QF002 was scheduled for departure from London Heathrow at 1315 hours UTC on 25 March 1990. Due to engineering problems with the aircraft allocated for this sector, VH-EBY was dispatched from Sydney as a replacement, thus causing a subsequent 18-hour delay in the departure of QF002. The flight eventually departed London at 0704 hours UTC on 26 March 1990 as QF002A. On arrival at London Flight Dispatch the crew were issued with the Flight Plan and accompanying Notams, Intams and company documentation. Prior to departure the crew was issued with a runway 27L, Brookmans Park 3G SID. This departure requires a right turn, shortly after take-off, towards the Burnham VOR. At a position 6DME from London, another right turn is required to intercept a track of 058 degrees to Chiltern NDB. Noise abatement procedures apply to this departure as well as an altitude requirement of reaching 3,000 ft nearing completion of the turn towards Chiltern NDB, above 4,000 ft over Chiltern NDB and a crossing altitude of 6,000 ft at Brookmans Park VOR. A speed constraint of 250 knots existed below 10,000 ft. The seating configuration on the flight deck for departure is shown at Figure 1. The First Officer was flying this sector from the right hand pilot's seat.

Following representations by the Australian Flight Attendants' Association concerning a newly installed seating configuration on VH-OJF, a Qantas Boeing 747-400, a special investigation was undertaken to determine if safety standards had been compromised. The upper deck seating configuration on VH-OJF was compared to the previous exit configuration utilised on Qantas 747-400s. Further comparisons were made between the Boeing 747-200 and SPs operated by Qantas. The investigation determined that while the new seating configuration did meet the regulatory requirements, the previously installed standard did provide a far superior emergency exit facility.

Introduction

This special investigation was initiated after a letter was sent to the Minister for Transport and Communications by the Australian Flight Attendants' Association (AFAA). This communication detailed a number of objections to a seating configuration which had been installed on the upper deck of VH-OJF, a Qantas Boeing 747-400. 

The Association's objections to the new seating configuration are: 

(1) the downgrading of the upper deck emergency exits from Type A to Type I; 

(2) the jump seat protrudes fully into the exit; 

(3) no assist space is available; 

(4) insufficient recess for the flight attendant to direct the evacuation; 

(5) the reversal of the jump seat to a forward facing seat; and 

(6) emergency procedures are not applicable to the exit. 

The following report details the background to the investigation and addresses the issues raised by the flight attendant's union. The aim of the investigation was to evaluate the safety deficiencies, if any, of the new configuration in relation to the previous configuration and those in situ on other 747 series.

At 1144 hours Eastern Summer Time, on 22 December 1990, during a search for a missing aircraft, Cessna 210 aircraft VH-PLD crashed in inhospitable terrain following a complete loss of engine power. The aircraft was destroyed by impact forces; the pilot, co-pilot, and two observers received fatal injuries, and two other observers suffered serious injury. The Bureau determined that a failure of a connecting rod bolt resulted in the loss of engine power. The connecting rod penetrated the crankcase, allowing engine oil to escape. The oil was blown back onto the windscreen, probably obscuring the pilots' vision during the forced landing approach.

Outline of incident

At 1142 Eastern Standard Time (EST) on 24 July 1989 the Cypriot flag liquefied gas carrier "Kouris" anchored off Bate Bay, New South Wales.

During the afternoon the westerly wind dropped to light airs. At about 2330 EST the wind began to freshen backing to a little east of south. At about 0315 EST on 25 July the officer of the watch reported to the Master that the ship was drifting. Initial attempts to start the engine failed and the second anchor was dropped. At about 0335 EST the ship grounded in shoal water near Merries Reef.

Driven by the wind and sea the "Kouris" was blown clear of the shoal water. Although the engines were available at about 0345 EST the rudder failed to operate. At approximately 0418 EST the ship grounded on Cronulla Beach and by 0436 it was apparent that the ship could not be freed by use of its engines at that time, and assistance was requested through Sydney Harbour Control.

The ship eventually refloated at 0315 EST on 27 July 1989 and berthed in Sydney late on 27 July to assess damage.

Captain CW Filor, Director Ship Operations, Department of Transport and Communications was appointed under the provisions of section 377A of the Navigation Act 1912 to conduct a preliminary investigation to determine the reasons for the grounding and to establish what actions the Master took to prevent pollution and to safeguard the lives of the crew. Captain MD O'Keeffe, of the Maritime Services Board also took part in the investigation.

