At about 1605 on 26 January 2012, a fire broke out in the number one cargo hold of the general cargo ship BBC Baltic while it was discharging cargo in Port Hedland. At the time, workers from Cervan Marine, a local engineering company, were gas cutting in the cargo hold using an oxy-acetylene torch. The ship's crew assisted by the local emergency services fought the fire and, by 1625, had extinguished it. There were no injuries as a result of the incident and damage to the ship and its cargo was not serious.



In carrying out the hot work on board BBC Baltic, neither the ship's crew nor the Cervan Marine workers properly considered and mitigated the risk of fire. All the precautions listed on the ship's hot work permit were not taken nor was the permit completed properly. Similarly, all the measures listed on Cervan Marine's job safety analysis were not taken. Furthermore, a toolbox meeting was not held to discuss the work and risk, define roles and responsibilities, and the action to take in case of a fire. 



As a result of inadequate risk assessments, there was no fire watch, none of the ship's crew was at the hot work site and Cervan Marine's workers did not have a clear understanding of the action to take in case of a fire. Consequently, action to fight the cargo hold fire with a fire extinguisher and other fire-fighting equipment was not taken immediately, resulting in a larger fire that took longer to contain.

On 25 January 2012, at about 1600 Eastern Daylight-saving Time, a Schweitzer helicopter company 300C helicopter (300C), registered VH-FUJ departed an agricultural property near Scottsdale Tasmania. The pilot was returning to his home base of Devonport at the conclusion of the day's aerial spraying activities.  The pilot was the only person onboard.

Whist flying over heavily timbered country, the engine power reduced, and the helicopter collided with the tree canopy before coming to rest on the ground. 

The pilot was not injured and immediately exited the helicopter, which caught fire and was destroyed. The accident highlights the value of helicopter pilots wearing a helicopter safety helmet.

On 25 January 2012, a Virgin Australia Boeing Company 737-81D aircraft, registered VH-YFC, (YFC) was being operated on a scheduled passenger service from Brisbane to Sydney.

On descent into Sydney YFC encountered unexpected and severe turbulence which lasted about 3 to 5 seconds.  As a result, three unsecured cabin crew members sustained minor injuries. 

Turbulence is one of the leading causes of in flight injuries and due to the nature of their work cabin crew are 26 times more likely to be injured than passengers.  Measures likely to mitigate the risk of injury from unexpected turbulence include aircraft design and cabin crew training

On 23 January 2012, the pilot of a Robinson Helicopter Company R44 Raven II helicopter, registered VH-HYC (HYC), was conducting a routine gas pipeline inspection flight between Parramatta and Castle Hill, New South Wales.

When 1 NM (1.85 km) north of Parramatta, the pilot of HYC observed a Piper Aircraft Corporation PA-28-161, registered VH-TAK (TAK), tracking northbound from Bankstown, pass overhead, about 20 ft above. In response, the pilot of HYC immediately lowered the collective and commenced a descending right turn.

A review of Airservices Australia radar surveillance data indicated that the distance between HYC and TAK reduced to 0.2 NM (370 m) laterally, with both aircraft at the same altitude of 1,400 ft. The aircraft were operating in uncontrolled airspace and were not subject to air traffic control services.

This incident highlights the advantages of utilising two communication systems, if fitted, to enhance traffic awareness. It further emphasises the benefits of notifying the appropriate air traffic control authority if intending to conduct aerial work within a known area of high traffic levels, such as the Bankstown Lane of entry.

What happened

On 18 January 2012at 2125 Eastern Daylight-saving Time, there was a loss of separation (LOS) between an Airbus A320, registered 9V-TAZ, and an Airbus A340, registered A6-EHH, 907 km NW of Karratha, Western Australia. The aircraft were under the air traffic control of Airservices Australia. The A320 was southbound at FL 350 and the A340 was heading west and cleared to operate in a ‘block’ level, anywhere between FL 340 and FL 360. The aircraft were estimated to cross waypoint TANEM within 2 minutes of each other. The relevant separation standards were 1,000 ft vertical separation or 15 minutes lateral separation at the same position. Controller 1, who approved the block level clearance, did not detect the traffic confliction prior to handing over to controller 2. After a short break, controller 2 handed back to controller 1, and the confliction was detected by controller 2 during the handover. Compromised separation recovery techniques were applied to re-establish vertical separation.

