Two aircraft were operating on reciprocal routes between Brisbane and Darwin when the crew of one aircraft became aware that both aircraft were flying at the same level near Mount Isa. The crew initiated avoidance action and clearance for operation at a lower level was given. Each crew saw the other aircraft pass less than 1 min later.

The pilot was conducting a short joy-flight with six passengers from the Sea World complex. About 4 km north of the complex, the helicopter was seen to climb steeply in a near-vertical nose-high attitude. As the helicopter fell backwards from the nose-high attitude, the tail boom was severed by the main rotor blades. The cabin and the separated tail boom fell to ground on the ocean beach of South Stradbroke Island; The main body of the helicopter exploded and caught fire, scattering debris over a wide area. All seven occupants received fatal injuries.

At about 2045 hours ESuT, Piper aircraft VH-MRQ crashed onto the northern face of a small tree-covered hill on Oxley Island. The accident site was located on a bearing of 098 degrees from Taree Airport, at a distance of 6.5 km. Both occupants were fatally injured in the accident.

The aircraft had departed Taree at 1849 for a return flight via Port Macquarie and Forster. The purpose of the flight was to conduct a Command Instrument Rating flight test. NDB aerial work was planned to be carried out at Port Macquarie, Forster and Taree. The last reported contact with the aircraft was at 2041, near the completion of the flight, while it was conducting aerial work at Taree.

The aircraft was seen and heard by witnesses located near the accident site. Some of these witnesses reported that the aircraft had appeared to be operating normally prior to it entering a sudden descent. However, others reported hearing the aircraft engine apparently operating erratically before seeing the lights of the aircraft descend rapidly from a relatively low altitude. A sudden increase in engine noise was followed almost immediately by the sounds of an impact. The accident was non-survivable.

The aircraft struck the tops of large trees at a height of 18 m before impacting heavily onto a 12 degree uphill slope. The left wing was torn off as it struck a tree adjacent to the ground impact point. The aircraft overturned and slid tail-first up the hill before coming to rest 80 m beyond the initial tree contact. Damage to the aircraft was extreme and was consistent with it having struck the ground at a relatively high speed, with the engine delivering substantial power.

Weather at the time of the accident was overcast and dark, with no low cloud or rain, and with a light wind from the north-east.

No evidence was found of any mechanical failure or pilot incapacity. The reported erratic operation of the engine shortly before the accident could be consistent with the exhaustion of fuel from one fuel tank, although more than sufficient fuel had been carried for the flight. The circumstances of the accident were consistent with a loss of control. However, there was insufficient evidence to establish the reason for the loss of control.

On 21 December 1991, at 1646 hours Eastern Summer Time, a Boeing 737-376, VH-TAJ, operating a scheduled passenger service, landed at Sydney (Kingsford Smith) Airport.

Shortly after reverse thrust was selected, a failure occurred in the right engine. The aircraft veered abruptly from the runway centreline and oscillated laterally before being stabilised.

Two flight attendants who were in forward facing seats in the rear of the aircraft received minor injuries during the aircraft deceleration, when their restraint system permitted excessive lateral movement.

The investigation determined that the right engine failed following the ingestion of a thrust reverser cascade, which had detached as a result of a fatigue failure of the mounting flange. The flight attendants' seat and restraint system did not comply with applicable Australian design requirements.

The aircraft was tasked to carry out a marine pilot pick-up from a departing tanker. The flight was conducted by two pilots operating under night visual flight rules. Conditions were a moonless night with no defined horizon, no outside lighting other than from the ship, and a surface wind that was light and variable. The ship was steaming in a northerly direction at 12.5 kts.

The flight proceeded normally until the aircraft was established on final approach to the helideck. As the aircraft descended through 500 ft the rate of descent had increased to about 1,000 ft/min. Although the pilot in command increased main rotor pitch, the aircraft's rate of descent continued to increase until just prior to impact with the water.

Both occupants were rescued approximately 1 h after they evacuated the helicopter. The report concludes that the standard approach technique used by the pilots, coupled with the prevailing weather conditions, caused the aircraft to enter a high rate of descent shortly after the aircraft started its normal final approach to the deck.

The high rate of descent was probably the result of entry to the incipient stage of Vortex-ring state'. A lack of visual cues and inadequate management of cockpit resources prevented the crew from recognising the abnormal situation until the aircraft was well into the descent. Recovery action was commenced too late to prevent impact with the water.

On Monday 12 August 1991, at 1023 hours Eastern Standard Time (EST), a McDonnell Douglas DC-10 Series 30ER aircraft (DC-10) operated by Thai Airways International was landing on runway 34 at Sydney (Kingsford Smith) Airport. The DC-10 was carrying 185 persons. At the same time, an Airbus A320-211 aircraft (A320), operated by Ansett Australia was on a short final approach for landing on runway 25. The A320 was carrying 110 persons.

