track progressed under the 4,000, 6,000, 8,000 and 10,000 foot CTA steps.

Prior to take-off the pilots were briefed by the contest organiser who had arranged the task based on the weather forecast for the day, which indicated that thermals would go to 8,000 feet. The briefing covered task details, weather, safety and some airspace considerations. Pilots were not provided with airspace maps by the organiser, nor did the briefing involve airspace higher than 8,000 feet.

The weather for the day was much better than forecast with reports of some gliders taking part in the competition reaching 12,000 feet in thermals.

At the time of the airspace incursion the gliders were returning from the task. The incursion occurred south of Ballarat within the area of the 6,000 foot CTA step. Had the glider been observing the limitation and flying below the 6,000 foot CTA step, it would have been required to climb in thermals to have reached Bacchus Marsh. This would have slowed the glider's progress.

One aim of pilots in such competitions is to gain as much height as possible and, on the final glide, trade that height for speed to arrive over the airfield with just sufficient height to finish, conduct a circuit, and land. The pilot involved in the incursion would probably have been taking advantage of the strong conditions to maximise his competitive advantage and was either not aware of, or was not respecting, the airspace boundaries of the area in which he was flying.  Because of the smoke from the bushfire, it is doubtful that the glider pilots were able to achieve the visual navigation accuracy needed when flying close to CTA step boundaries.

Glider pilots do not receive training in airspace to the same extent as the pilots of powered aircraft. They also do not hold a licence issued by the Civil Aviation Authority (CAA) and consequently do not receive advice from the CAA in regard to availability of airspace maps and associated information.

The gliding fraternities' understanding and respect of airspace, and the quality of briefings, has been the subject of a previous accident report. (Ref 9303898 VH-AYB, GMN, Benalla 24 November 1993).

Significant Factors

The following factors were considered relevant to the development of the incident:

  1. Glider pilots taking part in the competition were inadequately briefed in regard to airspace requirements.
  2. Glider pilots do not receive formal training in airspace considerations.
  3. The pilot was either not aware of or was not respecting the airspace limitations.
  4. Smoke from a bushfire would have made visual identification of CTA step boundaries difficult.
  5. The glider was flown in controlled airspace without a clearance.

Safety Action

This ASOR is to be referred to the Gliding Federation of Australia to reinforce the need for increased awareness of these matters. (Ref SADN 950070).

Occurrence summary

Investigation number 199500681
Occurrence date 25/02/1995
Location 25 km south of Ballarat
State Victoria
Report release date 17/05/1995
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Separation issue
Occurrence class Incident

Aircraft details

Manufacturer Cessna Aircraft Company
Model 404
Registration VH-TTZ
Sector Piston
Operation type Charter
Departure point Essendon VIC
Destination Ballarat VIC
Damage Nil

Aircraft details

Manufacturer Unknown
Model Glider
Registration Unknown
Sector Other

Separation issue involving a Piper PA-31-350, VH-JCH and Cessna 404, VH-CSV, Murray East, New South Wales, on 20 September 1994

Summary

VH-JCH was cleared by Albury Tower on the direct track from Albury to Canberra at 9000 feet. VH-CSV was on the same track flying from Canberra to Albury and believed (by Albury Tower) to be at 8000 feet. Accordingly, the pilot of VH-JCH was given a requirement to reach 9000 feet in time to avoid a conflict. This was complied with.

The pilot of VH-CSV called Albury Tower at 45 miles from Albury (10 miles prior to controlled airspace) and was cleared to Albury and to descend to 7100 feet which is the applicable route lowest safe altitude. VH-CSV then reported leaving 9000 feet. This was the first the Albury Tower controller knew that VH-CSV was at 9000 feet. The pilot was instructed to descend immediately to 8000 feet. This altitude change was probably achieved before the aircraft entered the control area and hence a loss of separation, technically, probably did not occur.

VH-CSV had originally maintained an 8000 foot cruise altitude but had later climbed to 9000 feet and advised Melbourne Flight Service of this change. The flight service officer was the only person on duty for this area of the network and a busy complicated period of work was in progress. She attempted to contact Albury Tower to pass advice of the level change but was unable to get through.

Albury Tower was also operating with one person on shift and was in a busy period. Uncontrolled airspace between Canberra and Albury between 8000 feet and 10000 feet spans a track distance of only 39 miles. Aircraft of the type involved in this incident transit that distance in a fairly short period of time. Due to the workload imposed by other tasks at both Albury Tower and Melbourne Flight Service, the co-ordination on the altitude change for VH-CSV was not achieved, although every effort was made.

Significant Factors

The following factors were considered relevant to the development of the incident:

1. Operation of air traffic service positions by one person during busy traffic periods.

2. Co-ordination on altitude change for VH-CSV, by the flight service officer, was not achieved.

Occurrence summary

Investigation number 199403319
Occurrence date 20/09/1994
Location Murray East
State New South Wales
Report release date 22/11/1994
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Separation issue
Occurrence class Incident

Aircraft details

Manufacturer Cessna Aircraft Company
Model 404
Registration VH-CSV
Sector Piston
Operation type Air Transport Low Capacity
Departure point Canberra ACT
Destination Albury NSW
Damage Nil

Aircraft details

Manufacturer Piper Aircraft Corp
Model PA-31-350
Registration VH-JCH
Sector Piston
Operation type Air Transport Low Capacity
Departure point Albury NSW
Destination Canberra ACT
Damage Nil