Preliminary report released 27 July 2012

This preliminary report details factual information established in the investigation’s early evidence collection phase and has been prepared to provide timely information to the industry and public. Preliminary reports contain no analysis or findings, which will be detailed in the investigation’s final report. The information contained in this preliminary report is released in accordance with section 25 of the Transport Safety Investigation Act 2003.

Abstract

On Thursday 24 May 2012 Transfield Services Australia Pty. Ltd. road/rail vehicles TS24, TS45 and TS63 were travelling in convoy in a westerly direction between Forrest and Haig, Western Australia.

On arrival at the Haig level crossing the lead vehicle TS24 left the track. The second vehicle, Toyota utility TS45 was stationary on the level crossing being prepared to leave the track. At approximately 1711 the following Hino truck road/rail vehicle (TS63) collided with the rear of Toyota TS45.

The driver of the road/rail vehicle TS45 was fatality injured and the driver of TS24 incurred minor injuries following the collision.

Safety summary

What happened

In the early hours of 18 May 2012, while transiting the Coral Sea, ID Integrity’s main engine shut down when its fuel pump reversing mechanism came free and jammed. This caused the camshaft to bend and slip in a drive coupling which resulted in the camshaft being out of timing and therefore the engine could not be restarted.

The ship drifted in a westerly direction towards the Australian coast and the Great Barrier Reef. During the afternoon of 19 May, the ship passed over Shark Reef, located about 60 miles east of the Great Barrier Reef Marine Park, without incident. The following day, the ship was taken in tow when it was about 35 miles to the east of the marine park and towed to Cairns for repairs.

What the ATSB found

The ATSB found that the engine manufacturer had identified the need for owners and operators to check the fuel pump reversing mechanism for cracks and secureness and provided this advice in service letters. However, on board ID Integrity, this advice had not been included in the engine manuals or planned maintenance system. As a result, over time and despite regular inspections, the system deteriorated and cracks developed in the mechanism undetected. This led to the failure of a fuel pump reversing link on 18 May.

The investigation also found that, once notified, the actions of the various stakeholders were appropriate and the response arrangements were effective.

What's been done as a result

ID Integrity’s managers have implemented a schedule to inspect all main engines in their fleet and undertake repairs as necessary. Staff from all company ships have been made aware of this incident and it has been included in crew training centre courses.

MAN B&W, the main engine designer, reiterated the need to include all service letter advice in manuals and maintenance systems. They also advised that service letters and updated manuals are always available on request through the website www.mandieselturbo.com via the Nexus (Customer extranet) link.

The ship’s classification society, ClassNK, initiated discussions with MAN B&W to enhance its knowledge of engine design and operation changes. ClassNK also improved the content and extent of information provided to its surveyors.

Safety message

Service advice from machinery manufacturers needs to be carefully assessed and implemented as necessary as part of a ship’s planned maintenance system. Furthermore, all associated documentation should be updated and regularly checked to ensure it remains relevant and reflects the latest available information.

On 16 and 17 May 2012, three aircraft were operated on scheduled passenger flights from Gladstone to Brisbane, Queensland without the runway lights being activated for departure.   

The runway lighting was controlled by a pilot activated lighting (PAL) system that was combined with an aerodrome frequency response unit (AFRU).  To activate the runway lights, pilots were required to make a sequence of three transmissions on the common traffic advisory frequency (CTAF).  A number of situational factors were associated with the crew not activating the runway lights prior to departure.   

Defining a specific place for PAL tasks in the crew’s sequence of procedures, and incorporating this into a pre-taxi checklist, could potentially ensure more reliability in performing these tasks.

Aviation Short Investigation Bulletin - Issue 12

On 13 May 2012, a Cessna Aircraft Company 208, registered VH-DZQ (DZQ), was conducting parachute operations at Bells Beach near Redcliffe aerodrome, Queensland. At about the same time, an amateur built Van’s RV-8 aircraft, registered VH-YGY (YGY), was on a scenic flight around the Brisbane area.

