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.

What happened

On 15 February 2011, the ATSB commenced an investigation into a pre-flight planning event that occurred at about 0017 Eastern Daylight-saving Time on 11 February 2011 and involved an Airbus A320-232 aircraft, registered VH-VNB. The initial report from the operating crew was that, prior to departure on the scheduled high capacity flight from Melbourne, Victoria to Perth, Western Australia, incorrect data was entered into the aircraft's flight management computer. The suspected 'error' was not detected by one of the flight crew until the aircraft was in the take-off roll. Subsequently, the second member of the flight crew reported that the speeds that were used were correct and were logical for the aircraft's weight and ambient conditions.

An initial examination of the available recorded data showed a consistent acceleration, rotation and climb with no abnormalities. The recorded speed at rotation correlated with that used for the flight and noted on the aircraft's data card. No equipment anomaly was recorded in the aircraft's technical log after the flight.

The ATSB's primary focus is on enhancing safety with respect to fare-paying passengers and, in particular, those transport safety matters that may present a significant threat to public safety or are the subject of significant public concern. In this instance, the contrasting flight crew recollections of the 'event' and the available data suggest that a transport safety matter as defined in Section 23 of the TSI Act may not have taken place.

The ATSB therefore considered there was limited potential to enhance transport safety by continuing this investigation, and has elected to discontinue it. However, the data already collected may be used by the ATSB for future statistical analysis and safety research purposes.

Abstract

On 2 February 2011, the boatswain (bosun) on board the Panamanian registered bulk carrier Hanjin Sydney died as a result of injuries he received after falling about 25 m from the hatch coaming of the ship's number eight cargo hold to the tank top below.

The bosun had climbed onto the top of the hatch coaming to free a cargo runner that had jammed in the head of a davit the crew were using to lift iron ore residue from the hold. He lost his balance while pulling on the wire to free it and fell into the empty cargo hold.

The ATSB investigation found that the crew had previous experience with the cargo runner jamming in the head of the davit. However, nothing had been done to prevent it from happening again.

As a result of the accident, Hanjin Ship Management have instigated the requirement for the ship's safety officer to be more proactive in toolbox meetings and safety 'walk arounds' to ensure that he is aware of issues which may not be automatically brought to his attention.

The ATSB is satisfied that this safety action adequately addresses the report's identified safety issue.

What happened

On 9 February 2011, a Piper PA-28-181 (Archer) aircraft, registered VH-NRF, departed Ballina on a private flight to Bankstown, New South Wales.

During the flight, the pilot noted the tachometer fluctuating. After consultation with the operator, it was determined that this was an indication problem, and the flight was continued.

When the aircraft was about 8 km NE of Bankstown at 1,200 ft, the engine lost power. The pilot commenced the engine failure response actions and elected to land on a street. During the landing the aircraft collided with powerlines and a power pole. The pilot and passenger sustained minor injuries.

It was considered that the engine failed as a result of fuel starvation. The reason for the tachometer fluctuation was not identified.

The operator conducted an investigation and considered that, as no apparent fuel leaks were found, the aircraft may have experienced excessive fuel burn.

As a result of this accident, the aircraft operator issued an internal circular to all instructors to emphasise to students the importance of fuel tank selection changes when responding to an engine failure; amended their operations manual with regard to fuel mixture leaning, and the use of fuel gauges and calibration cards; included the recording of fuel uplifted at the end of each flight so that accurate fuel flow calculations can be conducted; and a student pilot meeting was held to highlight this accident and the changes to the operations manual.

This accident highlights the risks associated with operating an aircraft that has different procedures from that previously familiar with and the importance of having accurate knowledge of the aircraft's fuel usage.

Safety summary

What happened

At 1115 Eastern Daylight-saving Time on 4 February 2011, a Robinson Helicopter Company R44 Astro helicopter (R44), registered VH-HFH, commenced circuit operations at Cessnock Aerodrome, New South Wales. On board the helicopter were a flight instructor, a pilot and a passenger.

Following a landing as part of a simulated failure of the hydraulic boost system for helicopter's flight controls, the instructor elected to reposition the helicopter to the apron. As the helicopter became airborne, it became uncontrollable and collided with the runway and caught fire. The pilot exited the helicopter; however, the instructor and passenger were fatally injured.

What the ATSB found

The Australian Transport Safety Bureau (ATSB) identified that a flight control fastener had detached, rendering the aircraft uncontrollable. The helicopter manufacturer had not recorded any previous instances of separation of this fastener. A number of separated components could not be located, preventing the identification of the specific reason for the separation.

A number of human factors contributed to the accident, including that the 'feel' of the flight control fault mimicked a hydraulic system failure.

Finally, the ATSB identified that fatal injuries sustained by the instructor and passenger were due to the post-impact fire and that a large number of R44s had not been modified to include upgraded bladder-type fuel tanks that reduce the risk of post-impact fuel leak and subsequent fires.

What has been done as a result

In response to the identification of a number of failures of the same type of self‑locking nuts in other aircraft, the helicopter manufacturer and Civil Aviation Safety Authority have highlighted the issue to operational and maintenance personnel.