Runways 34 and 25 intersect, and Simultaneous Runway Operations (SIMOPS) were in progress.

Landing instructions to the crew of the DC-10 included a requirement for the aircraft to be held short of the intersection of runways 34 and 25.

A Qantas Airways Boeing B747 aircraft was holding on taxiway Victor ('V'), north of runway 25 and west of runway 34, awaiting the landing of the A320 and a subsequent clearance to cross runway 07/25. The B747 was carrying 372 persons.

While observing the DC-10's landing roll, the captain of the A320 judged that the DC-10 might not stop before the intersection of the runways. He elected to initiate a go-around from a low height above the runway.

Under heavy braking, the DC-10 slowed to about 2 kts ground speed, at which time the nose of the aircraft was approximately level with the edge of runway 07/25.

During the go-around executed by the crew of the A320, that aircraft passed above the DC-10 on its left and the B747 on the right of its flight path.

On 22 November 1991 at 0912 hours Australian Central Standard Time (Greenwich Mean Time + 9.5 h), a Bell 214ST helicopter was ditched into the Timor Sea shortly after take-off from a floating production facility. The two crew and 15 passengers evacuated uninjured from the floating helicopter, prior to the right main flotation bag being punctured and the helicopter capsizing.

The report concludes that at a critical stage of the take-off, at an altitude of approximately 120 ft above the sea, one of the engines experienced a high-side speed excursion. This was followed by an aircraft main rotor speed increase which illuminated a cockpit indication warning that the aircraft main rotor speed was out of limits. The captain reacted to what he thought was an engine power loss by lowering the collective, which is the prescribed response to that situation, thereby unloading the main rotor which rapidly accelerated to 116.7%.

The electrical control unit of the ungoverned engine, sensing a power turbine overspeed, actuated the fuel sequence valve to shut off fuel to the engine. As the over speeding engine accelerated, the other engine, while attempting to compensate, decelerated to idle power because of the lowered collective command.

The captain's action in lowering the collective exacerbated the rapidity of the event, and because of insufficient aircraft altitude, there was not enough time for the engine still under power to pick up the load, or for the captain to take further corrective action to avoid a sea ditching. At the time of the emergency, the captain was demonstrating a take-off to his co-pilot.

Outline of incident

The fishing vessel 'TAMMY-R' departed Eden on Wednesday 18 April 1990 bound for fishing grounds off Gabo Island.

According to the crew, after some trawling the vessel completed its last trawl near position 37 56'S 149 56'E at approximately 0300 hours Eastern Standard Time on Thursday 19 April 1990. After boxing and stowing the catch, the Skipper decided to return to Eden in order to have a minor oil leak in the hydraulic steering repaired.

The Skipper set a course to clear Cape Howe and about half an hour later the trawler was apparently in collision with a merchant vessel and sank. The two crew members took to a life raft, eventually being rescued by helicopter some seven hours later.

Conclusions

It is concluded that:

1. The TAMMY-R sank as a result of a collision with another ship.
2. On the balance of probabilities TAMMY-R was in collision with METAL TRADER.
3. The most likely time of the collision is considered to be within the period 0414 - 0421.
4. The collision was brought about by the failure of TAMNY-R to give way to METAL TRADER crossing on the starboard bow.
5. The Skipper of TAMMY-R was negligent in that he failed to ascertain the course of METAL TRADER and whether a danger of collision existed before handing over to the relatively inexperienced Deckhand.
6. The Deckhand was negligent in that:
   a) he failed to ascertain that a danger of collision existed
   b) he failed to give way as required by Rule 15 (COLREGS) to a vessel crossing from starboard
   c) he failed to keep a proper lookout as required by Rule 5 (COLREGS).
7. The Master of METAL TRADER did not stop to offer assistance to TAMMY-R as, at the time, he was apparently unaware that a collision had occurred.
8. The Master of METAL TRADER failed to respond to the distress relays broadcast by Melbourne Radio as they were not received due to a fault in the ship's radio equipment.
   
   It is further considered that:
9. As it is not possible to determine with any certainty whether or not the Officer of the Watch of METAL TRADER was in fact aware that the collision had occurred, either:
   
   (a) the Watch aboard METAL TRADER was inefficient with respect to
   i. keeping a proper lookout (COLREGS Rule 5) in that TAMMY-R was not observed visually or on the radar.
   ii. in that it was unaware that the ship had been involved in a collision,
   
   or
   
   (b) the officer of the Watch was negligent in that:
   i. he failed to take necessary action to avoid collision as required by Rule 17(b) (COLREGS)
   ii. he failed to notify the Master that he had been involved in a collision; and
   iii. he wilfully ignored international conventions in that he failed to stop and render assistance to TAMMY-R.

Outline of incident

At 0505 hours local time on 21 February 1990 the Australian flag bulk carrier 'IRON KEMBLA', whilst on passage from Newcastle NSW to Tobata, Japan, collided with the Japanese fishing vessel 'KASUGA MARU' in a position approximately 4 miles WSW of Hino Misaki lighthouse in Kii Suido.

