What happened

On 25 November 2011, a Saab Aircraft Company S340B was being operated on a scheduled passenger service from Lismore to Sydney, New South Wales (NSW). During the taxi to the gate after arrival at Sydney, a cabin crew member noticed smoke coming from near a passenger seat and instructed the passenger to throw the source of the smoke into the aisle. The cabin crew member then discharged a fire extinguisher onto what was later identified as a mobile telephone. After several minutes, the smoke cleared.

An Australian Transport Safety Bureau (ATSB) investigator travelled to Sydney airport to commence an investigation into the event. The mobile telephone was transported to the ATSB technical facilities in Canberra for initial examination and then forwarded to the United States for detailed examination at a specialist facility.

The technical examinations found that a small metal screw had been misplaced in the battery bay of the mobile telephone; the screw puncturing the battery casing and causing an internal short circuit leading to heating and thermal runaway. It was probable that the screw had been misplaced during an earlier repair carried out on the telephone. That repair had not been conducted by an authorised service provider.

This investigation highlights the risks associated with the use of non-authorised agents for the repair of lithium battery-powered devices and reinforces the Civil Aviation Safety Authority (CASA) recommendations that these devices should be carried in the cabin and not in checked-in baggage.

Safety summary

What happened

On 17 November 2011, a wave knocked a seaman off MSC Siena’s accommodation ladder while he was rigging a combination pilot ladder in preparation to embark a harbour pilot. The ship was near Rottnest Island off the port of Fremantle. An immediate search for the seaman was initiated by Australian search and rescue agencies but the search was unsuccessful.

What the ATSB found

The ATSB’s investigation found that a risk assessment for the task of rigging the pilot ladder was not undertaken and a number of precautions, including taking into account the poor weather conditions, were not taken. With regard to this task, the ship’s safety management system was not effectively implemented and documented procedures, including issuing a work permit, were not followed.

What's been done as a result

Senior representatives from Allseas Marine, Greece, MSC Siena’s manager, attended the ship in Fremantle and conducted an internal company investigation. Since then, Allseas Marine has taken a number of steps to address the safety issues identified by its own and the ATSB’s investigation.

The company’s shipboard safety management system procedure for its work permit system has undergone major revision with regard to work over the side and a new, improved work permit form has been introduced. Importantly, the revised procedure specifically addresses the task of working on combination pilot ladders and task specific guidance and precautions have been provided.
Crew induction and familiarisation procedures, particularly for ships new to the company fleet, have been enhanced to support implementation of the revised work permit system procedure. On board training has been improved through safety videos and computer based training focusing on permit to work systems. A fleet wide safety campaign was carried out to promote the company’s work permit system. A requirement to report all work for which a permit is necessary to the company and submit the permit forms has been introduced.

Allseas Marine also obtained independent advice with regard to rigging pilot ladders. Based on that advice, the company considers that if pilotage services have not been suspended due to the weather conditions, rigging a pilot ladder may be permissible subject to the master’s overriding authority and judgment on safety matters.

The ATSB has assessed the action taken by Allseas Marine and is satisfied that it will adequately address the safety issues identified.

Safety message

Rigging a pilot ladder while working over the side of a ship can be a hazardous task and it is imperative that all the precautions necessary to prevent a person falling overboard are taken.

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 13 December 2010, the ATSB commenced a safety issue Investigation into Procedures and Practices used to Provide Access to Track, NSW.  Examination of the information collected during the Access to Track investigation identified significant similarities to aspects of other occurrences being investigated by the ATSB as part of the safety issue investigation of rail operations on the interstate rail line between Sydney and Melbourne, which commenced on 16 August 2011.

Accordingly the ATSB decided to examine the issues related to Access to Track as part of the broader RI-2011-015 safety issue investigation and the separate RI-2010-014 investigation was discontinued.

Safety summary

What happened

On 8 November 2011, a loss of separation occurred between a Boeing Company 737-8FE, registered VH-VUV, and a Boeing Company 737-838, registered VH-VXM, near Ceduna, South Australia. The aircraft were conducting scheduled passenger flights and were under the air traffic control of Airservices Australia (Airservices). The aircraft were operating on converging tracks at 39,000 ft. The procedural longitudinal separation standard of 20 NM (37 km) was infringed. It is likely that there was between 6 NM (11.1 km) and 12 NM (22.2 km) longitudinal separation between the aircraft.