At about 1229 Eastern Standard Time, DZQ departed Redcliffe aerodrome and at about 1249 dropped nine parachutists from Flight Level (FL) 140 at Bells Beach. The pilot of DZQ made all necessary radio broadcasts prior to and immediately after the parachute drop.

At about 1252, as YGY flew along Bells Beach, the pilot saw four parachutes and made a slight right turn to pass about 150 to 200 ft above and about 50 ft to the right of one parachutist. The location of YGY when the parachute-related broadcasts were made by DZQ meant that the pilot could not have heard the calls.

The incident highlights the importance of accurate information being available to pilots to facilitate an adequate pre-flight brief. The correct placement of parachute symbols on the Brisbane Visual Terminal Chart (VTC) or a NOTAM on current parachute operations would have alerted the pilot of YGY to the potential for parachutists in the Bells Beach area.

The incident also demonstrates the need for pilots to maintain continuous visual scans and not rely solely on radio broadcasts for traffic advice.

Aviation Short Investigation Bulletin - Issue 12

What happened

On 1 May 2012, the pilot of a Piper PA 25-235/A9 (Pawnee) aircraft, registered VH-GWS, was conducting agricultural operations from a local airstrip near Hallston, Victoria. Shortly after take-off, the aircraft collided with terrain near the base of a gully and was destroyed by a post-impact fire. The pilot was fatally injured.

What the ATSB found

The aircraft likely sustained a partial power loss shortly after take-off, resulting in an inability to continue climbing or maintain altitude. Damage sustained during the accident and post-impact fire prevented an identification of the specific reasons for the power loss. The ATSB also found that operation of the aircraft over hilly terrain probably limited the pilot’s emergency landing options and increased the severity of the terrain impact following engine power loss.

What's been done as a result

The investigation did not identify any organisational or systemic issues that might adversely affect the future of aviation safety.

Safety message

Some of the circumstances surrounding this accident are highlighted in the ATSB research report AR-2010-055: Managing partial power loss after take-off in a single-engine aircraft. Pilots and aircraft operators are encouraged to consider the topics covered in that report, which may assist in reducing the risks associated with partial or complete power loss after take-off. In addition, pilots are reminded that the timely dumping of any aircraft payload where possible can assist in improving aircraft performance and may provide additional options for a safe outcome.

At about 0815 Western Standard Time on 28 April 2012, a Gippsland Aeronautics GA8-TC 320 aircraft, registered VH-WOV, took off from runway 12 at Kununurra airport, Western Australia, for a sightseeing flight over the Bungle Bungle ranges. On board were the pilot and six passengers.

Despite the application of full throttle during the takeoff, the engine manifold pressure was lower than expected. The manifold pressure decreased further soon after the aircraft became airborne, to the point that level flight could not be maintained. The pilot initially prepared for a forced landing, but after finding that sufficient power was available to remain airborne, and assessing the surface of the selected field as unsuitable, the pilot elected to return to the departure airport. The pilot landed on the grass surface of the airport adjacent to the parallel taxiway, with no injuries reported and no damage to the aircraft. The low and decreasing manifold pressure was the result of an engine turbocharger system malfunction.

This incident highlights the importance of understanding the complexities of engine turbocharger systems. A turbocharger system malfunction may result in unpredictable engine power and aircraft performance. Furthermore, a turbocharger system malfunction does not necessarily mean that the engine will behave like a normally aspirated engine. Although this incident was the result of a turbocharger system malfunction, pilots are reminded that abnormal manifold pressure indications may be symptomatic of a serious problem, such as an engine exhaust system leak.

This incident also highlights the importance of pre-flight preparation. Self-briefing may help pilots respond to abnormal takeoff indications more effectively, and help manage the influence of perceived pressure when confronted with a time-critical decision.

Aviation Short Investigation Bulletin - Issue 12

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

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.

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

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