What happened

On 14 October 2011 at 0950 EST, a Boeing Company 747-400 aircraft, registered VH-OEH (OEH), operated by Qantas Airways, was taxiing for departure at Brisbane Airport. OEH was stopped at a taxiway holding point before applying power to initiate movement. At the same time, a Virgin Australia First Officer exited the rear door of a Boeing Company 737-800, registered VH-VUM (VUM).  The First Officer was standing on the rear push stairs as they were blown over by jet blast from OEH. The First Officer fell to the tarmac and sustained serious injuries.

Pilots are reminded of the very real danger posed by jet blast and the need to use only the minimum amount of power required to initiate aircraft movement.

Brisbane Airport Corporation (BAC) in collaboration with Airservices Australia responded to this incident by issuing a NOTAM requiring all aircraft vacating the international apron to do so without stopping and using minimum power.  Airservices Australia issued a local instruction to Brisbane tower and ground controllers to assist with the implementation of this requirement.

What happened

On 25 October 2011, a Cessna Company Aircraft 172, registered VH-PHV, departed Dairy Creek Aeroplane Landing Area (ALA), Western Australia for a private local area flight. The pilot was the sole occupant of the aircraft.

The flight was conducted to inspect a number of paddocks on Bidgemia Station, about 35 minutes flight time from Dairy Creek ALA. Prior to departure the pilot determined there was 80 litres total fuel on-board and then used an estimate of 30 litres/hour for fuel burn calculations.

Once reaching the paddocks, the pilot conducted land and cattle inspections for about 2 hours and 40 minutes before the engine failed due to fuel exhaustion. The pilot conducted a forced landing, and the aircraft was seriously damaged after impacting with trees, however the pilot was not injured.

The pilot stated that he did not conduct a formal fuel plan prior to the flight. During the latter stages of the flight, the pilot experienced a higher workload and forgot to return to a landing area to refuel.

This accident highlights the vital importance of pre-flight planning. Pilots should ensure that every flight is appropriately planned with accurate flight times and fuel calculations. CASA recommends private, visual flight rules flights should plan for 45 minutes of fixed fuel reserves.

What happened

On 13 October 2011, a Jetstar Airways Airbus Industrie A320-232 aircraft, registered VH-VGO (VGO), departed Christchurch, New Zealand on a scheduled passenger service to Brisbane, Queensland.

While VGO was on descent into Brisbane Airport, the air traffic controller was coordinating diversions and clearances for multiple aircraft due to significant weather in the vicinity. At 5,000 ft, the air traffic controller issued an instruction for VGO to turn left immediately due to conflicting traffic. The crew complied with the instruction and entered an active thunderstorm cell.

The aircraft encountered heavy rain, and the airspeed began to rapidly decrease. The autopilot disconnected and the pilot applied Take-off/Go Around thrust. The captain informed air traffic control (ATC) that they needed a different heading of 090 degrees to fly clear of the weather, which was subsequently granted. The aircraft landed at Brisbane Airport, there were no reported injuries to crew or passengers, and no damage to the aircraft.

High workload can cause narrowing of attention and task fixation. This makes it difficult to continually assess the big picture and develop appropriate strategies. Effective workload management includes, for line controller and supervisors alike; forward planning and seeking/providing assistance when needed.

In this incident, deteriorating weather combined with high traffic volume limited the options available to the controller to ensure separation. As a result, the controller used phraseology which led the flight crew to believe that there was an imminent risk of collision and to their subsequent turn into hazardous weather.

Safety summary

What happened

At approximately 0530 on 23 October 2011 Pacific National freight train 7SP5 derailed near Wirrinya, New South Wales. Train 7SP5 was travelling from Stockinbingal towards Parkes and was 14 hours into its journey from Sydney to Perth.

The lead bogie of the 42nd wagon of the train derailed three kilometres north of Caragabal. The wheels of the bogie ran derailed for about 15 km until reaching the turnout at the southern end of Wirrinya where wagons separated from the train and overturned.

The train crew were not injured. The last six wagons (all of which were multiple platform type) derailed. The derailment caused significant damage to the track and the turnout at Wirrinya.

What the ATSB found

The ATSB found that a dip in the track with adverse twist close to Caragabal caused the bogie to derail. The dip was caused by the formation subsiding due to localised formation weakness, resulting in an inability of the formation to support the track structure above.

There was no evidence of formation damage due to re-sleepering or any pumping of formation material up though the ballast and the track geometry appeared to be relatively stable for some kilometres either side of the derailment site. Track inspections had been conducted in accordance with the NSW Base Operating Condition Standards, but it is unlikely that the inspections would have identified any warning signs of formation weakness before the derailment. This was supported by the drivers of train 7SP5 not noticing anything unusual as they traversed this location. Based on available evidence, it is likely that the track dip developed under train 7SP5 and was caused by an undetected weakness in the track formation.

There was a history of track geometry defects around this location, but they were generally not significant when compared to defects identified and rectified in other locations. Notwithstanding this, analysis of track defect history is important for planning maintenance activities. There may be an opportunity for greater examination of maintenance history and defect data to help strengthen a predictive maintenance system.

