Bureau of Air Safety Invest!" Mid-Air Collision Between Cessna 172-N VH-HIZ and iperPA38-112VH-MHQ Near Tweed Heads, NSW 20 May 1988 BASI Report 881/1042 COMMONWEALTH DEPARTMENT OF TRANSPORT AMD REGIONAL DEVELOPMENT Department of Transport and Regional Development Bureau of Air Safety Investigation Mid-Air Collision Between Cessna 172-N VH-HIZ and Piper PA 38-112 VH-MHQ Near Tweed Heads, NSW 20 May 1988 BASI Report 881/1042 Released by the Secretary of the Department of Transport and Regional Development under the provision of Section 19CU of part 2A of the Air Navigation Act (1920). When the Bureau makes recommendations as a result of its investigations or research, safety, (in accordance with its charter), is ite primary consideration. However, the Bureau fully recognises that the implementation of recommendations arising from its investigations will in some cases incur a cost to the industry. Readers should note that the information in BASI reports is provided to promote aviation safety: in no case is it intended to imply blame or liability. ISBN 0 642 09595 4 December 1987 This report was produced by the Bureau of Air Safety Investigation (BASI), PO Box 967, Civic Square ACT 2608. Readers are advised that the Bureau investigates for the sole purpose of enhancing aviation safety. Consequently, Bureau reports are confined to matters of safety significance and may be misleading if used for any other purpose. As BASI believes that safety information is of greatest value if it is passed on for the use of others, readers are encouraged to copy or reprint for further distribution, acknowledging BASI as the source. CONTENTS SYNOPSIS 1 1. FACTUAL INFORMATION 1 1.1 History of the Flights 1 1.2 Injuries to Persons 1 1.3 Damage to Aircraft 1 1.4 Other Damage 1 1.5 Personnel Information \ 1.5.1 Pilots 1 1.5.2 Air Traffic Services Personnel 2 1.5.2.1 Coolangatta Control Tower 2 1.5.2.2 Brisbane Area Approach Control Centre (AACC) 2 1.5.2.3 Brisbane Flight Service Centre (FSC) -.-- 2 1.6 Aircraft Information 2 1.6.1 Cessna 172-N VH-fflZ 2 1.6.2 Piper PA38-112 VH-MHQ 2 1.6.3 Loading 2 1.6.4 Maintenance and Serviceability 3 1.7 Meteorological Information ; 3 1.8 Aids to Navigation 3 1.9 Communications 3 1.10 Aerodrome Information 3 1.10.1 General 3 1.10.2 Control Tower 3 1.10.3 Aircraft Movements 3 1.10.4 Special Aerodrome Procedures 4 1.11 Flight Recorders 4 1.12 Wreckage and Impact Information 4 1.12.1 Wreckage Disposition 4 1.12.2 Nature of Collision 4 1.12.3 Determination of Impact Angle 4 1.13 Medical and Pathological Information 4 1.13.1 Medical Reports 4 1.13.2 Psychological Report 4 1.13.3 Pathological Reports 4 1.14 Fire 4 1.15 Survival Aspects 4 1.16 Tests and Research 4 1.16.1 Computer Graphics 4 1.16.2 Cockpit Visibility 5 1.16.3 Visual Surveillance by the ADC/APP 5 1.16.4 Communications Workload 5 1.16.5 Voice Analysis 5 1.17 Additional Information 5 1.17.1 Air Traffic Disposition 5 1.17.2 Circuit Area Traffic 6 1.17.3 Air Traffic Service Procedures 6 1.17.4 Control Tower Manning 6 1.17.5 Visual Surveillance 6 1.17.5.1 Controllers 6 1.17.5.2 Pilots 6 1.17.6 Aircraft Anti-Collision Beacons 6 1.18 Useful or Effective Investigating Techniques 7 2 ANALYSIS 7 2.1 General 7 2.2 The Aircraft 7 2.3 The Pilots 7 2.4 Air Traffic Services Personnel 7 2.5 Air Traffic Services Facilities 7 2.6 Control Tower Manning 7 2.7 Meteorological Conditions 7 2.8 Operating Environment "~ 7 2.9 The Accident Sequence 8 2.10 Flight Path and Visibility Considerations g 2.11 Workload 9 2.11.1 Aerodrome/Approach Controller 9 2.11.2 Human Information Processing 9 2.11.3 Voice Stress Analysis , 9 2.11.4 Pilots 9 2.12 Aircraft Anti-Collision Beacons 9 3 CONCLUSIONS 9 3.1 Findings 9 3.2 Relevant Events and Factors 10 4 SAFETY RECOMMENDATIONS 10 APPENDICES 1 Relevant Maps and Charts 12 2 Coolangatta Air Traffic Control Duties 14 3 Transcript of Recorded Communications 15 4 Coolangatta Control Tower Cabin Floor Layout 24 5 Coolangatta Air Traffic Movements 25 6 Probable Attitudes at Impact 26 7 Presentation of Probable Flight Paths 27 8 Cockpit Visibility Diagrams 30 9 Analysis of Tower Communications 36 10 Specialist Report on Human Factors 37 11 Voice Stress Analysis 39 Note: (1) All times shown are Australian Eastern Standard Tune and are based on the 24-hour clock. (2) The accuracy of the illustrations provided in appendices 7 and 8 is determined by the degree of validity of the raw data described in section 1.16 of this report, and by the processes to which that data was