VH-WGG departed Williamtown at 0703 hours and proceeded to track via the 015 radial of the Sydney VOR at 8,000 ft. The pilot contacted the Sydney Departures North controller 28 NM from Sydney and the radar identification was passed to the Approach North controller, who raised a 'shrimp boat' (a small piece of plastic which adheres to the radar screen and allows the controller to write pertinent information on it for his/her reference) and placed it on the radar screen next to the radar return of VH-WGG.

The shrimp boat was not positionally updated nor was it annotated to indicate to which aircraft it was referring. When an aircraft passes overhead Sydney, its track impinges on all four sectors of approach/departures airspace and two flight progress strips (FPSs) are raised, one for approach use and one for departures. These FPSs are pink in colour to enable them to stand out from the other FPSs in use.

The aircraft is identified by the controller in whose airspace it enters, and the progress is then monitored by all four controllers by updating the position of their 'shrimp boats' on the radar screen and placing the pink FPS in the central (active) strip bay.

The aircraft departed private property located at Tates Straight on Lake Burrinjuck NSW for Cootamundra NSW at about 1730 ESuT. On board were the pilot and two passengers. After take-off the helicopter was seen to transit at a low altitude in a northerly direction. Three to four minutes after the helicopter departed, witnesses heard a sound like a muffled gunshot and shortly after, smoke was seen to rise from the direction in which the helicopter was headed.

The accident site was located in a valley about 3.5 km from the point of departure. The ground level at the south end, the direction from which the helicopter approached, was the highest ground elevation along the flight path. From this point the valley floor descended relatively steeply, and the upper ridges of the valley sloped more gently with the distance between the ridges widening along the direction of flight. Trees about 15 m in height covered the valley and ridges

Weather conditions observed at the lake were fine with little or no wind.

The main aircraft wreckage was located in the centre of the valley. Wreckage was distributed for a distance of about 180 m in the direction of flight, from an area adjacent to the estimated position of a power line which was suspended across the valley. The majority of the wreckage was located under the flight path. However, the main rotor head with three blades attached, two separated main blades, and the tail rotor gearbox with damaged blades were distributed adjacent to the flight path. The fuselage and the main transmission were located about 180 m from the power line and were consumed by fire. The aircraft had descended at an angle of about 15 degrees through the tree canopy. After striking the ground, it slid about 10 m before coming to rest. The engine was located about 13 m beyond the fuselage. The three persons on board received fatal injuries.

About 1 km from the south end of the valley, a power line extended across the valley at right angles to the direction of flight. The power poles were located on the tops of each ridge which resulted in a wire suspension distance of about 832 m. The east ridge is about 510 m AMSL, and the west ridge is about 480 m AMSL. The wreckage was located at about 380 m AMSL or between 100 and 120 m below the ridge heights. The power poles were located in clear spaces among the trees at the top of each ridge and could only be observed from a position in line with the suspended wire. The conductor was 4.2 mm in diameter and constructed of three strands of steel wire. The wire sag was reported by the electricity company to be about 41 m. The conductor was broken.

Examination of the recovered fuselage and tail boom showed evidence of a wire strike to the area of the helicopter just above the cockpit and repeated main rotor blade strikes to the fuselage and tail boom. The wreckage scatter both in the trees and on the ground was indicative of an in-flight breakup. There was no evidence of in-flight fire.

The engine exhibited signs of high-speed rotation at impact and the damage was consistent with ground impact damage. Failues to the main rotor head, tail rotor and gearbox, and rotor blades were analysed as overload failures.

It could not be determined why the pilot departed to the north rather than to the north west direct to Cootamundra, nor why he was conducting the flight at an altitude which placed the aircraft below the valley ridge lines.

The sun was positioned left of and at near right angles to the direction of flight and would not have interfered with the pilot's vision. The wire conductor was dull and would not have reflected sunlight. Consequently, the wire would blend in with the background features of trees, grass, water and sky making it difficult for the pilot to see and avoid.

Evidence gathered at the accident site indicated that the helicopter struck the suspended wire conductor while in normal cruise flight at a height of about 60 to 80 m above the ground. Wire contact occurred first on the upper fuselage and then on the main rotor head. The contact would have applied abnormal gyroscopic loads to the main rotor disc. These loads would result in the blades travelling outside their normal paths and striking the helicopter fuselage and tail boom. Metal components recovered from the fuselage and tail boom, and main rotor blade damage, indicates that there were multiple main rotor blades strikes on the aircraft structure. The main and tail rotors separated from the helicopter before it descended into the trees.

