What happened

On 24 November 2010, a Boeing Company 737-8FE aircraft, registered VH-VUX, was being operated a scheduled passenger service from Melbourne, Victoria to Hobart, Tasmania. The crew were advised that the runway would be wet for their arrival into Hobart. During the landing on runway 12, the crew reported that the initial braking was normal, however, in the final stage of the landing, the braking was not effective despite increasing brake pressure. Both crew stated that the aircraft felt as if it was sliding or aquaplaning.  The crew reactivated the thrust reversers, and the aircraft came to a stop beyond the end of the runway in the stopway area. There was no damage to the aircraft, or the tarmac and the aircraft was turned and taxied to the terminal.

A post-incident inspection of the runway found that there was rubber build up near the runway 30 touchdown markers and portions of the runway had been resurfaced but not re-grooved.

As a result of this incident, the aircraft operator issued a flight crew communication notice modifying the take-off and landing procedures for Hobart Airport in wet conditions. The airport operator issued Notices to Airmen (NOTAMs) stating that there had been reports of aquaplaning on landing in heavy rain and that the runway surface was ungrooved. In addition, they have brought forward a scheduled full resurfacing of the runway to November 2011, removed a runway surface treatment from the area around the centreline of the runway and grooved the resurfaced sections of the runway.

What happened

On 31 January 2011, a Boeing Company Aircraft 777-3ZGER, registered VH-VPH, was en-route from Phuket, Thailand to Melbourne, Victoria. When the aircraft was 170 NM north of Jakarta, Indonesia it encountered a period of sudden and unexpected turbulence. Six cabin crew members and four passengers received minor injuries.

At the time of the incident, the aircraft was established in the cruise and flying in cloud. The weather radar showed no significant weather in the immediate vicinity of the aircraft.

The flight continued to Melbourne where two cabin crew members consulted with paramedics, however no medical treatment was required.

The operator is considering including details of this occurrence in flight crew and cabin crew training to improve general crew awareness on the practical aspects of turbulence management and the importance of cabin discipline particularly relating to the handling of cabin equipment.

The operator is also considering changing a number of internal procedures to improve or standardise processes related to reporting injuries, providing support to crew in remote ports and assessing when crew are fit to return to duty.

What happened

On 15 November 2010, a Boeing Company 747‑438 aircraft, registered VH-OEI, departed Sydney, New South Wales on a scheduled passenger service to Buenos Aires, Argentina.

While on climb, the flight crew noticed a strong electrical smell in the cockpit, followed by smoke emanating from the left electronic flight instrument system (EFIS) control panel. The flight crew donned their oxygen masks and shortly after, observed that the circuit breaker for the left EFIS control panel had tripped and the engine indication and crew alerting system (EICAS) was displaying the message 'EFIS CONTROL L'.

About 7 minutes later, the flight crew reported that the fumes were still present and were very strong, despite the fact that the smoke had ceased. After discussing the situation, the flight crew elected to return to Sydney.

During the return, a fuel dump was commenced and a descent to 10,000 ft initiated. During the descent, the flight crew determined that the fumes had stabilised but elected to remain on oxygen as a precaution.

After landing at Sydney, the left EFIS control panel was inspected and replaced.

This incident affirms the importance of using supplemental breathing equipment as a defence against pilot incapacitation from exposure to fumes and smoke.

Safety summary

What happened

On 9 May 2011, a Qantas Airways Limited Boeing 747-400 aircraft, registered VH-OJH, was enroute from Sydney, NSW to Singapore, when during climb from 36,000 ft to 38,000 ft, the crew noted abnormal indications from the No.4 engine. The indications included an increase in both the exhaust gas temperature and vibration levels. The flight crew reduced the engine’s thrust, however the vibration continued near maximum levels and the engine was subsequently shut down.

The aircraft continued to Singapore for a safe landing and disembarkation of the passengers and crew.

What the ATSB found

The increase in the exhaust gas temperature and vibration from the No.4 engine was a direct result of the failure and separation of a single intermediate-pressure turbine blade. The turbine blade had fractured following the initiation and growth of a fatigue crack from an origin area near the blade inner root platform. Detailed modelling and analysis was undertaken by the engine manufacturer following the occurrence, and while the root cause for the IP turbine blade failure was not fully identified at the time of this report, it was considered that the wear and loss of material from the turbine blade outer interlocking shrouds had reduced the rigidity and damping effects of the shroud and may have contributed to the high-cycle fatigue cracking and failure. The manufacturer has advised that they are continuing work to understand the underlying mechanism of the failure and will advise the ATSB if any further information is obtained.

