Airbus A340 loss of directional control while landing at Sydney Airport

An Airbus A340 lost directional control while landing on runway 16 Right at Sydney Airport on 1 November 2000 at 1150 hours ESuT.

The aircraft slewed right and came to rest with the nose landing gear resting in soft ground off the runway. The crew had reported problems with the hydraulic system prior to landing. There were no injuries, and an emergency evacuation was not required.

A Sydney-based investigator from the Australian Transport Safety Bureau made an initial assessment of the occurrence. He will be joined by other specialist investigators to assist in determining the factors contributing to the occurrence. The aircraft flight data recorder is being sent to the ATSB facility in Canberra for analysis.

Ship’s officer injured recovering dead colleague from the sea

An Australian Transport Safety Bureau (ATSB) investigation report released today recommends that ship owners, operators and masters with totally enclosed lifeboats on their ships should consider fitting lifting rings with 'hand holds' attached to them, and the provision of foul weather recovery strops.

The ATSB report into the accident on board the French Antarctic support vessel L'Astrolabe states that, at about 0355 (local time) on 27 January 2005 a crew member on board the ship either jumped or fell from the ship into the Southern Ocean. In the days before the crew member had been exhibiting signs of depression and he was intoxicated at the time he went overboard.

The ship was 235 nautical miles to the south of Hobart at the time, and was returning from the French Antarctic base of Dumont D'Urville. When it was discovered that the crew member was missing, a search of the ship and sea was initiated by the ship's master. The crew member was found in the sea, about 4.5 hours after being reported missing. He was deceased when found.

One of the ship's lifeboats was used during for recovery of the deceased crew member. The relative movement between the ship and the lifeboat in the two metre seaway during the lifeboat recovery operation caused damage to the lifeboat, its fittings and the injury of one crew member. The second engineer almost severed his thumb when he caught his right hand between the swinging lifeboat fall block and the lifeboat hook assembly.

Neither the fall block nor the suspension ring had 'hand holds' attached, and the ship was not outfitted with foul weather recovery strops, thus the crew were required to manhandle the blocks and rings.

Copies of the report can be downloaded from the ATSB's internet site.

ATSB Report on fatal accident near Lockhart River on 7 May 2005

The ATSB Interim Factual Investigation Report into the Metroliner fatal aircraft accident on 7 May 2005 near Lockhart River has found that if the ground proximity warning system functioned as designed, the crew should have received a number of warnings from the system as the aircraft descended below the minimum obstacle clearance altitude of 2,060 ft.

However, because no data on the cockpit voice recorder (CVR) was useable, the functionality of the warnings could not be confirmed. Flight data recorder information from the accident aircraft continues to assist with the ATSB investigation.

Aircraft VH-TFU was 11 km north-west of Lockhart River aerodrome on the final instrument approach track for runway 12, travelling at about 290 km/hr, when it collided with South Pap, a steep tree covered ridge in the Iron Range National Park.

The two pilots and 13 fare-paying passengers perished, and the aircraft was totally destroyed by massive overload forces as the aircraft collided with trees and large boulders during the impact sequence, and the intense fuel-fed fire which followed.

Although the weather conditions in the Lockhart River area on the day of the accident were worse than originally forecast, the crew was advised by Brisbane air traffic control of the amended forecast details more than two hours prior to commencing the approach to Lockhart River. The weather conditions at the time of the accident were reported as being broken low cloud with squally rain showers and drizzle.

Air traffic control tapes indicate that the copilot was making radio calls during the flight, which may indicate that the pilot-in-command was flying the aircraft, but this has not been able to be confirmed.

The investigation is continuing and because of the extent of the damage to the aircraft and loss of CVR data, is extremely complex and painstaking.

The full report is available on the ATSB website.

Bulk carriers collide in the anchorage off Newcastle, New South Wales

Anchoring too close to each other and without due regard to the changeable weather conditions in the anchorage off Newcastle were the major causes of the collision between two bulk carriers, according to an Australian Transport Safety Bureau (ATSB) investigation report released today.

The ATSB report into the incident states that at 0939 on 24 June 2005, the bulk carrier Pilsum collided with another bulk carrier, China Steel Growth, while dragging its anchor. The two ships were anchored off the New South Wales port of Newcastle.

On the morning of 24 June, a southerly weather front came through the anchorage. At 0900 on 24 June, the officer of the watch on Pilsum detected that the ship was dragging its anchor. The master was informed, and he decided to weigh anchor and depart the anchorage.