Significant Factors

1. The aircraft was being flown at low altitude and struck a power line.

2. An in flight breakup of the helicopter occurred.

The pilot had planned to carry out a period of circuit training. Following discussion with the operator it was decided, primarily at the pilot's request and because of apparent under-confidence and a concern she had about recency, that her circuit procedures would be checked by an instructor prior to conducting solo circuit training.

Two uneventful dual circuits were conducted. Following the dual check the pilot carried out one solo circuit which resulted in a normal landing, a second circuit which required an overshoot as the aircraft was too high over the threshold, and a third circuit which appeared normal. The accident occurred on the fourth solo circuit.

During the fourth circuit the aircraft was observed to be below the normal glide path and flying faster than normal as it turned on to the final approach. The aircraft continued to descend, with wing flaps retracted, until it became obvious to the ground observers that the aircraft would crash short of the runway unless the pilot took corrective action.

Just prior to impact the pilot radioed that she was "going round". However, the aircraft collided with a 15 metre high tree 300 metres short of the threshold, as the call was being made. The aircraft came to a stop inverted, in a drain, 30 metres beyond the tree.

Insufficient evidence was available to determine the precise factors which led to the accident. Weather and mechanical problems were eliminated as possible factors. It is apparent from the aircraft's final flight path and the timing and tenor of the "going round" call that the pilot was unaware of the danger until just prior to impact.

The pilot was conducting a rice sowing operation and had entered the procedure turn on completion of the first swath run of his first load for the day. The aircraft appeared to be operating normally at about 300 ft, however, as it turned back towards the treatment area it was seen to overshoot the alignment for the reciprocal swath run. The nose then pitched down, and the engine noise was heard to increase significantly as the aircraft descended to the ground at a steep angle.

A small fire in the engine area was extinguished by the two markers, who arrived from the treatment area within minutes of the impact.

The aircraft had struck the ground in a left wing low, steep nose-down attitude. The left wing folded up against the fuselage and the engine was displaced to the right. Impact forces were high, causing major disruption to the fuselage, although the cabin area dimensional and structural integrity remained substantially intact.

No evidence of a pre-impact failure was found in the aircraft or its systems.

The weather conditions were fine and calm.

Findings

1. In an attempt to regain the alignment for the reciprocal swath run, the pilot tightened the turn, causing the aircraft to stall and enter an incipient spin to the left.

2. The height available was insufficient to permit the pilot to regain control of the aircraft.

Significant Factors

1. The aircraft stalled at a height from which the pilot was unable to effect a recovery.

Safety Action

During this investigation it was identified that the aircraft was fitted with an American Safety Inertia Reel Pt No 7260111-405 which does not comply with the requirements of CAO 101.17 for agricultural operations.

It is therefore recommended that the Civil Aviation Authority:

1. Advise agricultural operators that American Safety Inertia Reel Pt No 7260111-405 does not meet the requirements of CAO 101.17 para 5.9.3, and

2. Take steps to ensure that inertia reels which are fitted to aircraft engaged in agricultural operations do comply with the requirements of CAO 101.7 para 5.9.3.

On 19 June 1992, at approximately 1853 hours, a Beechcraft Baron 95-B55, registration VH-JDL, disappeared from Air Traffic Control radar display, without prior indication of difficulty. The aircraft wreckage was located the following morning on a moderately timbered slope, 700 metres above mean sea level and 45 kilometres north-east of Canberra, Australian Capital Territory.

The pilot and all five passengers were killed and the aircraft was destroyed by impact forces. The investigation determined that the aircraft departed Bankstown Airport loaded in excess of the maximum allowable take-off weight, and that the pilot did not comply with either Instrument Flight Rules or Night Visual Flight Rules rating recency standards required for the conduct of the flight.

While cruising at 8,000 feet, the aircraft entered a rapid descent, during which it reversed direction in a left turn. The descent was briefly arrested at a low altitude, however, the aircraft again turned left and descended rapidly. The aircraft exhibited flight characteristics consistent with those of an aircraft loaded to an aft centre of gravity position. There are indications that the centre of gravity moved further aft during the flight, until reaching a point at which the pilot was unable to prevent significant diversions in both climb and descent from the reference altitude, culminating in the rapid descent.