The fishing vessel capsized and one of the crew members lost his life.

Conclusions

1. Had both ships maintained their course and speed as those for the period 0452-0459, the collision would not have occurred.
2. The collision is considered to have been brought about by the KASUGA MARU altering back onto an easterly course after having first altered onto a northerly course, parallel to that of the IRON KEMBLA. This second alteration occurred almost simultaneously with the alteration to starboard (towards the east) by the IRON KEMBLA. The coincidence of the alterations made the collision inevitable.
3. The KASUGA MARU was not exhibiting the correct navigation lights, either those for a power-driven vessel under way or those for a vessel engaged in fishing, as required by the International Regulations for Preventing Collisions at Sea.
4. The Master of the IRON KEMBLA was correct in ordering an alteration of course to starboard when the KASUGA MARU was observed to alter course to port to run on a parallel course.
5. The Master of the IRON KEMBLA was correct in advising the Japanese Authorities immediately after the incident that a collision had occurred.
6. The master of IRON KEMBLA was correct in turning about in order to offer assistance to the crew of the capsized fishing vessel.
7. The Master of IRON KEMBLA is considered to have been at fault in assuming the KASUGA MARU to be power driven and that he therefore had the right of way, when the lights reportedly observed were those required to be shown by a sailing vessel.
8. The master of IRON KEMBLA could have prevented the situation developing by making an early, small alteration of course to port, to assist the small vessel to cross his bow.
9. The Master of IRON KEMBLA is considered to have been negligent in that he did not make use of all of the navigational equipment available to him in conning the ship.
10. The Master of the IRON KEMBLA is considered to have been remiss in not reducing speed immediately the capsized fishing vessel was sighted.
11. The Bridge Procedure aboard the IRON KEMBLA were deficient in that the Officer of the Watch did not, as a matter of course, monitor shipping on the radar so as to assist the Master by keeping him informed of the distances of other ships, or by targeting other ships on the ARPA.

Outline of incident

The Panamanian registered bulk carrier ALEXANDRE-P, a ship of 94532 tonnes deadweight and some 250 metres in length, loaded a cargo of iron ore at the Western Australian port of Dampier on 12 March 1990.

On completion of loading the ship proceeded to the outer anchorage in order to close and secure hatches, departing from the anchorage at 1610 hours Western Australian Standard Time on 13 March 1990, bound for Cape town and Gijon, Spain.

At 1400 hours WAST on 14 March 1990 the ship made a daily routine position report to the Federal Sea Safety Centre, Canberra under the Australian Ship Reporting System. The ship failed to keep its next scheduled broadcast at 1400 hours WAST on 15 March 1990 and 'ship overdue' procedures were put into motion at the FSSC.

Air searches commenced when the ship became 24 hours overdue on the afternoon of 16 March, flotsam eventually being located on 18 March in the area centred on position 20S 112E. The ship ENERGY SEARCHER arrived on the scene on 20 March and retrieved a life raft which was identified by the owners as belonging to the ALEXANDRE-P. No survivors were found.

Conclusions

1. The cargo of iron ore, lumps and fines, was presented for loading in a proper manner.
2. The cargo was loaded in accordance with the Master's/Chief Officer's requirements.
3. The loading sequence, which was modified as a result of No. 3 hatch jamming, although perhaps not the most preferable, is not considered unreasonable or to have placed undue stress upon the ship.
4. From the observations of witnesses, it is considered that the ALEXANDRE-P had not been well maintained, that there was heavy corrosion and wastage around the main deck and cargo hatches and also in the upper sections of the transverse bulkhead between holds 2 and 3.
5. From the position of the flotsam, it is considered that the ALEXANDRE-P foundered sometime around 1800/1900 hours ship's time on 14 March 1990 in approximate position 2020S 11200E.
6. Due to the fact that no distress message was heard by either coast radio stations or other shipping and due to the lack of survivors or further bodies, it is concluded that the foundering was both sudden and rapid.
7. The wind and sea conditions being light, are not considered to be causal factors to the loss.
8. A 2-3 metre swell from the southwest would have caused the ALEXANDRE-P to pitch moderately and also to roll slightly.
9. Although the cause of the foundering cannot be determined with any certainty and although beyond the scope of this investigation, it is considered that either a sudden, massive structural failure occurred, with the ship breaking into two sections or, there was some form of explosion in the engine room, of sufficient magnitude to rupture the ship's hull and cause rapid flooding and sinking.
10. Professional opinion is that the two recovered corpses bore evidence of flash burns and blast injuries, indicating that some form of explosion did occur.
11. If the foundering was in fact due to a major structural failure, it is considered that inspection at Dampier under the port state control provisions of the International Conventions would have been unlikely to prevent the foundering.