Pilsum's crew encountered difficulties recovering the anchor. While trying to weigh anchor Pilsum drifted towards China Steel Growth, which was anchored to the north.

At 0935 Pilsum pitched heavily, the propeller came clear of the water and the main engine was shut down by the overspeed trip. Pilsum's main engine was restarted, however at 0939 Pilsum collided with China Steel Growth. The two ships moved apart and made contact a second time before Pilsum finally made its way clear.

The report concludes that the ships in the anchorage off Newcastle on 24 June 2005 were anchored too close to each other. Pilsum did not have enough anchor cable laid out, and the officer of the watch did not fully utilise all available equipment while keeping the anchor watch.

The report also concludes that the advice to masters in the Australian Pilot publication does not sufficiently highlight the shortcomings of the Newcastle anchorage in adverse weather conditions.

Copies of the report can be downloaded from the ATSB's internet site.

Fatal Aircraft Accident Near Condobolin, New South Wales - 2 December 2005

The Australian Transport Safety Bureau (ATSB) is investigating the circumstances surrounding the Piper Navajo Chieftain four-fatality accident near Condobolin on 2 December 2005.

Four ATSB investigators have been on site near Condobolin since Saturday morning.

The Piper Navajo Chieftain was reportedly being flown by a commercial pilot and was en route from Archerfield to Swan Hill via Griffith. Weather in the Condobolin area was severe with extremely strong wind and thunderstorms across the aircraft's track. The pilot reported diverting around weather and shortly after this communication was lost.

Wreckage was found over a wide area in excess of 3.5 kms. A section of the tail was found about 3.5 kms from the main wreckage and one engine, with cowling and propeller attached, was found 500 metres from the main wreckage. All four (4) occupants of the aircraft received fatal injuries.

The investigation is continuing and will include examination of the wreckage and analysis of weather, air traffic control and radar information.

Witnesses to this accident are asked to contact the ATSB on 1800 020 616.

VIRGIN BLUE BOEING 737 EMERGENCY DESCENT

The Australian Transport Safety Bureau (ATSB) is investigating the circumstances surrounding a Virgin Blue Boeing 737 emergency descent incident on 2 December 2005.

The Boeing 737 was being flown from Townsville to Brisbane with a total crew and passengers of 104. During the rapid descent, a number of passengers suffered ear discomfort and some minor injuries.

On arrival at Brisbane the injured passengers were taken to hospital for observation and treatment and were discharged following treatment. None of the passengers were admitted to hospital.

The flight recorders are being replayed and analysed at the ATSB in Canberra.

The investigation is continuing and will include analysis of the cabin pressure rise and the reason for the cracked windscreen.

Commercial Fishing Vessel Safety Awareness Campaign begins in WA

As part of its national safety awareness campaign for commercial fishermen, announced in December 2004, the Australian Transport Safety Bureau (ATSB) will be conducting a series of informal face-to-face meetings with fishermen in two ports in northern WA, this week.

The aim of the meetings is to raise the awareness of commercial fishermen to similar causal factors, identified by the ATSB during investigations of 23 collisions between trading ships and fishing vessels conducted since 1990.

The meetings will complement a safety bulletin, published by the ATSB in December 2004, and form an important part of the safety awareness campaign.

The ATSBs safety awareness meetings will be held in conjunction with seafood safety and handling training workshops, which are being held by the Western Australian Fishing Industry Council (WAFIC), Challenger TAFE and WA's Department of Fisheries during the last week in July.

All commercial fishermen are encouraged to participate in the meetings, which will be held immediately after the training workshops in Broome and Point Sampson.

SEAFOOD SAFETY AND HANDLING TRAINING WORKSHOPS SCHEDULE

  • BROOME - Wednesday 27 July between 1:00 pm and 5:00 pm| Mangrove Hotel.
  • POINT SAMPSON - Friday 29 July between 12:00 pm and 4:00 pm| Point Sampson Community Hall.

Further information on the safety awareness campaign and the ATSB meetings can be obtained by contacting the ATSB on 1800 0200616 or by emailing the Marine Investigation Unit at: marine@atsb.gov.au.

Crew member fatality aboard bulk carrier

The electrician on board the Marshall Islands registered Probo Panda died from a heart attack following a suspected electric shock while the ship was at anchor off Gladstone in Queensland on 11 May 2005, according to an Australian Transport Safety Bureau (ATSB) investigation report released today.