What's been done since

The ARTC has implemented their Engineering Code of Practice (CoP) for its rail network in NSW as part of an ongoing program of procedure standardisation across the ARTC rail network. The CoP is slightly more stringent than the previous standards in its assessment of identified track defects. There was no evidence of pre-derailment track defects in this case, but where the formation may begin to collapse without resulting in a derailment, it is possible that the CoP may resulted in earlier maintenance action and potentially prevent a future derailment.

Safety message

The opportunity may exist for managers and maintainers of track infrastructure to strengthen their predictive track maintenance systems by considering greater examination of historical maintenance and defect data.

Safety summary

What happened

On 12 October 2011, the pilot of a Robinson R22 helicopter, registered VH-JNP, was performing aerial work near Saxby Downs in Queensland, when he heard a rattling noise behind the cabin and noted that the clutch light had illuminated. The pilot opened the clutch actuator circuit breaker and, at the same time, noted a burning rubber smell, prompting him to make an immediate precautionary landing and shut down the helicopter.

What the ATSB found

The problems with the helicopter’s drive system were traced to the clutch assembly where a group of MS21042L-4 locking nuts on the drive belt upper sheave had cracked and fractured. This premature nut failure had stemmed from the likely embrittling effect of residual hydrogen generated during the cadmium electroplating process applied during manufacture. The nut failures consequently led to a series of mating part failures and a breakdown of the clutch assembly, producing the symptoms experienced by the pilot and prompting the precautionary landing.

Importantly, after recognising the aural and visual warnings of problems developing with the helicopter’s drive system, the pilot followed the required emergency procedures and made an immediate and safe precautionary landing. Taking this prompt, prescribed action limited the damage sustained and very likely prevented a more serious outcome.

What was done as a result

At the time of this occurrence, the brittle failure of MS21042L-series nuts was an emerging airworthiness issue and several associated safety actions had already been implemented. In August 2011, 2 months before this occurrence, the helicopter manufacturer issued Service Letters alerting owners, operators and maintenance personnel to the potential for cracking of MS21042L-series self-locking nuts and requiring the immediate replacement of any cracked nuts found during inspections. The service letters had been issued in response to reports of cracked nuts being discovered on Robinson and other helicopter types.

On 12 October 2011 (the date of this occurrence), the Australian Civil Aviation Safety Authority (CASA) issued an Airworthiness Bulletin (AWB 14-002), alerting pilots and maintenance personnel of the need to closely monitor the condition of high-strength steel hardware (such as these nuts) with a view to identifying any failures that may have resulted from hydrogen-induced cracking.

On 4 April 2012, the manufacturer of the specific MS21042L-series nuts in question issued a Technical Quality Notice Bulletin, addressing in detail many procedural improvements that were being introduced to reduce the potential for hydrogen-related failures of this nut type.

Safety messages

A potentially serious accident was avoided by the prompt actions of the pilot, who recognised the symptoms of a drive system malfunction and promptly followed the emergency procedure requirements by landing immediately.

This occurrence highlights the importance of maintained vigilance during pre-flight and maintenance inspections, where close attention must be paid to the condition of all components within the helicopter’s critical flight systems. It also highlights the importance of pilots and maintenance personnel remaining attentive to the release of any information regarding new or emerging airworthiness issues that may affect the safety of their flight operations.

This investigation report was originally released in August 2012. This revision contains an update based on additional information from the outcomes of the engine manufacturer’s internal investigation into the occurrence.

What happened

On 16 October 2011, at about 1033 Coordinated Universal Time (UTC), a Boeing 747-438 aircraft, registered VH-OJS, operated by Qantas Airways, departed Suvarnabhumi Airport, Bangkok, Thailand on a scheduled passenger flight to Sydney, Australia.
About 8 minutes into the flight, as the aircraft was climbing through 13,000 ft, the crew reported hearing a loud bang and experiencing vibrations and abnormal indications from the No. 3 engine. Fumes were also reported in the cabin for several minutes after the event.

The flight crew shutdown the engine and broadcast a ‘PAN’ before jettisoning approximately 55 tonnes of fuel and returning to Bangkok where the aircraft landed safely at 1147 UTC. The engine failure was fully contained and there were no reported injuries to passengers or crew.

Aviation Short Investigation Bulletin - Issue 23

What happened

On 15 October 2011, a Cessna Aircraft Company 182P, registered VH-TIS, departed Ayr, Queensland on a private flight within the local area. On board the aircraft were the pilot and five passengers.

On descent from 1,000 ft into Ayr Aeroplane Landing Area (ALA), the pilot noticed a bird to the left of the aircraft, followed almost immediately by an impact with the windscreen. The bird penetrated the windscreen causing it to shatter.

The pilot selected full power, but the aircraft was unable to maintain altitude. Approaching 200 ft, the pilot selected a cane field to conduct a forced landing. TIS came to a stop and the pilot and passengers were able to exit the aircraft through the jump door and the windscreen. The pilot and passengers sustained minor injuries.

