What happened

At 0749 Eastern Standard Time on 17 April 2012, a Boeing Company 737-7Q8 aircraft, registered VH-VBL (VBL), departed Melbourne, Victoria, on a scheduled passenger service to Sydney, New South Wales.

The captain reported a burning smell in the cockpit on takeoff that dissipated at the top of climb. Shortly afterwards, the cabin supervisor advised the PIC of a very unusual smell in the front and rear of the passenger cabin.

The cabin supervisor and one other cabin crew member reportedly suffered minor side effects from the fumes. Another cabin crew member was unable to continue with his duties. As there was an extra cabin crew member on the flight, the supervisor assessed that his inability to continue with his duties did not pose a risk to flight safety.

After landing and following a review of the maintenance log, a company engineer advised that the fumes may have been the result of a recent engine wash.

No passengers reported feeling unwell during or following the flight, though some passengers in the front of the cabin were coughing during the flight. The captain at no time felt unwell and the first officer did not smell anything unusual throughout the flight.

Two of the cabin crew members were later deemed by a doctor to be unfit for work. 

The incident highlights the potential for crew incapacitation from exposure to fumes and that clear and unambiguous communication between the flight and cabin crew should be maintained during any unusual event.

Aviation Short Investigation Bulletin - Issue 12

Safety summary

What happened

On the morning of 29 April 2012, the owner-pilot of a Cessna 150 aircraft, registered VH-UWR was aerial stock mustering on a cattle station about 55 km north-east of Bourke, New South Wales. Some early patches of fog cleared such that the weather conditions were fine and calm.

After about 1.5 hours in the air, the pilot radioed stockmen on the ground to direct them to an area where cattle were not moving. The aircraft was observed circling over the area then in a steep descent followed by the sound of an impact. The aircraft was seriously damaged, and the pilot sustained fatal injuries.

What the ATSB found

While manoeuvring at low level the pilot inadvertently allowed the aircraft to aerodynamically stall, resulting in a high rate of descent and collision with terrain. There was insufficient information about pilot control inputs to establish the factors that precipitated the stall.

The pilot did not hold a valid medical certificate and had not completed a flight review for a number of years, increasing the risks of operating an aircraft, especially during aerial stock mustering.

Safety message

Pilot proficiency can decline without regular practice of non-routine procedures under the supervision of instructors or approved training/check pilots. As such, pilots should take every opportunity to refresh their knowledge and skills, at a minimum during a flight review every two years.

What happened

At about 1200 Central Standard Time on 18 April 2012 at the Nyirripi aircraft landing area (ALA) Northern Territory, a Cessna Aircraft Company 210 (Centurion), registered VH-TWP (TWP), was seriously damaged while attempting to land. The supervisory pilot was seriously injured and the pilot in command under supervision sustained minor injuries.

On landing, the aircraft ballooned twice. The supervisory pilot took control of the aircraft with the intent of recovering from the balloon to a normal landing. A gust of wind caused the aircraft to yaw significantly to the left, the supervisory pilot applied full power to go-around, but the aircraft did not climb. He then rolled the aircraft into a 30º right bank to remain over clear ground, closer to the runway.

Realising that the aircraft was going to impact the ground, the supervisory pilot rolled the wings level. The aircraft impacted fairly hard and skidded about 100 m before coming to rest north of the runway and about 600 m from the threshold.

The aircraft operator has issued guidance notes to all flight crew regarding windshear recognition and recovery, as well as a reminder of information in the procedures manual.

This accident demonstrates that should an approach become unstable, conducting a go-around early may be the safest course of action. A Bureau of Meteorology Research Centre report noted that not all dust devils are visible and that they pose a major hazard to light aircraft during landing.

On 20 October 2011, the Antigua and Barbuda Department of Marine Services and Merchant Shipping (ADOMS) requested assistance from the Australian Transport Safety Bureau (ATSB), in the recovery of evidence with respect to the alleged loss overboard of a crew member from the bulk carrier Shark Island, IMO No. 9116137, while the ship was at anchor off Karumba, Queensland, on 4 October 2012.

As the ship's flag State agency, ADOMS took the lead role in the investigation of this occurrence in accordance with the International Maritime Organization (IMO) Code for the Investigation of Casualties and Incidents. As a result, ADOMS is responsible for releasing all reports in relation to the occurrence.

Department of Marine Services and Merchant Shipping - Antigua and Barbuda W.I.
Inspection and Investigation Division
Steubenstrasse 7b
D-27568 Bremerhaven
Germany

MARECARE

What happened

On 13 April 2012, at about 1440 Eastern Standard Time, a Guimbal Helicopters Cabri G2 helicopter, registered VH-ZZT (ZZT), collided with terrain at Camden Airport, New South Wales. On board the helicopter was an instructor and a student.

The Guimbal Cabri G2 is a two-seat helicopter manufactured in France. It features a 7-bladed fenestron in place of a conventional tail rotor and a 3-bladed main rotor, which rotates clockwise when viewed from above. It received the European Aviation Safety Agency’s Type Certificate in December 2007.  ZZT was the first of the type to be registered in Australia.

The student was undergoing type endorsement training. The instructor simulated a jammed right yaw control pedal forward emergency in the hover.

The instructor then demonstrated a recovery procedure from the simulated emergency.  During the demonstration a rate of decent developed, which was assessed to be too fast.

