The ATSB final investigation report into the crash that killed the two occupants of a Robinson R22 helicopter at Yakka Munga Station in Western Australia, has found that a drive shaft to the main rotor blades failed.

Examination of the shaft revealed that it had failed as a result of a fatigue crack that initiated at a bolt hole in the shaft. Inappropriate procedures, including use of an unapproved sealant, were used when the shaft was last assembled.

During the investigation, the ATSB issued an urgent safety recommendation to the Civil Aviation Safety Authority (CASA) asking for an inspection of the R22 and R44 Australian helicopter fleet. CASA responded by mandating inspections of the shaft assembly to look for signs of damage and to remove those from service that had been assembled using an unapproved sealant.

As a result of the CASA mandated inspections, the use of unapproved sealants was found to be widespread within the Australian R22 helicopter fleet. The Robinson Helicopter Company advised that maintenance documents and training courses would be revised to clarify shaft assembly instructions.

The investigation also found that the survivability of the two occupants may have been adversely affected by the reduced capacity of the seat structures to deform as designed. That was due to the stowage of an excessive amount of baggage and equipment in the under seat baggage compartments.

The full investigation report (200304074) is available from the website, or from the Bureau on request.

The ATSB investigation into the fatal Aero Commander accident on 19 February 2004, 58 km NNW of Hobart is focusing on the reason for an overload failure of the wings in flight.

The ATSB interim factual report finds that the wreckage pattern was consistent with the aircraft having sustained an in-flight structural failure of both wings and the tailplane. The outboard left and right wing sections had separated from the aircraft at similar positions along the respective wings and in a downward direction. However, there was no evidence of corrosion, fatigue cracking or airframe modifications that could have degraded the strength of the wing or tailplane structures.

The aircraft was being operated on a visual flight rules ferry flight to Devonport. The pilot, the sole occupant, reported an intention to climb the aircraft to a cruising altitude of 8,500 ft. The aircraft was not required to be fitted with a flight data recorder or cockpit voice recorder and there was no other recorded information available.

The main parts of the aircraft, consisting of the forward and aft fuselage, inboard wing sections and flaps were found upside down in undulating terrain at 560 metres above mean sea level. Both engines and propellers were with the main wreckage. The remainder of the aircraft structure was scattered to the east-north-east of the main wreckage, with some less heavy items up to 1,300 m away.

The investigation is continuing and is examining aspects of the aircraft's structures, automatic flight control system, flight operations, air traffic control, meteorological conditions and human performance.

The ATSB investigation report 200400610.

The ATSB has two marine investigators in transit to investigate the fatal lifeboat accident at Port Hedland yesterday.

The Australian Transport Safety Bureau was advised late yesterday of the lifeboat accident in which two people received fatal injuries, another two suffered serious injuries, and a fifth less serious injuries.

The accident occurred on 7 October 2004 during a lifeboat exercise on the Hong Kong registered bulk carrier Lowlands Grace, while the ship was at anchor off the WA port of Port Hedland.

The ATSB is sending an investigation team to Port Hedland to determine the circumstances that led to this tragic accident and to make any necessary recommendations to prevent future accidents.

The ATSB team will work cooperatively with police investigators assisting the WA Coroner.

Until the team has arrived on site, the ATSB will not be able to comment on the circumstances of this tragic accident.

The ATSB has released a Preliminary Investigation Report into a 24 July 2004 Boeing 737 incident involving a ground proximity warning 22km south of Canberra aerodrome.

The report can be found on the ATSB web site www.atsb.gov.au.

The ATSB will not be commenting further on this Preliminary Report.

The final report into this incident is expected to be completed by March 2005 and an interim factual report will be released before that time if the circumstances warrant this.

Any necessary safety action that arises from the investigation will be recommended immediately and not held until the final report.

The Australian Transport Safety Bureau has been advised that two people were fatally injured in a Robinson R44 helicopter crash which occurred at about 6.30pm on 8 September 2004.

The accident occurred some 30NM, West South West of Roma, Queensland.

The ATSB is sending an investigation team to the site to attempt to determine the causal factors that led to this tragic accident and to make any necessary recommendations to prevent future accidents.

Until the team has arrived on site the ATSB will not be able to comment on the circumstances of this tragic accident.

Given the heightened interest, the ATSB has released an interim report on progress with its investigation into the tragic Benalla fatal accident, emphasising its complexity due to destruction of the aircraft and the need to carefully address all the safety issues.

The ATSB Preliminary Report into this six-fatality accident in a Piper Cheyenne was released on 31 August to provide early safety advice and warning to the industry.

