One seaman died and another was severely injured when a large wave broke over the bow of the container vessel Aotearoa Chief on 14 August 2004, according to an Australian Transport Safety Bureau (ATSB) investigation report released today.

The ATSB report into the incident states that the Hong Kong registered Aotearoa Chief disembarked its harbour pilot at about 6 pm, shortly after the ship had cleared the entrance to Melbourne's Port Philip Bay. The master then ordered an alteration of course to take the ship away from the coast. While on this new course, an abnormal wave broke over the forecastle head, where three crew members were working to secure the ships anchors for the intended voyage to Sydney. One man was thrown against the mooring machinery and suffered injuries from which he later died. Another sustained severe lacerations to one leg and the third man was unhurt.

The report concludes that the instruction given by the master to the crew members to secure the pilot ladder and anchors on the forecastle head was not clear in conveying his claimed intent for the crew only to secure the pilot ladder and not to go forward to the anchors until the master was satisfied it was safe to do so

The report also concludes that a strong southerly wind, combined with an opposing ebb tide and shoaling waters, probably caused an 'abnormal wave' which was larger than ones either preceding or following.

The report mentions a similar occurrence which happened off the NSW port of Newcastle in January 2005. This incident, with a number of similarities, occurred on board the Cyprus registered bulk carrier Nordrhine, and resulted in the death of another seaman.

Copies of the report (Marine Safety Investigation Report 206) can be downloaded from the ATSB website.

The ATSB's Preliminary Aviation Safety Investigation Report into the 7 May 2005 Lockhart River accident in which two pilots and 13 passengers perished has found that the Metroliner had descended about 1000 ft below the minimum obstacle clearance altitude when it collided with terrain. The aircraft had cut a swath of less than 100 m through heavy timber on the steep slope.

Preliminary information recovered from the flight data recorder and on-site examination of components indicates that both engines were producing about 30 to 35% torque. This is consistent with an approach power setting.

The aircraft was en route from Bamaga to Cairns via Lockhart River. The weather conditions in the Lockhart River area at the time of the accident were reported by the Bureau of Meteorology and people at Lockhart River as being broken low cloud with squally showers and drizzle. The crew reported that they were conducting the instrument approach to runway 12. It is unclear which of the two pilots was flying the aircraft at the time of the accident.

The wreckage was located in the Iron Range National Park about 90 ft below a 1300 ft tree covered ridge on the north-west slope of South Pap, a hill approximately 11 km north-west of Lockhart River on the final instrument approach track for runway 12.

The flight data recorder contained approximately 100 hours of useful data which has been assessed as being of reasonably good quality and contains data relating to the accident flight. Preliminary analysis of the data indicates that the aircraft had been descending at a constant rate, but with some turbulence evident, over the 50 seconds prior to the impact.

One of two former senior pilots who resigned from Transair PNG in mid 2002, who had previously raised some concerns about alleged regulatory breaches in PNG, has advised the ATSB that he has no knowledge of the accident and believes he cannot help the investigation. The other pilot has provided the ATSB with no information relevant to this investigation.

The investigation is continuing and will include analysis of recorded data, collation and analysis of operational, maintenance and regulatory records, other data and statements, recovered instruments and analysis of instrument approach procedures. The ATSB will release an Interim Factual Aviation Safety Investigation Report by December 2005.

Copies of the Preliminary Aviation Safety Investigation Report 200501977 can be downloaded from the website.

Fatigue was a major contributing factor to the longline fishing vessel Ocean Odyssey collision with the side of the container ship P&O Nedlloyd Taranaki. The ship was drifting while assessing its engine problem when the fishing boat ran into it, according to an ATSB investigation report released today.

The Australian Transport Safety Bureau report states that the N.S.W registered Ocean Odyssey collided with the port side of the container ship at about 0244 local time on 29 June 2004 near the entrance to Port Botany, after the boat's skipper had fallen asleep on watch. The boat was returning from its fishing grounds off the N.S.W coast at the time and was on autopilot. The container ship had had a main engine breakdown prior to the incident and was unable to get out of the way of the approaching fishing vessel.

