Air Safety Investigation Report 200100348 Fact Sheet

On 18 November 2001, a ballast tank of the Hong Kong-registered bulk carrier Nego Kim exploded killing eight crew members.

The Australian Transport Safety Bureau (ATSB) investigation has found that the explosion occurred when volatile paint fumes inside the inadequately ventilated tank were ignited.

The ATSB released the results of its investigation today.

The report states:

• The explosion occurred at 4.40pm on Sunday 18 November 2001, when the ship was anchored inside Dampier port limits waiting to load a cargo of scrap metal.
• Prior to the explosion, eight crew members had spent two hours spray painting inside a topside ballast tank.
• The explosion occurred when volatile paint fumes inside the inadequately ventilated tank were ignited, probably by the electric lead light the men were using.
• Three of the crew were killed when the tank ruptured. Four other members of the crew were blown over the side of the ship. The search and rescue operation mounted by local authorities recovered one body 23 hours later.
• The eighth crew member, who was probably working inside the tank, survived the explosion but died of his injuries in Royal Perth Hospital 16 days later.

The ATSB identified that the crew were not provided with adequate instructions or equipment for the painting work and were unaware of the dangers associated with the task.

The investigation also found that Dampier Port Authority's emergency response plan was deficient as it did not reflect the changed role of the authority in an emergency, following the closure of the port communications tower some months earlier.

As a result of the investigation, the ATSB has issued three recommendations:

• International Safety Management (ISM) manuals should include clear instructions for all operations in enclosed spaces, including the hazards of any operation and instructions regarding the wearing of appropriate clothing and protective equipment.
• ISM manuals should provide guidance on the conditions under which work in enclosed spaces should be undertaken.
• The Port of Dampier draft Emergency Response Plan should be reviewed to remove ambiguities and to ensure a consistent and appropriate approach to emergency situations within the port, including clear communications.

The report Marine Safety Investigation Report 174, is available from the website.

The ATSB today released its interim report on the fatal accident involving a Piper PA-28-161 aircraft and a Socata TB-9 aircraft near Bankstown Aerodrome on 5 May 2002.

Four people died in the accident, which occurred when the Piper (call sign VH-IBK) and Socata aircraft (call sign VH-JTV) collided about 2km ESE of the aerodrome, while on final approach to the runway.

The Piper aircraft had departed Wagga Wagga at about 1.34pm that day on a private flight to Bankstown, with a private licensed pilot and three passengers on board.

The Socata aircraft, with a flight instructor and student pilot on board, was conducting circuit training at Bankstown Aerodrome on runway 29L via left circuits.

The interim report states:

• The Socata pilots reported that, after they completed the turn onto final approach, their aircraft was lined up for runway 29L.
• Soon after, the instructor pilot saw the Piper was positioned close to the right of their aircraft and on a rapid collision course with the Socata.
• The two aircraft collided at about 3.25pm.
• Following the collision, the instructor pilot landed the Socata safely and the two pilots were uninjured.
• All on board the Piper died in the accident.

The ATSB investigates accidents in order to identify the contributing factors and to make safety recommendations which may prevent such accidents from happening again. The ATSB does not investigate for the purposes of apportioning blame or liability.

The interim report is a summary of factual information known at this point in time.

The report Interim Factual Report 200201846 is available from the website.

At approximately 1745 hrs on 26 September 2002, a single-engine Piper Cherokee Six aircraft, with 6 people on board crashed and caught fire shortly after take-off from Hamilton Island. All occupants were fatally injured.

A team of Transport Safety Investigators from the Australian Transport Safety Bureau (ATSB) is expected to arrive at the scene of the accident sometime during the afternoon today to commence an investigation into the circumstances surrounding this tragedy.

The investigator-in-charge (IIC) of this accident is expected to give a media briefing from the accident site at 1500 hrs today. However, please contact the ATSB on 1800 020 616 for confirmation of the briefing time.

The ATSB investigators will be examining the wreckage and aircraft documentation and would like to talk to any witnesses to this accident. Witnesses are asked to contact the ATSB on 1800 020 616.

In accordance with its policies and procedures, the ATSB is expected to issue a preliminary report concerning this accident in approximately 30 days.

ATSB releases preliminary report on Hamilton Island crash

Container ship's contact with a navigational beacon in Moreton Bay.

The ATSB is pleased that Coroner Hope has adopted much of the material in ATSB's final report on the tragic VH-SKC accident and stated that "ultimately it appears that the ATSB report was based on a substantial amount of scientific investigation and many issues were diligently pursued" (p21). The Coroner also cites (eg p6) the evidence of Dr Brock who was a consultant to the ATSB and part of the ATSB investigation team.

The Coroner concludes (p55) that: "It appears that the aircraft was unpressurised for a significant period of its climb and for the subsequent flight. While it is possible that the occupants died as a result of hypobaric hypoxia, I cannot exclude the possibility that some unknown and unidentified toxic fumes caused their incapacity and death".

The ATSB final report (p29) conclusion was very similar: "Due to the limited evidence available, it was not possible to draw definitive conclusions as to the factors leading to the incapacitation of the pilot and occupants of VH-SKC. The aircraft was probably unpressurised for a significant part of its climb and cruise for undetermined reasons. The pilot and passengers were incapacitated, probably due to hypobaric hypoxia, because of the high cabin altitude and their not receiving supplemental oxygen."

ATSB reported that testing established that carbon monoxide and hydrogen cyanide were unlikely to have been factors - there was no evidence of another toxic substance.