What has been done as a result

The engine manufacturer issued non-modification service bulletin (NMSB) 72-G739 in October 2011, which instructed operators to perform a once-around-the-fleet inspection of IP turbine blades for missing shroud interlock material. Accomplishment of this task was recommended by June 2012, taking advantage of any earlier planned maintenance opportunities. The operator indicated that they had completed inspections across the fleet with no instances of excessive wear identified.

Safety message

Operators and maintainers of Rolls-Royce RB211-524 engines are alerted to the potential for wear and degradation of the intermediate-pressure turbine blade interlocking shrouds, with the possibility that this mechanism, if not detected and addressed, could lead to turbine blade cracking and loss. Service experience has shown, however, that the probability of an intermediate-pressure turbine blade failure (from any mechanism) is extremely low, with only three reported occurrences across the RB211-524 engine operating history. While blade separation will likely cause malfunctions necessitating an in-flight engine shut down, the associated risks to the safety of continued flight are minor, in the context that such failures are very likely to be contained (i.e. no liberated debris) and procedures for managing engine failures in transport-category aircraft are detailed and effective.

What happened

On 5 November 2010, a Boeing Company 747-438 aircraft, registered VH-OJD departed Changi Airport, Singapore on a scheduled flight to Sydney, New South Wales. When the aircraft was climbing through 2,000 ft, a loud bang was heard accompanied with aircraft yaw and vibration. The crew shut down the number one engine, declared a PAN and received approval from air traffic control for a return to Singapore. The crew then jettisoned fuel for about forty minutes. Emergency services were in attendance when the aircraft landed safely a short time later.

A subsequent examination confirmed that the engine had sustained serious damage as the result of a compressor blade release from the stage 1 high pressure compressor (HPC 1). The engine was replaced, and the aircraft returned to service.

The aircraft operator is continuing to bring their RB211-524G engines to the latest modification status at engine shop visits. However, should the rate of engine failures increase significantly a review of current modification policy will be undertaken.

The ATSB has completed its technical analysis of flight recorder data from several Indonesian aviation accident events that occurred between 2009 and 2011.

The National Transportation Safety Committee (NTSC) of Indonesia is responsible for investigating these occurrences. The NTSC requested technical assistance from the Australian Transport Safety Bureau (ATSB) in the determination of the appropriate data frame layouts for the flight data recorder (FDR) information recovered from the occurrence aircraft. In accordance with clause 5.23 of Annex 13 to the Convention on International Civil Aviation, the ATSB appointed an accredited representative to assist the NTSC and initiated an investigation under the Australian Transport Safety Investigation Act 2003.

In cooperation with NTSC staff, suitable data frame layouts were determined for all recovered FDR data, and the information was provided in a report to the NTSC. The NTSC is responsible for releasing the final investigation reports on these occurrences.

National Transportation Safety Committee
Ministry Of Transportation Republic Of Indonesia
Transportation Building 3^rd Floor
Jalan Medan Merdeka Timur No. 5
Jakarta Pusat 10110
Indonesia

Phone  :  +62 21 384 7601
Email    :  knkt@dephub.go.id

Website: http://knkt.dephub.go.id/knkt/ntsc_home/ntsc.htm

______________

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

Safety summary

What happened

On 6 May 2011, the trailing bogie on the 47th wagon of freight train 4PM6 derailed after traversing the Carlton Parade level crossing at Port Augusta, South Australia. The wagon travelled over a second level crossing and re-railed itself when it entered a third level crossing about 1,300 m later.

The train continued towards Adelaide before it was stopped at Winninowie after the network controller had been alerted that the train was emitting sparks and that the half-boom barriers remained down and that warning devices continued to operate at the two level crossings.

What the ATSB found

The ATSB’s investigation found a number of factors affecting the passage of train 4PM6 due to the degradation of the track geometry in a short section of line after the Carlton Parade level crossing. Multiple track defects requiring urgent and priority attention in this short section had been detected by a track geometry car inspection 3 months before the derailment and there was a 30 km/h temporary speed restriction (TSR) in force at the time. However, the defects had not been adequately assessed and controlled in accordance with the Australian Rail Track Corporation (ARTC) Track and Civil Code of Practice and the 30 km/h TSR was probably inadequate to minimise the risk of derailment.

The investigation also found that track geometry defect exceedence reports did not contain fields to record the date and time as confirmation that field inspections had been carried out in accordance with the Code of Practice.