A local port pilot had just boarded the container ship which was preparing to enter port when the engine breakdown occurred. The crew on the bridge of the ship had illuminated the ship and switched on the correct signal lights after the breakdown. As they watched the fishing vessel approach, they sounded the ship's whistle in an attempt to alert the fishing vessel to the impending collision but were powerless to prevent the boat from running into the ship's side.

After the collision, the pilot requested that the pilot boat meet with the fishing boat to ensure that its crew were safe. The fishing boat then returned to its berth at the Sydney Fish markets where an investigation into the collision was initiated.

The report concludes that the skipper was fatigued at the time of the collision due to his work schedule and that his wheelhouse environment at the time was conducive to sleep.

Neither vessel used their VHF radio before or after the collision.

Copies of the report ( Marine Safety Investigation Report 203)can be downloaded from the ATSB website.

The ATSB's final report into the terrain proximity caution incident to the south-south-east of Canberra at 0544 am on 24 July 2004 has found that the flight crew of the Boeing 737 were affected by fatigue and they misinterpreted the instrument approach chart and entered incorrect data into the flight management computer.

The aircraft was being operated on an overnight service from Perth to Canberra, when it proceeded beyond the limits of the Church Creek Holding pattern, 10.9 NM south of Canberra. In doing so the crew manoeuvred the aircraft closer to terrain than intended. As a consequence the aircraft received a 'Caution Terrain' message from the aircraft's enhanced ground proximity warning system.

The crew had commenced a right turn back to the north towards Canberra shortly before the 'Caution Terrain' message. They then climbed the aircraft to a higher altitude.

The flight crew's fatigue was partly the result of an airconditioning fault that led to hot cockpit conditions from Perth to Canberra. Normal air traffic assistance was unavailable in Canberra until 40 minutes after the scheduled 0530 am opening time.

The aircraft operator has amended its procedures to require a higher altitude for aircraft holding to the south of Canberra and the chart publisher is amending charts to reduce the likelihood of misinterpretation.

The ATSB initiated a category 3 investigation, which was subsequently noted on the ATSB website in early August. The Bureau released a preliminary report on this occurrence on 22 September 2004.

The final ATSB investigation report ( Aviation Safety Investigation Report 200402747) can be downloaded from the website, or obtained from the ATSB by telephoning (02) 6274 6478 or 1800 020 616.

The ATSB's preliminary examination of recorders from the fatal Metroliner accident has found good data on the aircraft flight data recorder but not on the cockpit voice recorder.

The two recorders were located in the aircraft wreckage on the afternoon following the accident and carried to the ATSB Canberra laboratories, arriving at 7 pm on Monday. Both recorders were heat affected from the post-accident fire.

Useful data of reasonably good quality has been retrieved from the flight data recorder (FDR) and detailed verification and analysis of that information has commenced. The FDR contained a little over 100 hours of recorded aircraft operation.

Unfortunately, no useful information about the accident flight appears to have been recorded on the cockpit voice recorder (CVR). Preliminary analysis of the 30 minute CVR tape indicates that it contains a mixture of electrical pulses and fragments of conversations, some identified from previous flights. The CVR tape is subject to ongoing investigation.

While the lack of CVR information to help the investigation is very disappointing, the FDR data includes a number of flight parameters* and will be of major assistance.

Other ATSB investigators continue to work at the accident site near Lockhart River, interview relevant personnel, review documents and records, and plan lines of inquiry.

The ATSB expects to release available and verified factual information, including from the FDR, in a Preliminary Factual Air Safety Investigation Report, by early June 2005.

The ATSB will not be releasing detailed data from the FDR until the complex and painstaking process of verification and analysis has been completed. This may take a number of months and speculation in the meantime should therefore be avoided.

*FDR parameters for VH-TFU include:

• Elapsed Time Counter
• Pressure Altitude
• Indicated Airspeed
• Magnetic Heading
• Flap Position
• Roll Attitude
• Stabiliser Position
• Acceleration: Longitudinal Axis
• Acceleration: Vertical Axis
• Left Propeller (% RPM)
• Left Engine Torque (%)
• Right Propeller (% RPM)
• Right Engine Torque (%)
• VHF radio microphone keying

Over reliance on the accuracy of Global Positioning System (GPS) derived positions by a watchkeeper contributed to the grounding of the 35 m adventure cruise vessel True North at about 2300 on 7 August 2004, according to an Australian Transport Safety Bureau (ATSB) investigation report released today.