Following the birdstrike, the pilot focused on maintaining control of the aircraft. The decision to make a controlled landing into a cane field resulted in a safe outcome.

While it is difficult to prevent birdstikes, a number of proactive measures can be taken by both pilots and airports to reduce the risk. These include not flying at times of known high activity (usually dusk), looking for bird activity in the vicinity of the airport prior to departure and actively reducing bird attractants (water and food sources) from the airport surroundings.

Abstract

On 23 February 2011, an Airbus A330‑203 aircraft, registered VH-EBL, was being operated by Qantas Airlines on a scheduled passenger flight from Perth, Western Australia to Sydney, New South Wales. During the latter part of the take-off, the aircraft yawed suddenly and unexpectedly and the pilot in command rejected the take-off. Following braking, smoke and some flame emitted from the main wheel area, but emergency services were not required to apply any extinguishing agent.

The investigation found that there was no aircraft‑related problem, and the unexpected aircraft yaw was probably due to a lateral wind gust.

No organisational or systemic issues that might adversely affect the future safety of aviation operations were identified. However, the occurrence does provide a timely reminder of the risks associated with rejected take-offs at relatively high speeds, such as wheel fires. Pilot awareness of their potential exposure to sudden and unexpected lateral wind gusts during take-off may increase the likelihood of pilots differentiating between a lateral jerk to the aircraft and the effect of an engine failure.

The Papua New Guinea Accident Investigation Commission (PNG AIC) is investigating a double propeller overspeed and impact with terrain, followed by a fire that occurred 33 km south-east of Madang, Madang Province, Papua New Guinea on 13 October 2011. The accident involved a Bombardier DHC-8-108 aircraft, registration P2-MCJ, with two pilots, a flight attendant, and 29 passengers on board. Twenty-eight passengers sustained fatal injuries during the accident sequence, one passenger survived with serious burns and all three crew survived.

The investigation is being carried out in accordance with Papua New Guinea's obligations as the State of Occurrence under Annex 13 to the Convention on International Civil Aviation Aircraft Accident and Incident Investigation (Annex 13). Shortly after the accident, the PNG AIC requested Australian Transport Safety Bureau (ATSB) assistance in the conduct of the investigation by providing investigator support, technical advice and facilities support.

In accordance with paragraph 5.23 of Annex 13, the ATSB appointed an accredited representative and a number of advisers to assist the PNG AIC. To facilitate this support, the ATSB commenced an external investigation under the Transport Safety Investigation Act 2003 and assisted the AIC during the on‑site phase of the investigation, in the technical examination of a number of recovered aircraft items and components, with the download and analysis of the aircraft’s flight data and cockpit voice recorders and as requested by the AIC during the remainder of its investigation.

The PNG AIC is responsible for and will administer the release of the final investigation report into this accident. Any enquiries in respect of the ongoing AIC investigation should, in the first instance, be directed to:

Mr David Inau
CEO, PNG Accident Investigation Commission

Telephone: +675 323 2911 and 323 2151
Facsimile: +675 323 2139

Email: dinau@aic.gov.pg

Address:
Accident Investigation Commission
C/- PO Box 1489
Port Moresby
National Capital District
Papua New Guinea

______________

Released in accordance with section 25 of the Transport Safety Investigation Act 2003.

What happened

At 1500:51 Eastern Daylight-saving Time on 8 October 2011, a breakdown of separation (BOS) occurred 59 km north-east of Armidale, New South Wales between a Boeing Company 737-8FE (737), registered VH-YVA, and a Gulfstream Aerospace Corporation Gulfstream IV (G-IV), registered VH-CGF.

Both aircraft were under radar surveillance and subject to an air traffic control (ATC) service. The aircraft were on reciprocal tracks on air routes that intersected about 35 NM (65 km) north-east of Armidale.

The Australian Transport Safety Bureau (ATSB) established that the controller's mental model for separation correctly identified the situation and included a plan to manage the traffic. However, the instructions that were issued to the pilot of the G-IV contradicted that mental model in that the controller cleared the G-IV for descent through and below the level being maintained by the 737. The progression towards the BOS continued when the controller did not recognise the error during the G-IV pilot's read-back of the clearance.

Ultimately, the controller's earlier correct level input into The Australian Advanced Air Traffic System allowed a system alerting function to activate. In response to that alert, the controller initiated compromised separation recovery actions to recover the required separation standard.

The ATSB identified a number of human factors and individual work processes that contributed to the occurrence. In addition, a safety issue was identified in respect of differences in the traffic alert phraseology between the Manual of Air Traffic Services and Aeronautical Information Publication (AIP). These differences increased the risk of non-standard advice being provided to pilots by controllers during compromised separation recoveries.

In response to this safety issue, Airservices Australia (Airservices) amended the AIP to enhance understanding of the criticality of any safety alerts and avoiding actions being provided to flight crew. This amendment came into effect on 28 June 12.