An ATSB investigation report has emphasised the need for operators to heed the advice of aircraft manufacturers with regards to maintenance and upgrades to their fleet.

On 13 December 2016, a B200 King Air aircraft was conducting a visual approach to Moomba Airport in South Australia when the pilot observed the left engine fire warning activate. The pilot shut down the left engine, but omitted to feather the propeller. The additional drag caused by the windmilling propeller combined with the aircraft configuration for landing while in a right turn, requiring more thrust than was available. The aircraft landed in the sand to the left of the runway threshold and, after a short ground roll, spun to the left before coming to rest. There were no injuries, but the aircraft was substantially damaged.

No engine fire damage was found, which indicated the fire warning had almost certainly been a false alarm. The aircraft manufacturer had previously published a service bulletin for the optional replacement of the engine fire detection system with a system less susceptible to false warnings. The operator, however, who had limited experienced with false engine warnings in their fleet, elected not to replace the system on the aircraft.

The ATSB also found that the pilot had not received the operator’s published syllabus of training for that aircraft. Instead, a tailored training program was delivered based on the pilot’s experience on the C90 King Air and taking into account advice the operator received from the Civil Aviation Safety Authority (CASA). This training did not cover all the elements required under the Civil Aviation Safety Regulations.

As a result, CASA will be taking steps to refresh industry and its own officers’ knowledge of particular terms and concepts within the flight crew licencing regulations, so as to remove any doubt regarding their interpretation and applicability.

Read the final report: Engine shutdown and collision with terrain involving Beech Aircraft Corporation B200, VH-MVL, Moomba Airport, South Australia, on 13 December 2016

The management company of the Spirit of Tasmania II has implemented a raft of changes in response to an ATSB investigation MO-2016-001 into a mooring incident at Station Pier, Melbourne, in January 2016.

The changes will ensure that weather monitoring and mooring systems and procedures are regularly checked and verified for changing weather conditions. These will reduce the safety risks for ships with large numbers of passengers.

Spirit of Tasmania II was loading cargo, vehicles and passengers at Station Pier on 13 January 2016 when, just before 6pm, strong wind gusts blew the ship away from the wharf.

After breaking away, the stern swung around until the ship was 90 degrees to the wharf, parallel to nearby Port Melbourne Beach with a possibility of grounding.

ATSB Chief Commissioner Greg Hood says the investigation found a band of severe thunderstorms passed across the location of Spirit of Tasmania II, with little warning.

“With the ship’s bridge unattended during the port stay, none of its crew saw indicators of the approaching storm until just before the breakaway,” Mr Hood said.

“The crew responded swiftly, controlling the ship’s movement using its thrusters and main propulsion machinery. With two tugs assisting, it was returned to the wharf just after 7pm.”

The ship suffered minor damage to its lower bow ramp and bow doors. Shore infrastructure suffered extensive damage to the elevated roadway and ramp arrangement on the wharf and minor damage to wharf structures. No one was injured.

Since the incident, the ship’s managers, TT-Line Company, advised the ATSB of changes to shipboard weather monitoring and notification arrangements along with changes to heavy weather and mooring procedures.

Mr Hood welcomed the changes including weather triggers for increased shipboard readiness and immediate notification of weather warnings.

“In addition, there will be access to the Bureau of Meteorology (BoM) website from the bridge, changes to on-board wind speed alarm settings and a requirement for all mooring lines to be held on the winch brakes,” he said.

“TT-Line also engaged external marine consultants to examine and recommend any alterations to berthing arrangements and infrastructure at Station Pier.”

The ATSB has issued one recommendation to TT-Line to complete safety action to adequately address the safety issue with respect to mooring at Station Pier. TT-Line has 90 days to respond to the ATSB’s safety recommendation.

Further, the Victorian Ports Corporation (Melbourne) advised the ATSB that Melbourne vessel traffic service will broadcast BoM weather warnings on VHF channel 12. All masters of ships in port waters, including at berth or anchorage, are to ensure a listening watch is maintained at all times.

Also, the BoM has advised the ATSB that it continues to upgrade its marine weather services, including a one-stop webpage on its website for improved education, information and accessibility to marine and ocean services.