What has been done as a result

The ARTC through its Alliance Partner Transfield Services has undertaken additional training in the ARTC Track and Civil Code of Practice. This includes the responses required when multiple localised geometric defects are found.

The ARTC is also developing an improved reporting format for data from the track geometry car measurements for use in all states following the introduction of the new National Code of Practice - Track Standards.

Safety message

Multiple geometric track defects that are located in close proximity to each other significantly increase the derailment risk to rail traffic. The track condition should be thoroughly assessed and managed to ensure that appropriate speed restrictions are imposed until the track can be reinstated to design standards.

Abstract

On 30 March 2011, a Piper Saratoga PA-32R-301T aircraft, registered VH-LKI, with a pilot and five passengers on board was returning to Moree Airport from Brewarrina Airport, New South Wales under the night Visual Flight Rules (NVFR).

The aircraft flew overhead the airport at about 2000 Eastern Daylight-saving Time before the pilot conducted a left circuit for landing on runway 19. Witnesses observed the aircraft on a low approach path as it flew toward the runway during the final approach leg of the circuit. The aircraft contacted trees and collided with level terrain about 550 m short of the runway 19 threshold.

The pilot and three passengers were fatally injured. Two other passengers, who were seated toward the rear of the aircraft, were seriously injured. The aircraft was seriously damaged by the impact forces.

The investigation did not identify any organisational or systemic issues that might adversely affect the future safety of aviation operations. However, the pilot did not satisfy the recency requirements of his NVFR rating and the aircraft's take-off weight was in excess of the maximum allowable for the aircraft.

In addition, the aircraft's centre of gravity was probably outside that specified in the aircraft flight manual, with the potential to significantly diminish the aircraft's in-flight performance and pitch stability.

This investigation highlights the importance of ensuring that all operational requirements are satisfied prior to exercising the privileges of any ratings or licences. In addition, the investigation reinforces the importance of pilots operating their aircraft within the published flight manual limitations.

On 11 May 2011, the Indonesian National Transport Safety Committee (NTSC) requested technical assistance from the Australian Transport Safety Bureau (ATSB), in the recovery of information from the flight data recorder (FDR) and cockpit voice recorder (CVR) of a XAC MA60 aircraft that impacted the sea on approach to Kaimana Airport, Papua Barat, Indonesia on 7 May 2011. The 21 passengers and 4 crew on-board the aircraft were fatally injured in the accident.

The NTSC is responsible for investigating this occurrence. In accordance with clause 5.23 of Annex 13 to the Convention on International Civil Aviation, the ATSB appointed an accredited representative to assist the NTSC and initiated an investigation under the Australian Transport Safety Investigation Act 2003.

Download and analysis of the FDR and CVR was successful and both were found to contain good quality data including the entire accident flight. Support and information was provided to the NTSC during the course of the investigation and the ATSB's Technical Analysis Report was provided to the NTSC.

A final investigation report regarding this occurrence will be released by the NTSC.

The National Transport Safety Committee of Indonesia is responsible for releasing the investigation report.

National Transportation Safety Committee
Ministry Of Transportation Republic Of Indonesia
Transportation Building 3^rd Floor
Jalan Medan Merdeka Timur No. 5
Jakarta Pusat 10110
Indonesia

Phone  :  +62 21 384 7601
Email    :  knkt@dephub.go.id

Website: http://knkt.dephub.go.id/knkt/ntsc_home/ntsc.htm

______________

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

What happened

On 4 May 2011, at about 0730 Eastern Standard Time, a Bell Helicopter B206, registered VH-BNG, struck a single power line and conducted a precautionary landing in a nearby field.

The pilot had commenced end of the season, agricultural spraying operations of sugar cane fields earlier that day and was on his third chemical spray load. While approaching a paddock of four hectares, he calculated that with the required buffer zone of 100 m from each house, the effective spray coverage would only be one hectare. As the pilot flew over one of the houses, his focus was diverted from looking for powerlines, to a resident walking from the house to his car.

While observing the resident, the pilot considered where to start the spray run, taking into account, the buffer zone and that he needed to quickly get low over the cane field. After the pilot had assessed that the resident was comfortable with the presence of the helicopter, his focus moved to commencing the spray run and not to looking for powerlines. The pilot quickly descended the helicopter toward the field to begin the spray run and it struck a power line to the house. After a precautionary landing in the field, the pilot observed that the helicopter had sustained damage to the chin view windows and one main rotor blade.

As a result of this accident, the pilot advised that planning for future operations would be carried out by the pilot, not by persons indirectly involved in the operation.