What the ATSB found

The ATSB found that the two controllers involved were experiencing a high workload due to a range of factors, including the number of tasks and their limited experience. Airservices’ processes for monitoring and managing controller workloads did not ensure that newly-endorsed controllers had sufficient skills and techniques to manage the high workload situations to which they were exposed. In addition, Airservices’s fatigue risk management system (FRMS) did not effectively manage the fatigue risk associated with allocating additional duty periods. The ATSB is also concerned that there had been increasing traffic levels and complexity in some sectors in recent years, combined with a decrease in the experience levels of controllers and without a concomitant increase in controller resources. In addition, although Airservices has been in the process of developing and trialling a flight plan conflict function for procedurally-controlled aircraft for several years, the fact that it is still not operational is a safety issue.

What's been done as a result

Airservices reported that the airspace sectors involved in the occurrence had been re-sectorised into three sectors in November 2012 to manage workload and that a working group had been established to determine a suitable workload model to monitor and forecast controller workload on a sector by sector basis. The first stage of a flight plan conflict function had also been deployed in Brisbane Upper Airspace, with further roll out planned in Melbourne Centre in 2014.
In addition, Airservices reported that an updated FRMS had been implemented in July 2012 and that it had addressed the systems limitations outlined in the report.

Safety message

High workload can have significant effects on a controller’s performance. It needs to be monitored and managed using a systemic approach, particularly for less experienced controllers but also those who have recently received a new endorsement. Other recent loss of separation occurrences involving high workloads and newly-endorsed controllers indicate that this problem is not restricted to the sectors involved in this occurrence. Ideally the best way of managing workload is to reduce the level of work demands and distractions. If the work demands cannot be reduced, then another option is to ensure the controllers have the experience, skills techniques and support to effectively manage their task demands.

What happened

On 7 November 2011, the pilot of a Robinson Helicopter R22 Beta, registered VH-CME, was conducting cattle mustering operations on a station property about 93km north of Julia Creek, Queensland. The pilot was the sole occupant of the helicopter.

The pilot's task was to locate and muster cattle through a gate into the adjacent paddock.  Whilst manoeuvring the helicopter to land at about 5 ft above ground level, the helicopter's main rotor blade struck the ground. The pilot was not injured, however the helicopter was seriously damaged.

Mustering at low level has an inherent risk profile that requires a high level of awareness by the pilot. Mustering without any assistance from ground personnel, increases that level of risk.

What happened

Following landing at Sydney Airport on the 8 Nov 2011, one of the main wheels of a Virgin Australia Boeing 737-8FE, registered VH-VUF, was found to have separated at the hub. The failure was traced to fatigue cracks emanating from an unpeened area of the inner hub's bearing bore. The operator had complied with the manufacturer's wheel inspection requirements. However, as a result of the occurrence, the operator increased the frequency of the ultrasonic inspection of the wheel hubs.

Aviation Short Investigation Bulletin - Issue 11

Safety summary

What happened

On 5 November 2011, a Construcciones Aeronáuticas S A C212-CC (C212) aircraft, registered VH-MQD, was conducting parachute operations, in controlled airspace, over the Western Grass Drop Zone at Royal Australian Air Force Base Richmond Aerodrome (Richmond), New South Wales (NSW). Air traffic control (ATC) had assigned the C212 flight crew clearance to conduct a parachute drop.

A Boeing Company 737-7BX (737) aircraft, registered VH-VBP, operating a scheduled passenger flight from Sydney, NSW to Cairns, Queensland, was cleared by ATC to track via Richmond, underneath the C212. A loss of separation occurred between the declared parachute operations area and the 737. At the time, the paratroopers had just exited the C212 and ATC issued the 737 flight crew, who were in the process of taking avoiding action, with a safety alert. The last paratrooper out of the aircraft reported that while in free fall and about 10 seconds after exiting the aircraft, they were at the same altitude as the 737, about 2,000 m away.