The ATSB report into the grounding of True North in the approach passage to St. George Basin, in Western Australia's Kimberley region, states that the vessel grounded on or near Strong Tide Point after a voyage from Prince Frederick Harbour. On board at the time of the grounding were 26 passengers and 12 crew. No pollution resulted from the grounding.

The report concludes that the vessel grounded while being navigated by an auto helm unit and an Electronic Chart System (ECS) receiving position information from GPS satellites. The GPS derived positions plotted on the ECS differed from the vessels true position by about 300 m. This error was possibly caused by a combination of factors, including GPS system inaccuracy, geodetic datum ambiguity, and a possible recent change in the ECS operating systems computer or GPS receiver parameters.

The report finds that the vessel's master, who was alone in True Norths wheelhouse at the time of the grounding, was probably suffering from some effects of fatigue as a result of his work routine. The master did not adequately cross check the GPS positions on the ECS by other navigational means, nor did he maintain an adequate visual or radar check to ensure the vessel remained in safe water.

The report also concludes that there were deficiencies in the procedures which dealt with the mustering of passengers in the event of an emergency.

Copies of the report ( Marine Safety Investigation Report 205) can be downloaded from the website, or obtained from the ATSB by telephoning 1800 020 616.

The ATSBs final report into the fatal aircraft accident at Jandakot on 11 August 2003 has determined that the aircrafts right engine lost power soon after take-off when its engine driven fuel pump seized.

The Cessna 404 was being operated by one pilot and had five passengers who were to operate specialised equipment on the aircraft during maritime operations approximately 40 NM west of Jandakot. One passenger did not vacate the aircraft and was fatally injured. The pilot and the other four passengers sustained serious injuries as they vacated the aircraft. One of those passengers died from his injuries 85 days later.

In challenging circumstances, and with high-voltage powerlines crossing the aircrafts flight path 2,400 metres beyond the runway, the pilot turned the aircraft back to the aerodrome for an emergency landing. During the manoeuvring the pilot was unable to prevent the aircraft descending towards trees and scrub-type terrain, where it crashed and caught fire. Fuel from the ruptured wing tanks fed the fire.

A number of factors affect an aircraft's one-engine inoperative performance, including any variation from the airspeed to achieve the one-engine inoperative best rate of climb, control inputs made by the pilot to manage the situation and the effect of manoeuvring/turning the aircraft. One-engine inoperative climb performance significantly reduces during turns.

Jandakot did not have a dedicated aerodrome rescue and firefighting service and the first local firefighting unit arrived at the aerodromes emergency gate, about 1,500 m from the accident site about 12.5 minutes after being notified by the police. The Fire and Emergency Services Authority records showed that the first information from the accident site indicating that firefighting was underway was received about six minutes later.

The investigation found that the engine-driven fuel pump failed when its spindle shaft and sleeve bearing seized. Although the auxiliary fuel pumps were being used during the take-off, the low-pressure supplementary fuel was not sufficient to sustain engine operation at the take-off power setting.

A review of maintenance documentation revealed that a sleeve bearing replaced during the last overhaul of the engine driven fuel pump was not of the same material specification as the original bearing material. That material selection had the unintended consequence of increasing the likelihood of bearing seizure.

Following the occurrence, the operator modified other Cessna 404 aircraft in its fleet to incorporate a warning light to indicate low fuel pressure. The ATSB has previously issued safety recommendations to CASA regarding pilot training for engine-out operations, which are relevant to the circumstances of this accident.

Copies of the report ( Aviation Safety Investigation Report 200303579) can be downloaded from the website, or directly from the ATSB by telephoning 1800 020 616.

The Australian Transport Safety Bureau (ATSB) investigation report released today deals with the collision between a ship, Asian Nova, and a fishing vessel, Sassenach, off Townsville on 29 May 2003 in which a local fisherman lost his life.

The fishing vessel's skipper lost his life as a result of the collision, his body was recovered from the sunken trawler on 5 June 2003. The boat's other crew member, the deckhand, was able to jump clear at impact and was rescued some five hours later by a searching fishing boat.