The instructor attempted to abort the manoeuvre by increasing collective, applying full throttle to increase the rotor revolutions per minute and full right pedal to counteract the left yaw. The helicopter rotated to the left through several full rotations at an increasing rate.  The instructor was unable to recover the rotor RPM nor arrest the left yaw or left roll that developed.

The helicopter collided with terrain in a left skid-low, nose-high attitude.  The student suffered minor injuries and the helicopter was seriously damaged.

This accident highlights that different helicopter types have their own specific handling characteristics; and that pilots should be familiar with the emergency procedures prescribed in the flight manual and the immediate actions to be performed to ensure a successful outcome.

Aviation Short Investigation Bulletin - Issue 12

Section 21 (2) of the Transport Safety Investigation Act 2003 (TSI Act) empowers the Australian Transport Safety Bureau (ATSB) to discontinue an investigation into a transport safety matter at any time. Section 21 (3) of the TSI Act requires the ATSB to publish a statement setting out the reasons for discontinuing an investigation.
 
On 17 April 2012, the ATSB commenced an investigation into an airspace event, between an Airbus A330 aircraft registered VH-EBE and a Bombardier DHC-8 aircraft registered VH-TQL, near Cairns Airport on 21 March 2012.
 
Examination of the information collected during the investigation indicated a loss of separation assurance had occurred. However, the controller was aware of the potential conflict between the two aircraft and was actively managing the situation, which resulted in the separation standard between the aircraft being maintained.
 
The investigation did not find any systemic issues had contributed to the occurrence. The ATSB assessed that no safety issues would be identified through further investigation. On that basis, the ATSB has decided to discontinue its investigation.

What happened

On 15 April 2012, a Virgin Australia, Boeing 737-8FE aircraft, registered VH-VOL departed Gold Coast, Queensland on a scheduled flight to Melbourne, Victoria.

During climb, the crew observed that both engines were being supplied only from the right fuel tank. This resulted in a fuel quantity difference between the left and right fuel tanks. The crew conducted the fuel leak engine checklist which confirmed that no engine fuel leak existed. With centre tank fuel available, the crew selected the centre tank pumps on, which resulted in the fuel imbalance stabilising.

Given that the crew were unable to confirm fuel from the left tank could be used once the centre tank pumps were selected off, or that no fuel leak existed, they elected to divert to Brisbane, Queensland and declare a PAN. The aircraft landed without further incident.

An overhaul organisation inspected the engine fuel feed crossfeed valve and identified wear to the sealing materials and Teflon within the valve body as consistent with the existence of a leak within the valve. However, the overhaul organisation was unable to confirm whether the sealing material degradation would explain a high volume fuel leakage rate. 

Virgin Australia Airlines had previously established an inspection program for the crossfeed valves in accordance with Boeing recommendations. The operator also has a program in place to replace existing crossfeed valves with a modified version at scheduled maintenance servicing.  This program is currently under review for acceleration.

Aviation Short Investigation Bulletin - Issue 13

What happened

On 12 April 2012, a Cessna Aircraft Company 310R, registered VH-JOF, departed Jabiru aerodrome on a charter flight.  On board the aircraft were one pilot and two passengers.

While on final approach to Marlgawo Aircraft Landing Area the aircraft encountered suspected sudden and severe windshear at approximately 50 ft above ground level.  The aircraft landed heavily and was seriously damaged.  One passenger sustained minor injuries, the other occupants were uninjured.

The Flight Safety Foundation's Approach and Landing Accident Reduction tool kit provides guidance on avoiding, recognising and recovering from windshear. The tool kit reinforces the importance of following the windshear recovery technique recommended in the aircraft operating manual and flying a stabilised approach.

What happened

At about 0400 (CDT) on Wednesday 11 April an ARTC ballast train 8M24N travelling on the interstate mainline between Broken Hill to Kinalung derailed at the 1118.500 km mark. The derailment was initiated by the 26th wagon as a result of a loading irregularity. The crew of the train was physically unhurt. There was minor damage to the wagon and considerable track damage over a 4 km length.

Safety message 

Uneven loading of ballast wagons increases the potential of derailment. In 2010, the Independent Transport Safety Regulator (ITSR) released a Rail Industry Safety Notification (RISN) No. 32 on the "operation of less than safely loaded wagons". Although the notice refers to coal trains, some of the issues raised in the RISN are also applicable to ballast trains such as ensuring the appropriate wagon loading configurations are in place.

To ensure wagons are evenly loaded, the rail operator's procedures for checking the load distribution need to be followed and carried out to the required standard.

What happened

On 6 April 2012 a Boeing Company 737-838 aircraft (B737), registered VH-VXI, on a scheduled passenger flight from Sydney, New South Wales to Darwin, Northern Territory was involved in a breakdown of separation with an Airbus Industries A330-243 aircraft (A330), registered B-6073, on a scheduled passenger flight from Melbourne, Victoria to Shanghai, China.

Both aircraft were operating under Instrument Flight Rules and were in airspace controlled by Brisbane Centre utilising radar.

The B737 and A330 were on converging tracks at Flight Level (FL) 360. As the aircraft approached Tindal, Northern Territory at 1342 Central Standard Time, a breakdown of separation occurred when the distance between them reduced to about 3.5 NM, before vertical separation was established. The incident occurred about 16 minutes after a handover between two Air Traffic Controllers.

As a result of a number of incidents involving handovers, Airservices Australia advised the ATSB that they had amended the handover procedure to require supervision and for the relinquishing controller to remain at the console to provide assistance until the accepting controller indicated that assistance was not required.

The incident highlighted the importance of separation assurance and thorough handovers.