The helicopter manufacturer also reduced the compliance time on a current service bulletin requiring that all‑aluminium fuel tanks fitted to older R44 helicopters be replaced with more impact‑resistant bladder‑type fuel tanks. A second bulletin aimed at removing a possible impact‑related ignition source was also issued.

Safety message

This accident reinforces the importance of thorough inspections by maintenance personnel and pilots. It is also a powerful reminder not to take off after identifying a possible problem with an aircraft. In addition, the accident highlights the risk of carrying unnecessary personnel during practice emergencies, and reinforces the safety benefits of incorporating the requirements of manufacturer's service bulletins in their aircraft as soon as possible.

Abstract

At about 1328 on Saturday 5 February 2011, scheduled XPT (Express Passenger Train) ST24, travelling from Melbourne to Sydney, passed signal 09-6 at Henty while it was displaying a Stop (red) indication, an event commonly referred to as a Signal Passed at Danger (SPAD). The train stopped about 95 m past signal 09-6 with the front of the leading power car on the Yankee Road level crossing. The investigation concluded that notwithstanding a reported issue with the brakes on the leading power car, the driver of train ST24 did not apply sufficient braking effort to enable train ST24 to be stopped before passing the Up-home signal (09-6) at Henty.

Abstract

At 1305 Eastern Daylight-saving Time on 1 February 2011, a breakdown of separation occurred 22 km south of Williamtown (Newcastle Airport), New South Wales between a Boeing B737-7Q8 (737), registered VH-VBK, and an Israel Aircraft Industries Ltd Westwind 1124 (WW24) aircraft, registered VH-AJG. Both aircraft were in communication with and under the jurisdiction of Department of Defence (DoD) air traffic controllers based at Williamtown.

Separation between the aircraft reduced to 0.7 NM (1.3 km) on radar and 400 ft vertically when the required separation standard was 3 NM (5.6 km) or 1,000 ft. The vertical separation achieved was as a result of the 737 flight crew responding in accordance with a resolution advisory provided by their aircraft's traffic alert and collision avoidance system.

The investigation identified a series of errors by the Williamtown Approach controllers involving separation assurance, coordination and communication, and compromised separation recovery.

The investigation also identified three safety issues. The DoD advised that they reviewed and amended Williamtown procedures, introduced compromised separation recovery techniques training and trialled use of the conflict alerting function in the Australian Defence Air Traffic System at Williamtown.

What happened

On 31 January 2011, an Airbus A320-232 aircraft, registered VH-VQN (VQN), was taxiing for runway 29 at Darwin Airport, Northern Territory on a scheduled passenger service to Sydney, New South Wales.

The crew required a clearance to cross runway 11/29 in order to access the main taxiway for runway 29. On reaching the runway holding point, the crew received a clearance from air traffic control to cross the runway.  Prior to crossing, the crew checked the runway and approach paths for traffic. The pilot in command (PIC) stated that they were clear to the left, but the copilot noted that there was an aircraft lined up and stopped on runway 11. Soon after, the copilot observed the aircraft commence its take-off roll. He advised the PIC, who immediately stopped the aircraft. VQN had taxied past the holding point, but was short of the runway, resulting in a runway incursion.

Shortly after, they observed a Cessna 404 aircraft, registered VH-UOP (UOP), on a scheduled passenger service from Darwin to Snake Bay, Northern Territory take off on runway 11. A breakdown of runway separation occurred.

Air traffic control had provided the instruction for VQN to cross the runway based on the expectation that UOP would have commenced the take-off soon after receiving a take-off clearance.

Runway incursions are recognised as an ongoing safety concern for the aviation industry and have been cited in numerous accidents world-wide. This incident emphasises the need for controllers to remain vigilant in monitoring and scanning the runway and highlights the significance of pilots conducting a thorough visual inspection of the runway and approach paths prior to entering or crossing any runway, even if a clearance from air traffic control has been provided.

After a number of dual circuits, the pilot was authorized to carry out solo circuits with touch and go landings. After the first touchdown the pilot applied full power then selected the flap to 10 degrees. The aircraft entered a rapid turn to the left, and the pilot abandoned the take-off. The aircraft slid sideways off the strip and the nosewheel was broken off. The pilot was carrying out her first solo period of touch and go landings. After applying full power she noticed that the aircraft was accelerating more quickly than when she had been under dual instruction. The pilot had previously required forward pressure on the control column while retrimming the aircraft. On this occasion she had not had time to retrim and the investigation revealed that the aircraft had been "wheelbarrowing" on the nosewheel when directional control was lost.

The pilot held in the circuit area at his destination for about 10 minutes before carrying out a normal landing. He recalls checking that the landing gear indicated down and locked before landing. However, when the nosewheel was lowered onto the runway, the noseleg collapsed. The aircraft skidded on its nose for about 150 metres before coming to rest on the runway. The nosegear indicator still showed a green light after the aircraft came to rest. The cause of the nosegear collapse could not be determined. The false safe indication of the nosegear was possibly caused by a foreign object under the downlock microswitch.

The pilot advised that he was taxying towards the take-off threshold of the ALA, using the grassed area alongside the gravel strip. He noticed an anthill about 30 centimetres high in front of the aircraft, but while turning to avoid the obstruction the left mainwheel struck the anthill. The gear leg broke at its attachment point to the wing, resulting in substantial damage to the wing and the left flap.