Poor watch handover practices and a poor lookout were identified as major contributing factors in the collision which occurred at about 0001 on 29 May 2003. The 225 m long, fully loaded, Panamanian bulk carrier fouled the trawl warps of the Australian registered fishing vessel and the prawn trawler was dragged against the hull of the bulk carrier, damaging its port quarter and causing it to capsize and sink.

The report concludes that the handover of watch on the bulk carrier should not have occurred until the ship had passed the fishing vessel and that neither of the officers on watch had followed internationally recommended practice or company requirements when changing watch. In addition, the oncoming officer of the watch did not adequately assess the navigational and traffic situation before altering course as he approached the fishing vessel.

On Sassenach the assessment that the ship would pass clear was made on scanty information.

The report makes recommendations about watch changeovers, lookouts, and about correct use of navigational recording devices.

Copies of the report ( Marine Safety Investigation Report 195) can be downloaded from the website, or obtained from the ATSB by telephoning 1800 020 616.

The ATSB's final report into the tragic helicopter accident near Mackay that killed all three crewmembers found that spatial disorientation of the pilot was likely and includes a number of safety recommendations to prevent a recurrence.

The Bell 407 helicopter, operating under the night Visual Flight Rules (VFR), was en-route from Mackay to Hamilton Island, to pick up a patient, when it crashed into the sea.

The report found that the circumstances of the accident combined most of the risk factors known to be associated with helicopter Emergency Medical Services (EMS) accidents. These included pilot experience and training, organisational and operating environment issues.

While the ATSB could not conclusively determine why the helicopter departed controlled flight, it found that spatial disorientation of the pilot in dark night conditions over water was likely.

As a result of the investigation, safety improvements related to helicopter EMS operations, particularly operations at night, have been taken or are planned by the organisations involved in the operation and oversight of the flight.

These include:

• a revision of standard operating procedures for helicopter emergencies and the requirement for pilots to hold a command instrument rating, have received crew resource management training
• the establishment of centralised clinical coordination and tasking of aero-medical operations for Southern Queensland through a centre in Brisbane with a parallel system planned for North Queensland by July 2005.

The ATSB is bringing this report to the attention of the Australian Health Ministers' Advisory Council and copies of the report ( Aviation Safety Investigation Report 200304282) can be downloaded from the website, or obtained from the ATSB by telephoning 1800 020 616.

A leak in the main water ballast line in the engine room of the Panamanian registered bulk carrier Harmonic Progress led to the ship becoming disabled in the Coral Sea at 1230 on 16 April 2004, according to an Australian Transport Safety Bureau (ATSB) investigation report released today.

The ATSB report into the disabling of Harmonic Progress states that the flow of water ballast into the engine room bilges was not sufficiently controlled before it reached a depth of 1.5 metres. At that depth, the water entered the motors for the main engines lubricating oil pumps and caused them to short circuit. The lack of lubricating oil prevented the main engine from being able to be operated, resulting in the ship drifting westward towards the outer edge of the Great Barrier Reef for 43 hours before assistance arrived. The ship was in ballast, making for Hay Point when the incident occurred.

A harbour tug from Townsville and a large salvage tug from Brisbane were able to take Harmonic Progress in tow about 40 nautical miles from the Great Barrier Reef. Harmonic Progress was towed to the port of Gladstone, where initial repairs were undertaken in order to enable the ship to proceed under its own power to Brisbane. At Brisbane, the ship entered dry dock, where inspection, repair and testing of ballast valves and pumps took place. No one on board was injured during the incident and no pollution resulted.

The ATSB investigation report concludes that leaking valves in two water ballast tanks resulted in the main ballast line being pressurised following ballast water exchange operations which took place a week before the leak in the engine room was found. The report also concludes that the crew had failed to identify that a critical valve had been left open after the ballast water exchange when they were attempting to isolate the leak prior to the ship becoming disabled.

The entire ship's crew, with the exception of the chief engineer, had joined the vessel about two weeks before the flooding, when new owners and managers took over the ship. The crew were unfamiliar with the ballast system and did not use a systematic approach to find the source of the water leaking from the ballast line. In addition, the pre-delivery inspection of the ship prior to the change of ownership is suspected of being inadequate.

Copies of the report (Marine Safety Investigation Report 202) can be downloaded from the website, or obtained from the ATSB by telephoning 1800 020 616.