Summary

Shortly after 1700 hours on 2 March 1992 the Philippine registered bulk carrier Longevity, on passage from Kimitsu, Japan to Newcastle NSW, was in collision with the British yacht Blue Goose of Arne some 50 miles to the east of Sandy Cape. The Blue Goose of Arne was dismasted and also holed on the starboard hull.

The Longevity turned about and provided assistance to the lone yachtsman in effecting repairs to the yacht's hull, after which both vessels continued on their voyages.

Sometime later, the Blue Goose of Arne suffered further damage when it plunged off a wave crest, as a result of which it flooded and sank. The yachtsman, supported only by his lifejacket and clutching his emergency radio beacon, was eventually rescued by helicopter.

Conclusions

It is considered that:

1. While on the 225 degrees course the Longevity was proceeding in a safe crossing situation and would have crossed about two miles ahead of the Blue Goose of Arne.
2. By altering course to port at 1658 the Master precipitated the collision.
3. The master failed to properly ascertain the situation with respect to the Blue Goose of Arne and whether it was safe to alter course to 180 degrees.
4. The Master also failed, having altered course to 180 degrees, to ascertain whether a safe situation existed, before handing over the watch to the Second Mate.
5. In taking over the watch from the Master, the Second Mate accepted an unknown situation, which rapidly developed into the collision.
6. The Second Mate's actions were directed by the recommendations of the Master, not as a result of a correct assessment of the situation.
7. After the collision, in turning and providing assistance to the yacht and in reporting the incident, the Master fully fulfilled his obligations.
8. The yachtsman failed to maintain a lookout and, in particular, a watch on the Longevity. As a result, he was unaware of the course alteration by the Longevity and the developing situation.
9. Although the time the yachtsman spent clinging to the raft and in the water was a feat of physical endurance, his rescue and ultimate survival were due to the fact that he had an EPIRB.

Summary

At about 1836 on 26 March 1992, the Australian roll-on/roll-off vessel Searoad Mersey, was unberthing from Webb Dock, Melbourne to undertake its regular voyage from Melbourne to Devonport.

During the unberthing operation a stern rope, being retrieved very rapidly, swung and whipped as the eye of the rope neared the ship's side. The eye of the rope hit the Second Mate, who was leaning over the rail, and caught around his head and shoulders. The Second Mate was pulled over the ship's side and into the water. When he was recovered from the water, he was dead.

The Victorian Coroner, who held an inquest into the Second Mate's death on 4 and 5 April 1993, found the death had occurred from a combination of drowning and multiple injuries. In detailing the circumstances of the incident the coroner stated, inter alia:

"The evidence is clear that it was the normal practice of the deceased to retrieve the mooring lines at maximum rate, even though he was aware of the danger of rope whip and had discussed the danger with colleagues. To this extent I am satisfied the deceased himself, contributed to the cause of death."

Conclusions

The Inspector concludes:

1. The Second Mate was effectively lassoed by the eye of the mooring rope and thrown over and against the side of the ship.
2. The accident was caused by the setting of the winches to maximum speed.
3. Other factors relating to the accident involve the unmooring operation and include: (a) the position of the remote controls at the shipside bulwark (b) the position of the winch control switches within the remote control box, relative to the ropes they controlled (c) the failure of ship board staff to realise that the shipside controls allowed the speed of recovery to be controlled (d) the failure of the ship's crew to report the potential danger when it was known that the mooring ropes were prone to whip.
4. The shipboard staff were not properly instructed in the operation of the shipside control valves, specifically the proportional speed control.
5. Given the rapidity with which the accident happened, the Inspector is unable to conclude that: (a) the Integrated Rating assisting the Second Mate had time to operate the emergency stop (b) the misalignment of the blue winch contributed towards the accident.
6. No responsibility can be attributed to the Integrated Rating on duty on the after mooring platform.