Conclusions

The Cypriot liquefied gas carrier "Kouris" came into heavy bottom contact in shoal water off Merries Reef at about 0335 on 25 July 1989, disabling the ship's rudder and sustaining extensive bottom damage. Through being unable to steer and manoeuvre normally as a result of the rudder damage the ship grounded on Cronulla Beach at approximately 0438. The cause of the contact with Merries Reef and the subsequent grounding are as follows:

1. the starboard anchor carried away under a shock load in excess of its nominal breaking load.
2. the failure to maintain the engine in a running condition when first started between approximately 0325 and 0330; this failure may have been due to either: - (a) an intermittent failure in the engine control system, or (b) human error in failing to recognise the need to cancel the "Emergency Stop - Engine Overspeed" control and/or ensure sufficient air supply to start engine.
3. the failure of the port anchor cable at approximately 0327 through the sudden load put on a short scope of cable when the cable stopper was applied with between 2 and 3 shackles paid out in approximately 20 metres of water.
4. The failure by the Master, Chief Officer and Second Officer to obtain weather forecasts and strong wind and gale warnings.
5. The failure of the Master at 0200 25 July to appreciate the significance of the wind shift and that the ship was anchored to a lee shore.
6. The general lack of communication and understanding of responsibility by the officers aboard.
7. Captain Schluchter used six shackles of cable rather than the eight shackles theoretically required in 25 metres of water. Had he used eight shackles he would have used the total length of cable available to him and had none in reserve. The investigating officers are satisfied that the use of six shackles under the conditions prevailing on the afternoon of 24 July was reasonable.
8. In not allowing the crew to leave the ship Captain Schluchter reduced the risk of injury to the crew and ensured that the ship had sufficient crew when the "Kouris" refloated.
9. In completing the inerting operation of the cargo tanks the risk of fire or explosion was minimised, thus protecting life and property.

Outline of incident

The Philippine registered bulk carrier SINGA SEA, a ship of 26586 tonnes deadweight and some 175 metres in length overall, loaded a mixed bulk cargo of mineral sands and copper ore at the West Australian ports of Geraldton and Bunbury between 27 June and 2 July. At 0915 hours Western Standard Time (WST)* the ship sailed for Rotterdam via Cape Town, where it was expected to take on bunker fuel.

At 0600 Universal Co-ordinated Time (z) (1400 WST) on 3 July the vessel made a routine position report to the Department of Transport and Communications' Federal Sea Safety Centre (FSSC) under the Australian Ship Reporting System (AUSREP) based on the ship's noon position at 1200 WST. The ship failed to keep its next scheduled broadcast at 1400 WST on 4 July and the search and rescue procedures were put into operation by the FSSC.

At 1018 WST on 7 July a "P3" Orion of the RAAF took off from Pearce RAAF base to search for the missing ship, followed by another sortie on 8 July with the primary task of searching for survival craft. Neither search found any trace of the ship.

On 12 July a search was undertaken of the West coast of Australia by a chartered civil aircraft, as it was possible that liferafts or debris may have drifted onto the coast by then. No trace was found of SINGA SEA, or of any pertinent wreckage.

By 27 July the SINGA SEA had failed to arrive in South Africa and no radio traffic had been heard from the ship. As the cargo had been loaded in Australia and the ship hab been participating in the AUSREP System, a preliminary investigation was commenced into the loading of the ship and the procedures followed by the Federal Sea Safety Centre as they related to the reporting of the SINGA SEA under the AUSREP scheme.

Shortly after midnight WST on the night of 2/3 August, the Greek flag bulk carrier STANDARD VIRTUE saw a single red flare in approximate position 34°19'S 112°22'E, and subsequently recovered six survivors from a lifeboat belonging to the SINGA SEA.

The survivors reported that the vessel had sunk rapidly, after breaking in two in heavy seas, on 4 July 1988. They had been adrift in the lifeboat since that time.

The survivors all definitely stated that no other person had survived the wreck of the vessel, and that no other life raft or boat had been seen subsequent to the sinking. No further searches were therefore carried out for survivors.