At approximately 1236 EST, tug VH-KKZ took off towing glider VH-GQR which was towed north of the airfield to a height of 2000 ft, before releasing from the tug. The barograph trace from the glider showed that it had not encountered any thermal activity and was continually descending after release from the tug.

At approximately 1240, tug VH-UTK took off towing glider VH-GZR which was towed north of the airfield to a height of 2200 ft, before releasing from the tug. After the glider released, the tug descended and returned to the airstrip via a standard recovery pattern.

When the glider VH-GQR was first seen by a witness, it was north of the field on the downwind leg of the circuit pattern at approximately 400 ft. The weather conditions at the time were fine, with high-level cirrus cloud. The witness monitored the progress of the approach and assessed that the glider was lower and closer to the airfield than for a standard circuit. The glider flew a close oblique base leg for strip 09, positioning for landing.

Coincident with the approach of the glider to strip 09, tug VH-UTK, was returning to the airfield for runway 09 after releasing the glider VH- GZR. The tug had turned onto an extended final approach at 900 ft. Approaching 500 ft, the pilot lifted the left wing to check for conflicting traffic turning base for runway 09. The pilot did not see any traffic so continued the approach and at approximately 300 ft, had a momentary glimpse of the glider above the aircraft as they impacted.

The two aircraft remained together momentarily, until the glider separated from the tug and fell away having been cut in two by the propeller of the tug.

Both aircraft were fitted with an aviation transceiver, however no radio transmissions were heard from either pilot. The tug radio was reported to have been on at the time of the accident. The glider radio was recovered from the aircraft for laboratory examination, but due to the extensive damage to the unit, no meaningful information could be acquired from the unit.

Engineering analysis of the glider wing that had sustained propeller slashes, determined that the glider descended onto the left side of the tug, in a wings-level attitude, skidding to the right. The glider had an overtake speed of approximately five knots with a nose-down attitude of three degrees relative to the longitudinal axis of the tug.

Analysis

The aircraft were operating in an un alerted see-and-avoid environment. The tug was a high-wing aircraft, with a resultant masking of upward vision. The expectation of the tug pilot was to have conflicting traffic coming from a standard circuit, however, the accident glider was conducting a non-standard circuit. The glider was painted white and had minimal contrast against the sky background with the sun overhead. For much of the time preceding the impact, the aircraft were on constant tracks with little relative movement to aid visual detection. The combination of the foregoing factors and the final manoeuvring of the glider placed both pilots in the situation of not being able to sight each other. The use of radio would have alerted the pilots to the presence of the other aircraft in the circuit, and would have added to the safety net.

The pilot landed on the property airstrip in order to correct a problem he was having in communicating with Canberra Air Traffic Control (ATC). Apparently having made adjustments to the radio installation, the pilot attempted to hand start the engine, but had not succeeded before he was met by the property owner and an employee who then provided some assistance. With the engine restarted, the pilot advised Canberra ATC by relay through an aircraft tracking from Goulburn to Canberra of his intention to depart. He was instructed to call again after take-off.

After take-off from the airstrip, the aircraft overflew the property owner as it turned onto a southerly heading. The aircraft was then observed to adopt what appeared to be a nose high attitude as it flew away from the strip. At a height of 200-300 feet, the aircraft was seen to commence a steep descent, while rotating to the right. The descent was not checked before the aircraft impacted the ground, right wing low, in a near vertical attitude.

No radio transmissions were heard from the pilot following take-off.

The report of the autopsy conducted on the pilot indicated that he had suffered a physical incapacitation before the aircraft impacted the ground.

Summary

On 22 July 1991, the Netherlands flag livestock vessel Zebu Express was lying at anchor in Darwin Harbour. The Master & Second Mate had left the ship, the Chief Officer being the Officer in Charge.

In the morning the Chief Engineer & Second Engineer began working in the bow thruster compartment, cleaning the electrical motor of the bow thruster.

Early in the afternoon the Chief Engineer observed the Second Engineer to be in physical difficulty in the lower part of the compartment & raised the alarm. He then made several attempts to assist the Second Engineer, entering the compartment without using a breathing apparatus.