What the ATSB found

The ATSB identified that Airservices Australia (Airservices) had no standard, documented procedure to assure separation of aircraft departing Sydney via Richmond during parachute operations at Richmond, nor a documented means for controllers to display in the air traffic control computer system when a parachute drop clearance had been issued.

The ATSB also found that two of the controllers involved had not been provided with training in compromised separation recovery techniques. Furthermore, Airservices’ process for recognition of prior learning, and the subsequent training provided to one of the controllers, had not effectively addressed the variances between that controller’s skills and knowledge (after an absence working overseas) and the operational role requirements of a Sydney Terminal Control Unit air traffic controller.

What's been done as a result

Airservices advised that the Sydney Terminal Control Unit Local Instructions were amended to include a requirement for coordination between the Sydney Approach West controller and the adjacent Departures position when parachute operations were being conducted at Richmond.

Airservices also amended their procedures manual to include human-machine interface directives for the display of information for aircraft involved in parachute operations.

Safety message

This occurrence highlights three important safety lessons for air traffic controllers and flight crew:

• Documented procedures and phraseology are crucial when managing risks associated with unfamiliar operations
• Terminal area speed restrictions help maintain aircraft separation— air traffic controllers should always consider the potential safety implications before cancelling a speed restriction
• Flight crews need to be aware that the cancellation of a speed restriction may not always be available when requested, due to operational ATC requirements.

Introduction

On 5 September 2013, the Australian Transport Safety Bureau (ATSB) released its final investigation report into the loss of control involving Eurocopter1 AS350BA, registered VH RDU, which occurred 93 km north of Rockhampton Airport, Queensland on 8 September 2011. Subsequently, the ATSB became aware of new and significant evidence in relation to the helicopter’s hydraulic pump drive system, including the associated drive belt. Information had been provided through the ATSB’s confidential reporting scheme (REPCON) indicating the reporter’s safety concerns about the hydraulic pump drive belt. As a result, and in accordance with clause 5.13 of Annex 13 to the Convention on International Civil Aviation Aircraft Accident and Incident Investigation, the ATSB reopened the investigation.

This supplementary report highlights the additional information gained as a result of reopening the investigation and confirms that the drive belt that was installed in VH-RDU at the time of the accident was authorised for use and within its service life limit. Review and analysis of the additional information determined that, while it would be beneficial to add some additional information to the final investigation report, no change was necessary to the findings in the report that was released to the public on 5 September 2013.

What happened

On 29 October 2011 a Bell Helicopter Company B206 BII Jetranger, registered VH-AYP, departed Maitland Aerodrome, New South Wales for a local training flight with an instructor and student on board.

On descent into the aerodrome, the instructor demonstrated a practice autorotation from 1,000 ft above ground level (AGL). The demonstration was not a planned exercise for the flight. It was intended that engine power would be restored and the autorotation would cease before ground contact, as a power termination.

The aircraft was levelled at approximately 5ft to 10ft AGL and the collective raised in anticipation of a power termination.  At the same time, the low RPM horn sounded, and light illuminated.  The throttle had not been opened completely as required and was wound to the full open position as the helicopter settled to the ground. 

The helicopter landed heavily and sustained serious damage.

The ATSB has been advised by the flying training organisation of the following proactive safety action in response to this occurrence:

• A briefing is to be conducted before any emergency training is performed.
• Implementation of the, IMSAFE personal checklist for both instructor and student, to assess their fitness to fly prior to every lesson.

Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, a limited-scope, fact-gathering investigation was conducted in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.

What happened

During a voyage from Tin Can Bay, Queensland to Brisbane, Queensland, the vessel's crew activated the tug's 406 MHz EPIRB, thus declaring an emergency, about 80 nm ENE of Cape Moreton after the tug's steering was damaged and couldn't be fixed. The crew of three were airlifted off to safety and a tug from Brisbane was sent to take it in tow.

Safety message

Regardless of the length of a voyage, or their experience, the crew should always adequately prepare their vessel before departing port. The proper stowage and securing of equipment to prevent movement in a seaway and the carriage of spare parts to repair critical equipment are essential parts of a thorough voyage preparation. The dangers of being ill-prepared for a voyage have been illustrated in previous ATSB investigations.