Read the final report: Breakaway of Spirit of Tasmania II, Station Pier, Port Melbourne, Victoria, on 13 January 2016

The ATSB has today released an update into the tragic accident involving a B200 King Air aircraft that collided with a retail facility at Essendon Airport on 21 February this year. Sadly all four passengers and the pilot died in the accident.

ATSB Chief Commissioner Greg Hood said ATSB investigators have done an extensive amount of work to date.

“Investigators have gathered and assessed a large volume of evidence such as CCTV footage and witness statements. The team has also inspected the engines in close consultation with the manufacturer,” Mr Hood said.

“The aircraft’s fire-damaged CVR was retrieved and transported to the ATSB’s technical facilities in Canberra for examination and download.

“While the CVR was successfully downloaded, no audio from the accident flight was recorded. All the recovered audio was from a previous flight on 3 January 2017. The ATSB is examining the reasons for this.”

Mr Hood said that while the team is diligently assessing the physical and digital evidence, the considerable damage to the aircraft is presenting challenges.

“The extensive damage caused by the collision and post-impact fire has meant investigators are yet to determine a clear picture of the causal factors behind the accident and loss of life,” Mr Hood said.

“I offer my deepest sympathies to the families and loved ones of those on board the aircraft. Every effort is being made to determine the cause of this tragic accident.”

This update does not contain findings. The ATSB will present the findings of its investigation in the final report, due out in around 12 months. Further updates will be provided if significant information comes to hand.

If the ATSB identifies any safety issues during the course of the investigation, it will immediately bring them to the attention of relevant operators and authorities for safety action.

Read the preliminary report: Loss of control and collision with terrain involving B200 King Air, VH-ZCR at Essendon Airport, Victoria on 21 February 2017

As the range of products using batteries grows, the potential for in-flight issues increases.

On a recent flight from Beijing to Melbourne, a passenger was listening to music using a pair of her own battery-operated headphones.

About two hours into the flight while sleeping, the passenger heard a loud explosion. “As I went to turn around I felt burning on my face,” she said. “I just grabbed my face which caused the headphones to go around my neck.

“I continued to feel burning so I grabbed them off and threw them on the floor. They were sparking and had small amounts of fire.

“As I went to stamp my foot on them the flight attendants were already there with a bucket of water to pour on them. They put them into the bucket at the rear of the plane.” The battery and cover were both melted and stuck to the floor of the aircraft.

Flight attendants returned to check on her wellbeing. For the remainder of the flight, passengers endured the smell of melted plastic, burnt electronics and burnt hair. “People were coughing and choking the entire way home,” the passenger said.

The ATSB assessed that the batteries in the device likely caught on fire. The ATSB reminds passengers using battery-powered devices that:

• batteries should be kept in an approved stowage, unless in use
• spare batteries must be in your carry-on baggage NOT checked baggage
• if a passenger’s smart phone or other device has fallen into the seat gap, locate their device before moving powered seats
• if a passenger cannot locate their device, they should refrain from moving their seat and immediately contact a cabin crew member.

More information about Travelling safely with batteries and portable power packs(Opens in a new tab/window).

Other ATSB news stories and investigation reports about lithium-ion batteries:

• Aviation incident sparks lithium battery warning
• Personal electronic device fire in-flight involving Boeing 747
• Crew’s prompt in-flight response to smoking device.

On 11 November 2016, a Cessna 208B aircraft was on a re-familiarisation training flight with an instructor and trainee pilot on-board.

After take-off, at an altitude of about 500 ft, the instructor noted the climb speed reducing while the trainee continued to maintain the nose attitude for best angle of climb. At the same time, the instructor heard the engine lose power and a thin film of fuel partially obscured the windscreen.

As the airspeed reduced to 60 kt, the instructor took control and identified a suitable area for a forced landing and began a left turn at the target glide speed of 85 kt. At the completion of the turn, they selected 30 degrees of flaps to provide a short climb, which allowed the aircraft to clear two hangars and an area of trees.

After clearing the hangars and trees, the aircraft landed without further incident.

A post-accident examination of the engine found the number eight fuel nozzle locking plate missing—probably not reinstalled when fuel transfer tubes and nozzles were installed after replacement.