The STANDARD VIRTUE diverted towards Fremantle where, on 4 August, the six survivors were lifted off by helicopter arranged by the Sea Safety Centre. After being landed at Fremantle, the survivors were briefly hospitalised before being repratriated to the Philippines.

*See Appendix A for an explanation of the times used in this report.

Conclusions

The actions and procedures of the Federal Sea Safety Centre between the time that the position report from the SINGA SEA became overdue and the time 24 hours had elapsed were correct and in accordance with the AUSREP guidelines.

By deciding not to initiate an air search after the scheduled position report from the SINGA SEA was 24 hours overdue, having established that the ship had not been heard by ships specially tasked to attempt radio contact, or by coast radio stations handling traffic from the ship, the stated objective of the AUSREP scheme was compromised.

The decision by the Director not to fly an air search for the vessel on 6 July was made in the face of mounting evidence that something may have been amiss with the vessel and was not consistent with the primary objective of AUSREP.

The air searches carried out on 7 and 8 July were conducted properly and in accordance with sound and established search and rescue practices.

Given the circumstances of this particular AUSREP incident and the availability of an RAAF aircraft the decision not to fly a daylight visual search for survival craft on 9 July, or subsequent days, was questionable, following the unsuccessful flare search of 8 July.

Following notification of the rescue of survivors from the SINGA SEA on 3 August, an air search for survivors was undertaken. The decision not to conduct further searches after 3 August was correct, and made on the information available.

At approximately 1609 hours on 20 May 1988, Cessna 172-N registered VH-HIZ and Piper PA38-112 Tomahawk registered VH-MHQ collided on the downwind leg of the right hand circuit for Runway 14 at Coolangatta, Queensland. The aircraft had been engaged in training flights in the Coolangatta circuit area. Both broke up after the collision and fell into swampland. A flying instructor and a pilot under instruction in each aircraft received fatal injuries.

Outline of incident

On the evening of 3 December 1987, the small Australian coastal trader Leichardt was passing through Endeavour Strait, northern Queensland, on passage from Horn Island to Weipa. The Mate took over the watch from the Master at 2000, navigation being conducted by radar, there being no lights in the area.

After rounding Entrance Island, Leichhardt was more than half a mile south of the intended track. Although the Mate adjusted course to regain the track, the vessel grounded momentarily on a charted shoal. The vessel was stopped & soundings showed flooding in No 2 starboard fuel tank, which was empty.

Clearance was eventually granted to the vessel to proceed to Groote Eylandt, where it arrived safely on 7 December 1987.

Conclusions

Poor passage planning, in particular the laying off of the course line only two cables from a known danger, in an area where currents were known to be strong.

Navigation was not carried out using the appropriate, large-scale chart.

Not only was the Mate unfamiliar with the Endeavour Strait, he did not appreciate that the vessel was standing into danger.

The helicopter was on a 65-min flight from Troughton Island to the drilling vessel Energy Searcher. The flight departed Troughton Island at 0717 hours Western Standard Time with thirteen passengers and two crew on board. Approximately 30 min after takeoff, while cruising at 4,500 ft, a loud bang was heard accompanied by the onset of severe airframe vibration. The pilot immediately lowered the collective pitch control and reduced the helicopter's speed, while the co-pilot transmitted a distress message and instructed the passengers to fasten their seat belts. Although the vibration made reading of the instruments difficult, the pilot was able to determine that main rotor RPM was approaching 120%. The pilot increased the collective pitch in an attempt to control the main rotor RPM but this caused the vibration level to increase. He then lowered the collective pitch control, turned the helicopter into wind, and established an autorotative descent. The pilot observed that one main rotor blade was tracking irregularly. Passing 1,000 ft, the automatic inflation system for the flotation bags was armed. The helicopter contacted the water surface at a forward speed of 10-15 kts approximately parallel to the swell. The flotation bags immediately began to inflate. At the same time the main rotor blades struck the water, causing the fuselage to roll right until inverted. During the rollover, the left and right cabin windows were forced from their frames and the left side hinged door forced open. All passengers escaped from the cabin through these openings. The pilots exited through their respective doors, the co-pilot taking a portable emergency locator beacon. The short time interval between touchdown and the rollover prevented deployment of the life rafts. However, one raft was later released by a passenger. The survivors were located a short time after the ditching by a search aircraft and were later rescued by another helicopter and transferred to Troughton Island.