What the ATSB found

The two controllers were experiencing a high workload due to a range of factors, including traffic levels, weather diversions and the airspace configuration, and controller 1 had limited opportunity to consolidate their training and skills before being rostered onto more complex sectors and situations. The ATSB found that 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 had limited formal guidance regarding how to determine appropriate consolidation periods for en route controllers on one sector before they were transitioned to commence training on another sector. Further safety issues were also identified relating to the application of block level clearances, and the continuing absence of an automated air traffic conflict detection system available for conflictions involving aircraft that were not subject to radar or ADS-B surveillance services.

What's been done as a result

Airservices reported that changes had been made to the configuration, training and rostering arrangements for the airspace sectors involved in the occurrence. The commissioning of a radar in northern West Australia had reportedly alleviated controller workload in two of the airspace sectors, with enhanced surveillance of the majority of aircraft operating in that airspace expected with the mandate of automatic dependant surveillance- broadcast (ADS-B) effective in December 2013. A working group had also been established to determine a suitable workload model to monitor and forecast controller workload on a sector by sector basis. In addition, 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. The ATSB is not satisfied that Airservices has adequately addressed the identified safety issues regarding formal guidance for consolidation periods for newly-endorsed controllers and the limited formal guidance to controllers and pilots regarding the conditions in which it was safe and appropriate to use block levels. As a result, the ATSB has made formal recommendations to Airservices.

Safety message

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 and techniques to effectively manage their task demands. Overall, high workload can have significant effects on a controller’s performance, and it needs to be monitored and managed using a systemic approach, particularly for less experienced controllers but also controllers who have recently received a new endorsement. The instances of other recent loss of separation occurrences involving high workloads and newly-endorsed controllers on other sector indicates that this problem was not restricted to the sectors involved in this occurrence.

On 10 January 2012, a Dornier Werke GMBH 328-100 aircraft, registered VH-PPJ, landed at Horn Island Airport, Queensland, after having departed Cairns, Queensland to conduct a search and rescue operation with two flight crew and three technical crew onboard.

The aircraft touched down on the runway normally, at about 48 kts, the pilot flying released the power levers from the reverse thrust position, the right propeller moved to a ground idle position, but the left propeller remained in the reverse thrust position and the aircraft veered off the side of the runway.

The FO attempted to correct the deviation through rudder input; however, despite full right rudder, the aircraft continued to diverge left. At the same time, the nose-wheel weight-on-wheels sensor showed the nose wheel alternating between ground and air modes, resulting in the nose-wheel steering not being operational.

A subsequent engineering inspection found that the left power lever appeared not to spring as far forward as the right power lever when released from reverse thrust. The levers and shaft assembly were inspected and found to be serviceable. A lubrication of the springs in the reverse thrust system was carried out.

The operator reported that the thrust levers required positive handling to move from the reverse thrust to the ground idle position, rather than relying on the spring tension. The first officer did not recall receiving specific instruction on operating the power levers.

The operator advised the ATSB that it had conducted the following safety action: All crew have been alerted to potential difficulties with the operation of power levers; an external advisor has been recruited to review the safety system and check and training program; the organisation is assessing the ongoing introduction of simulator training.

At 1900 Eastern Daylight-saving Time on 12 January 2012 a Beech Aircraft Corporation 23 (Musketeer) registered VH-DFC (DFC) was on final approach to runway 18 at Mildura aerodrome, Victoria. With one stage of flap selected and passing about 300 ft above ground level (AGL), the pilot responded to a heavy sink rate by applying full throttle.

After climbing slightly, the aircraft then ballooned high. The pilot allowed the aircraft to climb to regain glide path then put the nose down and retarded the throttle to continue the approach. The aircraft then dropped rapidly and impacted runway 18 prior to the intersection with runway 09/27.

The aircraft sustained serious damage when the nose wheel separated from the fuselage. The pilot vacated the aircraft uninjured, while the sole passenger sustained minor injuries.

This accident demonstrates the importance of pre-flight planning for landing variables, such as wind. It also highlights that should an approach become unstable, conducting a go-around may be the safest course of action.