The missing locking plate allowed the fuel transfer tube to slowly migrate out of the nozzle adaptor over the 86 hours since the maintenance occurred. Fuel escaped, leading to engine power loss in flight.

Australian Transport Safety Bureau Chief Commissioner Greg Hood says the incident serves to underline the importance of ensuring all maintenance is completed entirely and correctly.

“The locking plate was not installed during scheduled maintenance, and yet the fuel leak did not develop for a further 86 flight hours,” he said. “This demonstrates how the effects of incomplete maintenance can take a long period of time to manifest.”

Read the final report: Engine failure and forced landing involving Cessna 208, VH-TYV, Darwin Airport, Northern Territory, on 11 November 2016

Effective use of Crew Resource Management procedures by a Fairchild SA227 flight crew helped them safely deliver 13 passengers from Armidale, NSW, to Brisbane, Queensland, after a mid-flight engine failure.

At 7.55 am on 12 October 2016, the aircraft was about 170 km south of Brisbane when it suddenly yawed to the right.

The flight crew noted that all right engine indications were normal except for a low torque reading and low fuel flow. They confirmed that the right engine was not delivering power, shut it down and feathered the right propeller.

Air traffic control gave them a direct track to Brisbane Airport. After completing their normal and single engine landing checklist, the Fairchild landed at Brisbane Airport runway 19 without further incident.

Australian Transport Safety Bureau Chief Commissioner Greg Hood says that, following the aircraft yaw, the flight crew actively employed their crew resource management procedures to identify and confirm the engine fault and shut it down.

“The use of these procedures reduced the risk of an incorrect diagnosis of the fault, or activation of the incorrect engine controls during shut down,” Mr Hood said.

The ATSB investigation found that the failure of a retainer ring that led to an engine gearbox malfunction, was within the required gearbox inspection intervals and without prior warning of an impending failure.

As a result of this occurrence and subsequent to an update by the engine manufacturer to the engine manufacturer’s service bulletin, the aircraft operator has advised the ATSB that they have reduced their engine oil testing interval from 150 hours to 100 hours.

Retainer ring

Read the final report: Engine failure involving Fairchild SA227, VH-VEU, 170 km south of Brisbane, Queensland, on 12 October 2016

Education and training helped the crew of a Fokker F28 MK 100 manage two emergencies, including a hydraulic failure that compromised nose-wheel steering.

The crew’s response ultimately ensured the safe landing, taxiing and subsequent evacuation of 97 passengers, three cabin crew and two flight crew on a Newman to Perth flight on 23 September 2016.

About 550 km north of Perth, the flight crew were alerted to the issue resulting from the hydraulic failure. They arranged for assistance to be available at Perth airport to tow the aircraft from the runway to the gate.

The flight crew notified Air Traffic Control of the fault and discussed the implications of the failure. Without nose-wheel steering, they planned to land the aircraft on runway 21 at Perth Airport and roll through to the end of the runway, where a pre-positioned tug would tow it to the allocated gate for passenger disembarkation.

Rather than use the engines for electrical power and air-conditioning during the aircraft tow, the captain elected to start the auxiliary power unit (APU) during the approach. The APU would then supply air for the air-conditioning system after landing and electrical power after the engines were shut down.

The aircraft landed without further incident and rolled through to the end of runway 21.

Despite the pre-arrangement, there was no tug waiting for the aircraft, so the flight crew used differential braking to turn the aircraft off the runway and onto the taxiway before stopping.

At this point the cabin crew manager reported to the captain that fumes were present in the cabin. An emergency evacuation was conducted, during which three passengers received minor injuries.

Australian Transport Safety Bureau Chief Commissioner Greg Hood says the incident highlights the importance of training and procedures, and the need for organisations to educate their workforce about safety incidents.

“The flight crew were confronted with consecutive emergencies,” Mr Hood said. “They responded to each situation in accordance with their training and procedures, which resulted in everyone safely evacuating the aircraft with only minor injuries reported.”

Read the final report: Emergency evacuation involving Fokker F28, VH-NHY, Perth Airport, Western Australia, on 23 September 2016