Summary

The Japanese registered wood-chip carrier Daishowa Maru arrived off Twofold Bay, New South Wales at 1818 local time on February 1992. As the ship was not to berth until 0700, 11 February, the Master proceeded to the Quarantine Anchorage, where the ship anchored at 1930 on 10 February 1992.

Shortly after midnight, in strong winds, the ship dragged anchor and although attempts were made to weigh anchor and head out to sea, it was driven ashore on Whale Spit, off Tororago Point, at 0040, 11 February.

The ship was eventually refloated at 1000 on 13 February 1992 and towed to anchorage in the outer bay. An underwater survey showed that the ship had suffered considerable damage to the bottom plating, but the hull had not been breached, and no pollution occurred as a result of the grounding.

The propeller, rudder and steering gear had also all been damaged, therefore the owners decided that the ship should be towed to Japan for repairs. The towage operation commenced on 14 February 1992.

Conclusions

It is considered that:

1. With the wind from the east-south-east the Daishowa Maru was provided very little protection from the wind by Jews Head.
2. The Twofold Bay Quarantine Anchorage is not a safe anchorage for large vessels in a strong easterly wind or heavy easterly swell.
3. The strong wind and high swell warnings issued by the Bureau of Meteorology should have indicated to the Master that, under the forecast conditions, the Twofold Bay Quarantine Anchorage was not safe, placing the ship on a lee shore.
4. The anchor broke out of its holding and the Daishowa Maru commenced dragging anchor during the height of the passing squall, at sometime between 0015 and 0020 on 11 February.
5. While waiting for the engine and anchor party to be ready the Master and Second Officer both failed to ascertain the direction in which the ship was dragging.
6. In his concern to head the ship to the east and pick up the anchor, the Master failed to fully evaluate the situation and consider alternative actions. It is further considered that the bridge watchkeeping procedures aboard the Daishowa maru were deficient in that:
7. The ship's officers failed to keep a proper record of the anchor position bearing and distances.
8. The ship's officers failed to fully utilise the equipment available to them to monitor the ship's position while at anchor.

Aerospatiale AS355F1 helicopter VH-NJL was to land on a sports oval as part of a police public relations display for school children. It approached from the north-east and entered a steep descent from about 22 m above ground level. The descent rate was reported to be higher than normal. This high descent rate continued until ground impact. The helicopter bounced and completed two anticlockwise rotations before coming to rest. A small fire, which began in the engine bay, grew to completely destroy the helicopter.

The pilot had planned to fly his own aircraft, a Rockwell 114, to Moorabbin via Flinders Island. On the day prior to the flight his aircraft was found to be unserviceable. Over the years he had flown Piper PA 32 aircraft on several occasions. The local aero club agreed to hire a Piper PA 32R-301 Saratoga aircraft to the pilot for the flight.

On the day of the flight the weather in the morning at Launceston was poor with low cloud. At about 1000 hours the chief flying instructor gave the pilot a brief check flight, consisting of two circuits at a height of 800 feet. As the day progressed the weather at Launceston improved. A complex low-pressure trough was over the area moving east. The forecasts covering the route, together with the Flinders Island and Moorabbin terminal forecasts indicated that low cloud conditions could be expected.

A flight plan was not submitted for the flight. At 1342 hours the pilot called Launceston tower for taxy clearance for a flight to Moorabbin via Targa Gap at 3,000 feet. A clearance was given to track out of the control zone on this route, at not above 3,000 feet. The aircraft departed at 1348 hours on climb to 3,000 feet. The pilot was advised that the area QNH was 1006.

At 1352 hours the pilot advised the tower he was approaching Nunamara and that he would be at 2,500 feet due to cloud. In response the tower controller told the pilot to close on this frequency passing Targa Gap and that the area frequency was 126.5. This call was acknowledged by the pilot. No further calls were heard from him.

That evening the Melbourne Search and Rescue Centre was advised that the aircraft had not arrived at Moorabbin.

Initial checks and search activity did not find the aircraft. A full-scale search was started the following morning. Areas to the north-east of Launceston could not be searched that day due to low cloud. The following morning the wreckage was sighted from the air.