Both the Chief Engineer & Second Engineer collapsed in the lower part of the bow thruster compartment. Attempts to rescue the two men were made by the Assistant Engineer, wearing a self-contained compressed air breathing apparatus, but he was unable to effect a rescue.

The bodies of the Chief Engineer & Second Engineer were eventually recovered from the bow thruster compartment by members of the Darwin Fire Service.

A surveyor of the Australian Maritime Safety Authority conducted an investigation into the incident under the provisions of the Navigation Act.

Conclusions

The deaths of the two engineers resulted from their failure to follow the well-publicised safety procedures for safe entry into, and rescue from, enclosed spaces.

It is considered that:

1. The Second Engineer died as a result of becoming asphyxiated by accumulated vapour produced by the Drew Electric electrical cleaner being used in a confined, enclosed space without adequate ventilation.
2. The Chief Engineer also died as a result of being asphyxiated by the accumulated toxic Drew Electric vapour when he went to the assistance of the Second Engineer without donning breathing apparatus.
3. The on-board operational procedures were deficient in that: the crew had not been properly trained in the use of emergency equipment, specifically the breathing apparatus, and in emergency procedures; the officers failed to implement standard safety procedures for when working in an enclosed space.
4. The absence of the Master and the Second officer reduced the capability of the crew to deal with the emergency situation that arose.
5. Some form of mechanical, fresh-air ventilation should be available for use in bow thruster compartments, to provide for periods of maintenance work involving chemical solvents and cleaners.
6. The hazard-warning label on the Drew Electric drum did not accurately reflect the dangers inherent in the chemical. The word "safe" was misleading, referring only to its non-flammable properties. Drew electric is extremely hazardous in confined spaces where the ventilation is inadequate. While this hazard was noted, the general impression of the wording did not fully impart the danger of asphyxiation.
7. The Owners should have ensured that the ship was provided with all available safety data on the chemicals placed on board for domestic use.
8. The data on 1. 1. 1 -trichloroethane contained in the ICS Chemical Guide is inadequate in that it does not indicate, under the headings "The Main Hazard" and "Effect of Vapour" that vapour may cause asphyxiation.

Summary

On 9 September 1991 the 6710 tonnes deadweight Panamanian registered motor tanker Jovian Loop grounded on Unison Reef in the inner two-way route of the Great Barrier Reef, while on passage from Broome to Townsville with a part cargo of tallow.

The ship was refloated after one hour, without assistance, and continued on its voyage to Townsville. No pollution resulted from the grounding and the ship sustained only minor damage.

Under the provisions of the Navigation (Marine Casualty) Regulations the Marine Incident Investigation Unit undertook an investigation to identify the circumstances of the grounding.

Conclusions

It is considered that:

1. At 0333, in a position with Rocky Point Island bearing 225° at 2.0 miles, the Pilot altered the course of the Jovian Loop to a heading of 153° Gyro, for 152° True, and ascertained that the heading was correct by observing the relative positions of Barrow Island light and Noble Island.
2. After the Pilot left the conning position the Helmsman, without instruction from the Pilot or 2nd Mate, changed over to automatic steering, but failed to check the course setting. As a result of this the Jovian Loop went off course to port, settling on a heading of 132°.
3. The grounding of the Jovian Loop on Unison Reef was a direct result of the ship's deviation from the course ordered by the Pilot and of the 2nd Mate's failure to notice the deviation.
4. The 2nd Mate failed in his responsibilities in that: (i) he failed to monitor the Pilot's actions; (ii) when left in sole charge by the Pilot he failed to monitor the ship's progress, instead busying himself with writing up the logbook; (iii) he failed to appreciate the danger posed to the ship by proceeding on a course of 135°.
5. When taking over the watch at 0355 the mate failed to pick up the discrepancy between the course line drawn on the chart (152°) and the course being steered as handed over by the 2nd mate (135°).
6. The Master was remiss in that he did not leave instructions with the Officer of the Watch to be called if the Pilot left the bridge for more than a few minutes.
7. The Master acted correctly in ascertaining the soundings around the ship and of the ship's tanks.
8. Manoeuvring the engine astern, shortly after 0400, before ascertaining whether the hull had been breached was a dangerous course of action.
9. The onboard operational procedures were poor in that: (i) a proper passage plan had not been prepared and followed; (ii) no proper record of courses, alterations of course and positions was maintained; (iii) there was no proper supervision, by the officer of the watch, of when the helmsman should change over to automatic steering mode.