Outline of incident

On the afternoon of 9 May 1987, the bulk carrier River Embley, laden with a cargo of bauxite, was making an easterly passage through the Torres Strait at maximum draught. At 1700, the vessel grounded momentarily when to the south of the Alert Patches buoy, as a result of which the vessel sustained damage to the hull & flooded the forepeak tank & No 1 void space.

The vessel was taken to a safe anchorage, where temporary repairs were effected, to enable it to proceed to Gladstone to discharge the cargo.

No one was injured & no pollution resulted from the incident.

Conclusions

• A detailed passage plan for the passage had not been prepared.
• The Pilot had not briefed the Master fully on his intentions.
• The ship's speed was excessive for the depth of water available at the time.
• It would have been prudent for the Pilot to have made an earlier alteration of course.

Outline of incident

On 21 April 1987 at approximately 0710 ships time (0810 EST) the Cypriot registered cargo vessel "RUCA CHALLENGE" of 1587.46 gross tons on passage from Haifa, Israel to Cairns, Australia, via Singapore, with a cargo of potassium nitrate, ran aground on Piper Reef in position 12° 14' 80" S 143° 14' 40" E.

(Prior to the grounding the ship's time was UTC + 9 hours. The clocks were altered at noon 21 April, to align with Eastern Standard Time (EST) being UTC + 10 hours. All times given in this report are based on the 24-hour clock and are EST).

The vessel was refloated without external assistance at approximately 1700 on 21 April and, after establishing that the vessel was seaworthy, the Master continued the voyage to Cairns, berthing at 2030 on 23 April. No pollution resulted from the grounding.

Cargo was discharged on 24 and 26 April and the vessel sailed at 1350 on 26 April for Brisbane to complete discharge of the potassium nitrate. Off Fitzroy Island, the vessel anchored to allow a Lloyds Register classification surveyor, together with a diver, to make a kore detailed hull inspection in clear water. Some hull damage was noted; however the vessel was considered to be in a seaworthy condition and continued on passage to Brisbane.

After further inspection by Lloyds Register and on completion of discharge, the vessel sailed from Brisbane on 2 May 1987. Repairs were undertaken whilst in Brisbane and are due for completion at the next drydocking, in 1988.

Conclusions

1. I find that the "RUCA CHALLENGE" went aground through errors in navigation in that the Chief Mate failed to correctly establish the vessel's position at regular intervals after 0617 on 21 April.
2. Given the apparently conscientious plotting between 0400 and 0617 I was initially prepared to accept that the Chief Mate did continue to plot the vessel's position after 0617 and that these positions were subsequently erased. However, he could give no clear and satisfactory indication of what islands, reefs or light structures he was using for navigational checks and was, as is shown in his statement, very much confused as to what reef was what or where. Therefore, I have to reject his claim that he did continue to properly plot the vessel's position.
3. Given that no plotting of positions was apparently undertaken after 0617 and that the vessel was steering 170° (T) to make good a course of 175°, the course made good was in fact very close to 175° (T) allowing for the actions of the Chief mate in altering course to starboard for a short period prior to the grounding.
4. Due to confusion in his mind the Chief mate did not properly establish the vessel's position. He offered no excuses and accepted that the vessel grounded as a result of his errors.
5. No other person directly contributed towards the grounding.
6. The actions taken by the Master in refloating the "RUCA CHALLENGE" were successful. However, his initial action in trying to get the vessel off the reef before establishing the seaworthiness of the vessel does not show mature judgement of the circumstance after a grounding, despite being somewhat of a normal reaction.
7. As he was unfamiliar with the passage inside the reef and the lack of a large-scale chart of the area, the Master would have been more prudent to have utilized the services of a pilot of the Queensland Coast and Torres Strait Pilot Service.
8. In view of a pilot not being employed, the restricted passage width between Inset and Piper Reefs and the small-scale chart in use, a more prudent master may have considered that his presence on the bridge was warranted.
9. Subsequent to the grounding, the Master should have reported the incident to the Federal Department of Transport in accordance with the provisions of section 268 of the (Australian) Navigation Act 1912. This was not done, and the Department of Transport's Sea Safety Centre was only advised of the incident when a passing vessel reported the "RUCA CHALLENGE" ashore on Piper Reef.