On 8 January 2012, at about 2141 Eastern Daylight-saving time, a loss of separation assurance occurred between a Boeing Company B737-8FE, registered VH-VUJ (VUJ) and a Boeing Company B737-838, registered VH-VZS (VZS), near Tamworth Airport, New South Wales (NSW).
Both aircraft were conducting scheduled passenger services, under the instrument flight rules, with VUJ operating from Sydney, NSW to Brisbane, Queensland and VZS operating from Brisbane to Sydney. Due to weather diversions, the aircraft were operating on reciprocal tracks at the time of the occurrence.

The air traffic controller assigned VUJ climb to the same level maintained by VZS. On activation of the air traffic control system's Short Term Conflict Alert (STCA), when the aircraft were 17.5 NM (32.4 km) and 2,200 ft apart, the controller issued both flight crews instructions that ensured vertical separation was maintained in excess of the required standard and a breakdown of separation avoided.
The controller later reported feeling mentally fatigued following a shift with high complexity and workload. They had not identified the confliction before the STCA, but once aware, the controller's knowledge and application of effective compromised separation recovery techniques was integral in managing the situation.

Following the occurrence, Airservices Australia advised that compromised separation recovery refresher training would be provided to controllers again, in addition to sessions on separation assurance techniques, and that they were implementing a renovated Fatigue Risk Management System and a Normal Operations Safety Survey program.

This incident highlights the need for awareness of the effects of high workload and sustained task complexity on performance, the importance of regular breaks and implementation of strategies, such as the use of conforming levels, when able. In addition, the knowledge and application of effective compromised separation recovery techniques by air traffic controllers is integral in the management of compromised separation situations.

During the morning of 3 January 2012, the pilot of a Robinson Helicopter Company R22 helicopter, registered VH-FHR, was conducting low-level aerial work along the Dutton River, 45 km east-north-east of Richmond Aerodrome, Queensland. The pilot was the sole occupant. At about 1130 Eastern Standard Time, when at about 20 to 30 KIAS and 250 ft above ground level, the pilot felt a 'kick' to the helicopter and the machine suddenly yawed to the left. Shortly after, a second 'kick' and yaw occurred, followed by the sounding of the low rotor RPM warning horn. The pilot entered autorotation and attempted to recover forward airspeed with the little height he had at the time.

The pilot was unable to arrest the helicopter's rate of descent before the machine impacted the sandy riverbed heavily and rolled onto its right side. A post-impact fire commenced immediately, but the pilot was able to egress with minor burns. The helicopter was seriously damaged on impact and subsequently destroyed by the post-impact fire.

The 'kicks' and yaw experienced may have been due to environmental effects such as the effect of the gusting and swirling winds and mechanical turbulence.

This accident highlights the need for helicopter pilots to be mindful of conducting operations with a combination of forward airspeed and altitude which may place the machine in the 'avoid' area of the respective height velocity diagram.

Helicopter pilots who regularly fly at low altitude may consider the benefits afforded by the wearing of helmets and additional personal protective clothing and equipment.

Preliminary report released 2 February 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.

What happened

On 6 January 2012, the Panama registered general cargo ship Tycoon was moored in Flying Fish Cove, Christmas Island. The ship remained at the moorings over the following days while cargo operations were carried out.

In the early hours of 8 January, the wind speed and sea state increased and the moorings failed to keep Tycoon in position. At about 0620, the ship made contact with the adjacent rock-face and shore crane pylon. Despite several attempts to move Tycoon away, it continued to pound against the rock-face and pylon and the engine room began flooding through a tear in the hull.

At about 0930, the decision was made to abandon ship. At 1030, the crew climbed down the ship's accommodation ladder one at a time and jumped into the sea. From there, they were recovered by the crews of three Royal Australian Navy rigid hull inflatable boats which were standing by to assist.

At about 1100 on 9 January, the ship suffered a catastrophic failure of its hull. The contents of the number two hold were exposed to the sea. Damage to the hull near the engine room had already allowed oil and other pollutants to be washed into the sea.

The ATSB is continuing its investigation into the incident and a draft investigation report will be complied. When the draft investigation report is approved for release, it will be forwarded to directly involved parties for comment.