The aircraft had struck the ground at very high speed on a track of 106-108 degrees magnetic. The elevation of the initial impact area was approximately 1,870 feet. Prior to impact it passed through a plantation of young trees at a descent angle of 18 degrees and a bank angle of about 40 degrees right wing down.

Examination of the badly damaged wreckage did not reveal evidence of any pre-impact defects. The aircraft had been filled with fuel prior to departure.

There were no witnesses at the accident site. Two persons had seen the aircraft approaching Targa Gap. At that stage it was tracking north-north-east towards the gap. It was just below the cloud base which was at about 1,750-1,800 feet. Much of the terrain directly ahead of the aircraft from Targa Gap was at or above the height of the aircraft. It may not have been possible for the pilot to turn around in the valley which narrows approaching the gap.

The pilot's qualifications limited him to operating under visual flight rules only. The observations of bank angle and descent path at high speed strongly suggest that the pilot lost control of the aircraft while operating in cloud. The route via the Targa Gap is the shortest route to Flinders Island. An alternative but slightly longer route is via the Tamar River. This route would have enabled the aircraft to track over low terrain and almost certainly remain clear of cloud for the departure.

The aircraft was fitted with a Narco model ELT-10 emergency locator transmitter. During the severe impact, the beacon was damaged and hence no signal was transmitted to assist in the search for the aircraft. A second beacon was carried in the pilot's navigation bag. This was found to be unserviceable, with batteries that had leaked and corroded the internal case of the beacon. It was switched off.

The Narco ELT-10 beacon fitted was of a type required to be able to operate after a shock of 50 times the force of gravity (G). There are beacons available which are designed to withstand an impact shock of 500 G.

Significant Factor

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

1. The route selected by the pilot was over hilly/mountainous terrain, covered by low cloud in the higher terrain areas.
2. The pilot, who was not qualified to operate in non-visual conditions, probably lost control of the aircraft after inadvertently entering low cloud.

Safety Action

Although there are no specific safety actions being formulated as a direct result of the investigation of this occurrence, the Bureau is conducting a research project on emergency locator transmitters. This research is based on information obtained from several investigations, of which this is one.

The project will continue into 1994 and will cover the effects of new legislation introduced by the Civil Aviation Authority in relation to the carriage of emergency locator transmitters.

At 0832 hours on 12 March 1992, a Boeing 767 aircraft VH-EAO was cleared to land on runway 16 at Sydney (Kingsford Smith) Airport. At the same time, a Boeing 727 aircraft VH-TBR was on final approach to the intersecting runway 07. During the approach air traffic control monitored the progress of both aircraft on radar.

The B727 was instructed to continue the approach and to expect a late landing clearance. After the B767 landed it was instructed to expedite its movement through the intersecting runway. Subsequently, the B727 crossed the runway 07 threshold before the B767 had cleared the intersection, thereby infringing runway separation standards.

At 0707 hours, on 4 July 1992, Boeing 727-277 aircraft VH-ANA took off from runway 01 at Brisbane Airport on a regular public transport flight to Sydney. As the landing gear was retracting, the crew heard a loud bang emanate from the rear of the aircraft This was followed by cockpit indications of a fire in, and a loss of thrust from, the no. 2 (centre) engine.

Ground witnesses saw large flames streaming from the rear of the aircraft. The crew shut down the engine, completed the engine-fire checklist, and flew a circuit for a landing on runway 01. During the landing roll, the crew were advised that there were still signs of fire around the centre engine, so a decision was taken by the aircraft captain to evacuate the aircraft. After clearing the runway and stopping the aircraft, the evacuation of passengers and crew was carried out from the two front doors and the forward left overwing exit.

During the evacuation, two passengers received minor injuries. The fire was extinguished quickly by airport fire personnel.