The aircraft tracked from Bankstown to the Benalla area via Jervis Bay and the pilot had planned to conduct a Global Positioning System (GPS) approach at Benalla. The investigation determined that the aircraft's track was a consistent 3.83 degrees left of the direct track prior to commencing the GPS approach. The aircraft was equipped with a radio altimeter and an approved GPS receiver. The pilot was qualified to track and conduct instrument approaches using the GPS.

The investigation is continuing and, among other things, includes aspects relating to:
the operation of the aircraft; previous flights; aircraft maintenance history; post mortem and toxicology findings; air traffic control system and its operation; availability of ground-based navigation aids; statements from witnesses and other involved persons; GPS carried and GPS software; and electronic devices including mobile phones.

At this stage there is no evidence that the flight was affected by electronic interference. There was adequate satellite coverage for the operation of the GPS. The operation of the approved GPS carried for this flight, using the installed software, does not require manual input of waypoint position coordinates.

The investigation of this accident is necessarily complex due to the destruction of the aircraft during the high speed impact and post-impact fire (see pictures attached and at www.atsb.gov.au) and it will take several months to methodically analyse the available evidence so that all possible causal factors are identified together with safety issues.

In accordance with ATSB practice, as safety issues are identified, the ATSB makes recommendations to, and liaises with, organisations best able to effect change in order to enhance safety. These safety actions are not held until the final report is released.

The ATSB continues to liaise with the Victorian State Coroner who has been briefed on this report.

The ATSB appreciates the support of the industry and community in continuing to provide information that may assist its investigation and prevent another accident.

The Australian Transport Safety Bureau (ATSB) has advised that the door that fell from a Raytheon Beechcraft King Air B300 aircraft on Tuesday 7 September 2004 has been located.

The ATSB would like to thank media outlets for their cooperation in publicising our request for assistance in finding the cabin door.

The door was located to the south-west of Theodore, Central Queensland.

With the assistance of the Queensland Police Service the door will be delivered to the ATSB's laboratories in Canberra for examination.

The ATSB will now be in a much better position to determine why the door fell off.

The ATSB's investigation report will be made public and placed on the ATSB website when the investigation has been completed.

The Australian Transport Safety Bureau (ATSB) has found that fatigue cracking in the blade slots of a high-pressure turbine disk led directly to the uncontained failure of the left engine of a Boeing 767 aircraft that occurred near Brisbane on 8 December 2002.

The aircraft was operating a scheduled passenger service to Auckland, New Zealand and was forced to return to Brisbane airport after the failure. Damage to a wing leading-edge flap from engine debris and the weight of the fuel being carried for the trans-Tasman flight led the flight crew to perform a prepared emergency landing, during which the passengers were instructed to adopt the 'brace' position.

In its investigation report released today, the ATSB found that growth of the slot cracking resulted in the fracture and release of a large segment of the first-stage high-pressure turbine disk, puncturing the engine casing and nacelle, before striking the engine pylon and an adjacent leading edge flap panel. While the reasons for the disk cracking were not conclusively established, the ATSB found that several aspects of the disk manufacturing process or subsequent repair operations could have contributed to crack formation.

As a result of the investigation findings, the engine manufacturer has implemented changes to the disk manufacturing and repair processes and has revised the inspection requirements for the disks fitted to the affected engine model. Both the US Federal Aviation Administration and the Australian Civil Aviation Safety Authority have mandated the new inspection requirements.

The full investigation report 200205780.

The Australian Transport Safety Bureau (ATSB) is seeking assistance from the public to locate a door that fell from an aircraft at about 0715 EST Tuesday 7 September 2004.

The aircraft, a Raytheon Beechcraft King Air B300, was en route from Brisbane to Central Queensland at position 149 degrees 51 minutes East, 25 degrees South (approximately 14 NM WSW of Theodore township) and descending through 17,000 ft when the cabin door separated from the aircraft.

The door is curved, coloured white and about 1.5 m by 0.8 m by 15 cm. The likely area of interest is bounded by Theodore, Glenbar Station, Flagstaff Hill and Forest Hills Station.

Anyone locating the door is requested not to move the door but to mark the location and to contact the ATSB on Freecall 1800 011 034 (24 hour number).

A media briefing on the circumstances of the 8 September 2004, Robinson R44 Helicopter, VH-JWX near Roma, Queensland will be held in the Roma airport car park, outside the terminal at 6.00pm today, 10 September 2004.

The Investigator in Change, Mike Cavenagh, will provide factual events that are known to the investigation team at this point in time.

With the exception of this media briefing all media contact will continue to be addressed by the Bureau's central office, details below.