The WA Coroner has also supported the safety recommendations that the ATSB had either already made or had proposed in submissions and that is very welcome.

While an investigation report into a remote 440km/h impact crash and subsequent fire which destroys much of the evidence is always open to criticism, based on its initial reading of the 75-page report, the ATSB does not accept the Coroner's criticisms concerning the ATSB.

The ATSB cannot prepare an investigation report that is suitable for an adversarial legal process because this is contrary to its 'no blame' legislation based on Annex 13 to the Chicago Convention. The proposal to share investigation information with those who may use it in blame proceedings also has limitations. The Coroner, police or regulators could have undertaken their own parallel inquiries for such purposes.

The ATSB investigation report was prepared to satisfy the Bureau's Commonwealth legislation (which it did), not to satisfy the WA Coroner or any other parties who may have had an agenda related to blame or litigation. The ATSB nevertheless provided extensive expertise at its expense to assist the Coroner during the Inquest.

The Coroner criticises the ATSB for deficiencies and delays with the forensic tests done in Brisbane - however, coroners not ATSB have control/powers with respect to autopsies and forensic testing. The ATSB relies on coroners to authorise the conduct of such testing and has no powers to do so itself. Improving cooperation with coroners in relation to sharing evidence is a key element of a memorandum of understanding currently under discussion with coroners across Australia. Coroner Hope's final remark (p75) that "The various Coronial jurisdictions clearly have a role to play in this context to ensure that sensible co-operation can take place." is welcome.

The Coroner's criticism (pp 9-10) of the letter written by the ATSB Executive Director to the Coroner on 26 March 2002 (copy attached) is noted. The letter was written and sent only after the Executive Director had obtained legal advice that it would be appropriate to do so given that the Inquest was in the nature of an inquiry.

The Bureau is deeply concerned at the personal criticism directed towards its senior Perth-based investigator (pp17ff). It does not agree that there is evidence to conclude that the investigator "demonstrated an unfortunate lack of compassion for grieving families who were searching for answers." The investigator had the difficult job of finalising the investigation report after several staff had resigned/retired from the Bureau and had to face aggressive cross-examination.

The Coroner refers to the Transport Safety Investigation Bill 2002 that is before the Commonwealth Parliament and suggests that this may need to be amended. This Bill has been extensively discussed with representatives of the Coroners and their suggestions have been incorporated. There is positive and helpful ongoing discussion with Coroners on draft regulations and a future memorandum of understanding.

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The Australian Transport Safety Bureau (ATSB) today released a report on the circumstances of a serious incident where a fare-paying scheduled passenger flight encountered microburst windshear near Brisbane last year.

Windshear is a change in wind speed and/or direction, including updrafts and downdrafts. An aircraft may experience a significant deterioration in flight performance when exposed to windshear of sufficient intensity or duration.

On 18 January 2001, a Boeing 737-476 aircraft (VH-TJX) encountered microburst windshear at 7.29am while conducting a go-around from runway 19 at Brisbane aerodrome.

The aircraft was operating a scheduled fare-paying passenger service from Sydney to Brisbane when it encountered an intense thunderstorm.

The report states:

• As the aircraft passed 1,000 feet during the landing approach, it encountered rain and some isolated hail. The approach lights for runway 19 were visible to the crew, and the pilot in command elected to continue the approach.
• At about 500 feet, the weather deteriorated rapidly, and the aircraft encountered hail and turbulence.
• At a height of 171 feet above ground level, the pilot in command discontinued the approach and applied go-around engine thrust.
• The aircraft commenced to climb normally at about 3,600 feet/minute, however, shortly after the go-around was initiated, the climb performance substantially reduced to less than 300 feet/minute due to the effects of the microburst downdraft and from flight through heavy rain.
• The pilot in command applied maximum engine thrust to improve the aircrafts heavy climb performance, and advised the Aerodrome Controller that the aircraft had encountered severe windshear.
• The crew then diverted the aircraft to Maroochydore where it landed without further incident.

The occurrence highlights that thunderstorms and convective activity in terminal areas are a significant issue in Australian and international aviation.

This incident also highlights that without extensive Doppler weather radar capabilities, and in the absence of appropriate systems designed to detect hazardous windshear in Australia there is a need for collaborative decision making among forecasters, controllers, pilots and operators during periods of intense or severe convective weather.

In its report, the ATSB made a number of recommendations to Airservices Australia, the Bureau of Meteorology and the Civil Aviation Safety Authority (CASA). It also notes that a number of safety actions have been initiated or implemented by the operator, Airservices and CASA as a result of the investigation.

The safety actions include:

• CASA is developing regulatory requirements and standards for organisations providing meteorological services in support of air navigation and air traffic services within Australia and its territories.
• Airservices Australia will develop a refresher training module based on the circumstances of this occurrence and will mandate its completion for all Full Performance Controllers.

The operator has initiated or implemented a number of safety actions as a result of the ATSB investigation, including:

• The development of a weather radar training package for flight crews and enhancement of flight crew education on the performance deterioration of aircraft in heavy rain.
• Undertaking a project to integrate qualified meteorologists into its dispatch processes in order to initiate best practice improvements.

The Australian Transport Safety Bureau (ATSB) investigation into a reported fire in the cargo hold of British Airways Flight 16 is under way.

An ATSB engineer visited the incident site on Saturday night, 10 August.

Aircraft components are being transported to the ATSB laboratory in Canberra for analysis.

The ATSB anticipates there will be a preliminary report into the incident issued in 21 days.

However, it may take several months for the investigation to be completed.

The ATSB will not make any further statements at this time.