subjected. LIST OF ABBREVIATIONS AACC Area Approach Control Centre. ADC/APP Air Traffic Controller performing Aerodrome/Approach Control functions. AFIZ Aerodrome Flight Information Zone, ARR/R Arrivals Sector, Radar. AYR Automatic Voice Recording. BN SEC 1R Brisbane Control Sector One, Radar. BN SEC IP Brisbane Control Sector One, Procedural. COORD Air Traffic Controller performing Coordination functions. FISS Flight Information Service Supervisor. FIS 4 Flight Service Flight Information Sector 4. FIS 4 CDTR Flight Service Flight Information Sector 4 Coordinator. FPS Flight Progress Strip/s. FSC Flight Service Centre. FSFD Flight Service Flight Data. FSO Flight Service Officer. IFR Instrument Flight Rules. KM Kilometres. OMC Operations Monitoring and Control. QNH Altimeter sub-scale setting to obtain elevation or altitude. SMC Air Traffic Controller performing Surface Movement Control functions. VFR Visual Flight Rules. VMC Visual Meteorological Conditions. SYNOPSIS been flown during this sequence. At 1607 hours the aer- odrome/approach controller (ADC/APP) cleared VH-HE At approximately 1609 hours on 20 May 1988, Cessna for a further touch-and-go landing and requested the aircraft 172-N registered VH-HE and Piper PA38-112 Tomahawk to make an early right turn after becoming airborne. registered VH-MHQ collided on the downwind leg of the right hand circuit for Runway 14 at Coolangatta, VH-MHQ was cleared for takeoff at 1558 hours and had Queensland. The aircraft had been engaged in training flights completed one right hand circuit with a touch-and-go land- in the Coolangatta circuit area. Both broke up after the col- ing. During the second circuit the ADC/APP instructed the lision and fell into swampland. A flying instructor and a aircraft to make a left hand orbit. At that time it was on pilot under instruction in each aircraft received fatal injuries. downwind at a position a few degrees north of a bearing of 230 degrees magnetic from the control tower. In the latter The Piper VH-MHQ had been instructed to make a left orbit stages of this orbit the two aircraft collided. while on the downwind leg to permit an inbound commuter aircraft, Cessna C404 VH-SON, to overtake, descend and 12 Injuries to persons become the number one aircraft in a landing sequence. The Injuries Crew Passengers Others Cessna VH-HE had been requested to make an early right turn on becoming airborne from a touch-and-go landing. This Fatal 4 request was made to clear VH-HE from the runway centre- Serious line so that a landing clearance could be issued to a Fokker Minor/None - ' Friendship FK27 VH-FNO, then following on short final. Total 4 Both VH-MHQ and VH-HE complied with their respec- 1J Damage to Aircraft. Both aircraft were destroyed by tive instructions and requests and were observed commencing the collision and the subsequent ground impact forces. the appropriate manoeuvres. Air traffic control personnel did not maintain continuous visual surveillance of these two 1.4 Other Damage. No other property was damaged during aircraft involved in the accident throughout their respective the accident sequence. manoeuvres. During these manoeuvres Cessna 210 VH-MDG contacted Coolangatta tower and advised that it was 41 nau- 13 Personnel Information tical miles (76 km) to the south of the aerodrome. 1.5.1 Pilots. The pilot in command of Cessna 172 VH-HE For a significant period, activity had been normal for a Friday was aged 28 years. He held a Commercial Pilot Licence but had increased substantially in the 10 minutes prior to the which was current to 31 August 1988, together with a Grade accident. At the time of the accident there were five other One Flight Instructor rating. His licence was appropriately aircraft on tower frequency - the leader of a formation flight endorsed to allow him to act as pilot in command and instruct of Tiger Moth aircraft operating to the north, clear of the on Cessna 172 aircraft. His total flying experience at the Coolangatta control zone, a Piper PA28 VH-MCS in the time of the accident was 1548 hours, of which 646 hours had Burleigh Heads area, a Cessna C172 VH-KZG in the been gained on Cessna 172 aircraft. His most recent profi- Springbrook area inbound to Coolangatta, a Cessna 404 VH- ciency check had been completed on 21 April 1988 when he BUY landing on Runway 14 and a Beechcraft BE36 VH-TYZ successfully completed a flight test, conducted by an Exam- at the Runway 14 holding point. iner of Airmen, for upgrading to a Grade One Flight Instruc- tor.