Summary

In the early hours of 30 November 1991, while on a positioning voyage from Singapore to Cebu City in the Philippines, the Australian registered fishing vessel Northern L caught fire. The six crew were unable to fight the fire and abandoned the vessel in approximate position latitude 8 degrees 03 minutes North, longitude 118 degrees 34 minutes East, taking with them an emergency radio and the vessel's 406mHz emergency position indicator radio beacon (EPIRB). At about 0500 explosions were heard coming from the vessel, which sank shortly after.

At sunrise the crew took stock of their surroundings and activated the vessel's EPIRB.

At about 0830, the Australian Marine Rescue Coordination Centre received a distress alert from the United States MRCC, Washington that a distress beacon belonging to the Australian registered fishing boat had been detected in position 8 degrees 02 minutes North 118 degrees 33 minutes East.

These details were passed to Westpac MRCC in Japan, and Manila MRCC in the Philippines.

At 1130 (UTC+8) the Liberian registered tanker Nagasaki Spirit, en route from Dulang, Malaysia, to Santan, Indonesia, was requested by Westpac MRCC to proceed to a position 08 degrees 03.3 minutes North and 118 degrees 34.3 minutes East to investigate the EPIRB signal. At 1245 the Nagasaki Spirit sighted an orange canopy and by 1340 the six survivors had been taken on board the tanker.

The master of the Northern L (a Philippine national), the mate (an Indian national) and the two engineers (both Indonesian nationals) were landed in Santan. The two Australian crew remained with the Nagasaki Spirit until the ship arrived off Brisbane on 14 December.

Conclusions

1. The circumstances described and without evidence to the contrary it is concluded that the loss of the vessel was due to fire and the unrestricted flooding of the engine-room and the adjacent spaces below the main deck.
2. It is concluded that the fire originated in the engine-room. It is not possible to determine with certainty the cause of the fire or the reason for the sinking. However, the most likely cause may be attributed to the escape of diesel oil from a fractured fuel line spraying on to a hot machinery surface, igniting the oil and causing intense heat in the confined spaces of the engine-room. Fuel from the bunker fed the fire.
3. The outbreak of fire occurred while the engine-room was unattended. Had the person on watch been in the engine-room the fire would have been detected at an early stage and therefore it is probable that it could have been controlled and extinguished.
4. The supply of air to the fire and the fire's rapid unrestrained spread were the direct result of the engine-room not being isolated from the spaces either side of it or above it. It was accepted practice on board to operate with all doors, watertight or not, open.
5. Access to the remote controls to the engine-room fuel supply, the vessel's ventilation units and the engine-room CO2 fire smothering system was cut off by the fire, due to the engine-room not being secured and the access to the engine-room at frame 51 being open.
6. It is not possible to determine the source or sources of the explosions reported by the survivors. It is possible that the explosions were as a result of the rupturing of pressure vessels and/or the fuel in the tanks being heated to a level whereby the oil's flash point was reached.
7. Whatever the level of proficiency of the master and crew, the absence of any water on the fire main, compounded by the inability to secure any breathing apparatus, rendered the crew totally unable to fight the fire. Evacuation of the vessel to await the outcome of the fire was their only option.
8. The quality of the operational procedures and standards practised (or not practised) aboard the Northern L created the conditions in which accidents were more likely to occur, and where emergencies were more likely to get out of hand.
9. The position of the controls for the remote shutting down of the fuel supply from engine-room fuel tanks and the release of the engine-room CO2 fire smothering system were in accordance with the relevant legislation, notwithstanding that on this occasion access to them was cut off by the fire. However, their position within the enclosed main deck was not an optimum position, given the construction of the upper deck at conversion.
10. If the engine-room door at frame 51 had been removed, or was left open as a standard practice, the remote stops for ventilation and engine-room pumps were positioned contrary to the regulations.
11. The controls for the watertight doors were not above the bulkhead deck, as required by the regulations.
12. The diesel gas oil shipped in Singapore was within the declared specifications.
13. The liaison in 1989, between the Department of Transport and Communications, and subsequently the Australian Maritime Safety Authority, and the American Bureau of Shipping was deficient in ensuring that the converted vessel met the letter or spirit of the Australian regulations in respect of fire control and subdivision.