The investigation revealed that a fatigue failure had occurred in the first-stage compressor fan disc of the no. 2 engine leading to disruption of the engine. The fire resulted when a section of engine disc severed the main fuel line to the engine. Deficiencies were also revealed in the Brisbane Airport emergency plan and in some aspects of the training of rescue and firefighting personnel.

When the helicopter had not arrived at its destination, a search was commenced. The wreckage was found the following morning close to the intended route for the flight. The main rotor hub with the blades attached was found approximately 140 m from the burnt-out fuselage which had bounced several metres after impacting the ground in a steep nose-down attitude.

There were no witnesses to the accident. The pilot was reported to have been fit and well rested prior to the flight. On ferry flights, he generally flew the helicopter at about 1500 ft above ground level (AGL). The weather in the area on the morning of the accident was reported to have been fine and calm.

The relative positions of the main rotor hub assembly and the fuselage indicated that separation of the main rotor occurred during flight. Examination of the main rotor mast showed that the mast failed in torsional overload between the swash plate and the hub assembly. One of the elastomeric blocks on the teeter stop assembly had been subjected to a compressive force of sufficient magnitude to fracture the elastomeric block retaining strap. However, the area of the mast behind the teeter stop had not experienced any deformation. The damage to the teeter stop and the mode of failure of the mast is the type of damage that might be caused by a mast bump.

Among the causes of mast bump are pilot manipulation of the flying controls and failure of one or more of the control linkages to the main rotor. Examination of the control linkages indicated that they failed in overload, consistent with main rotor assembly separation. Pilot induced mast bump can occur if the main rotor disc loading is reduced to less than 0.5g. Under such conditions, the main rotor can travel outside its normal limits and bump against the mast.

On this occasion the reason(s) for a reduction in g loads could not be determined. There were no known aircraft, with which the helicopter might have conflicted, operating in the area at the time. Information from another local aircraft operator indicated that large concentrations of birds were not uncommon in the area at that time of the year. However, notwithstanding the severe fire damage to the fuselage, no evidence was found in the wreckage of the helicopter having struck a bird. Further, the drive train between the engine and gearbox were inspected on site, and the engine and main rotor gearbox were stripped and inspected in a workshop. No faults which could have contributed to the accident were found.

Factors

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

1. For reasons which could not be determined, a mast bump occurred during flight.

2. The main rotor mast failed due to torsional overload as a result of the mast bump.

The gyrocopter took off from Albion Park aerodrome and was subsequently seen flying very low over local houses before it departed the circuit area on an easterly heading. It was later observed flying low over Lake Illawarra towards a residential area on the eastern shore. After passing low over houses the gyrocopter was seen to enter a steep turn to the left. During the turn it descended and collided with a tree in a nearby reserve. The machine was destroyed by the impact and the pilot was fatally injured.

No defects were found with the gyrocopter that could have contributed to the accident. It is likely that the pilot attempted a manoeuvre beyond his ability on the aircraft type. The reason such a manoeuvre was attempted in the vicinity of a residential area was not determined.

The helicopter had been engaged in spraying operations for more than three hours and was refuelled on several occasions whilst the engine was running. This procedure, which is approved by the Civil Aviation Authority, is known as "hot refuelling".

The pilot reported that he landed the helicopter to the left and rear of a stationary utility vehicle which contained the refuelling equipment. After the helicopter came to rest, and contrary to normal hot refuelling procedure, the driver reversed the utility towards the helicopter and stopped under the main rotor disc. The driver then took a fuel hose from the tray of the utility to the helicopter. Upon returning to the utility, he climbed onto the rear tray to start transferring fuel but was struck on the head by the main rotor blades and received fatal injuries.

The driver had been conducting hot refuelling for more than five weeks. The procedure called for the vehicle to remain stationary after the helicopter landed. The pilot was required to park the helicopter in a position where the main rotor disc was clear of the utility. With the vehicle parked in this position relative to the helicopter, the driver could safely climb onto the rear tray to pump fuel into the helicopter without fear of being struck by the rotor. The reason why the driver departed from this procedure was not established.