The electrician died while working on one of the ship's engine room light fittings. He had been missing for several hours and was only found after a search of the vessel was instigated by the master.

The ATSB report into the fatality on board the products / oil / bulk / ore carrier Probo Panda, states that it is likely that the electrician was crouching on a deep frame at the lowest level of the engine room so he could reach the light fitting. He may have received an electric shock which knocked him off balance, causing him to fall between the deep frame and an adjacent pipe. The subsequent exertions, attempting to climb free probably induced a coronary artery occlusion.

The report concludes that the electrician had a pre-existing heart condition, coronary artery atheroma and, that the medical examination standards used to assess him were inadequate in terms of detecting conditions such as coronary heart disease.

The report also concludes that working on live electrical equipment and not implementing the measures outlined in the ships safety management system increased the likelihood of the electrician receiving an electrical shock. Also, working alone in an isolated area for an extended period of time without supervision or monitoring resulted in the electrician not being found in time to administer first aid.

Copies of the report can be downloaded from the website.

Cadet's fatal fall through open deck grating in engine room

A 20-year-old engineer cadet died from severe head injuries after falling seven metres while working in a ship's engine room, according to an Australian Transport Safety Bureau (ATSB) investigation report released today.

The ATSB report into the incident states that, at about 0920 (local time) on 16 May 2005, the engineer cadet on board the South Korean bulk carrier Golden Bell was working with other engine room staff when he fell through an open section of deck grating. The cadet landed seven metres below, on the engine room's bottom deck plates. He suffered severe head and internal injuries.

The cadet had apparently failed to see that a section of deck grating had been removed, in order to facilitate the placement of a ladder. The opening was not physically guarded in any way and only had an inappropriately placed sign to warn engine room staff of the danger that existed.

The ship was at anchor of the Western Australian port of Dampier when the incident occurred.

The cadet was evacuated by helicopter to the Nickol Bay Hospital in Karratha (20 km from Dampier), and despite the efforts of medical staff at the hospital, he died later that afternoon.

The report concludes that the open section of grating was not roped off or otherwise protected, and the danger sign was poorly sited and manifestly inadequate. Additionally, the ship's operating procedures did not specify that any open areas of deck grating should be roped off or otherwise protected.

The report's recommendations include that ship owners, managers and masters should revise operational procedures to reflect the need to ensure that open deck areas on board their ships are adequately safeguarded.

Copies of the report can be downloaded from the ATSB's internet site at www.atsb.gov.au.

Bulk carrier and fishing vessel collide off Western Australia's south-west coast

Failing to keep a proper lookout was the major cause of yet another collision between a trading ship and a commercial fishing vessel, according to an Australian Transport Safety Bureau (ATSB) investigation report released today.

The ATSB report into the incident states that, at 0535 (local time) on 15 April 2005, the Greek registered bulk carrier Spartia and the Western Australian cray fishing vessel Hannah Lee collided 17 nautical miles west of Cape Bouvard. Spartias crew had detected the fishing vessel about 20 minutes prior to the collision, using the ships radars. They had assessed that a risk of collision existed but, as Hannah Lee was on their port side, they maintained Spartias course and speed, in accordance with the international collision regulations. Hannah Lees skipper was preoccupied with keeping his vessel on course and had failed to see Spartia in the time leading up to the collision.

When it became obvious to Spartia's bridge team that Hannah Lee was not going to give way, the master ordered avoiding action. This manoeuvre was ineffective and Hannah Lee hit Spartia a short time later. No one was injured in the collision and there was no pollution.

The report concludes that the lookout being kept by the skipper of Hannah Lee in the period leading up to the collision was manifestly inadequate. In addition, his judgement, actions and situational awareness, with regard to what was happening around his vessel, were affected by fatigue. This was probably as a result of his work routine and other activities he had undertaken in the week prior to the collision. The report recommends that State and Territory marine authorities consider reviewing current work practices on fishing vessels, with a view establishing crew fatigue management guidelines.

The report also concludes that the action taken by the crew of Spartia to avoid the collision, when Hannah Lee was only one nautical mile away, was too little, too late.

The ATSB has investigated 23 collisions between ships and fishing vessels since 1990. The failure to keep a proper lookout was identified as a factor in each of the collisions.

The report (Marine Safety Investigation Report 211) can be obtained from the website.