On 14 January 2010, a Royal New Zealand Air Force (RNZAF) Red Checkers aerobatics team CT-4 Airtrainer aircraft collided with terrain while practicing for an upcoming aerobatics display. The pilot was fatally injured in the accident and the aircraft was destroyed by a post-impact fire.

An Appareo Systems GAU1000 data recorder was fitted to the aircraft to gather performance data as part of a fatigue monitoring programme. Although the recorder was severely fire damaged, it was recovered from the aircraft wreckage by RNZAF investigators, who subsequently requested assistance from the Australian Transport Safety Bureau (ATSB) in the recovery of any stored data on the recorder that may have survived the accident and fire.

Following preparatory research into the nature of the recorder's design and operation and the subsequent non-destructive examination to evaluate the physical condition of the damaged unit, a number of attempts were made to recover data from the removable secure digital/multimedia memory card (SD/MMC) - all of which were unsuccessful. Further examination of the recorder, however, located an on-board NAND flash memory device, which subsequently yielded a large quantity of valid recorded data after its removal from the primary circuitry and interrogation in a universal reader/programmer unit. The data was provided to the RNZAF on 12 August 2010.

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

During preflight performance calculations, the crew of an Airbus A321 inadvertently referenced the performance chart for a longer runway length. That produced inappropriately high take-off reference speeds that would have adversely affected the operation of the aircraft in the case of an engine failure.

Jetstar Airways advised that they had reminded pilots to independently calculate take-off data and prohibited the use of bookmarking the performance manual. They also commenced an internal investigation.

The application of correct operating data is a foundational and critical element of flight safety, but errors in the calculation, entry and checking of data are not uncommon. The ATSB has published a research report that addresses this issue.

Safety summary

What happened

At about 1246 on 11 June 2011, the harbour tug Adonis, with four persons on board, capsized during an operation with a second tug, Wolli, to relocate a barge in the port of Gladstone, Queensland. Three of the persons on board escaped the capsizing tug but the fourth did not and drowned in the tug’s wheelhouse.

What the ATSB found

The ATSB found that while the masters of the two tugs involved with the tow were aware of the risks of tugs capsizing, neither of them realised that Adonis had entered a classic capsize scenario when it moved abaft of the barge’s port bow before the barge had begun to slow down. The barge’s speed was not reduced in time to allow Adonis’s master to regain control of the tug and manoeuvre it back into a safe position ahead of the barge. The tug’s crew were not able to release the towline using the towing hook’s quick release arrangement before the tug capsized.

Investigation of the accident found that the retrospective fitting of a set of ‘H’ bitts to the tug, aft of the towing hook, had a detrimental effect on the tug’s manoeuvrability. The fitting of the ‘H’ bitts, and a towing winch, also resulted in Adonis being unstable when undertaking towing operations over the stern. This fact was not identified by the tug’s owners because the tug’s stability had not been recalculated following the fitment of the additional equipment.

What has been done as a result

Sea Swift, the owners of Adonis, have produced new procedures covering the quick release arrangements on its tugs and enhanced the training and familiarisation of its crews with these arrangements. The company has also carried out a review of all its tugs’ towing and quick release arrangements and introduced regular testing of this equipment.

In addition, a program for the review of all stability data for its tugs which were purchased overseas has been instigated, and an experienced training manager has been employed to review and monitor the company's health and safety policies and practices. A review of Sea Swift’s training assessment for new masters or potential masters for the towing fleet has extended the period of training to include mentoring runs and supernumerary runs with other masters to facilitate the development of a greater understanding of towage requirements.

Safety message

The masters of tugs, regardless of size, need be actively aware of the signs that a tug might be in danger of capsizing and what to do to lessen this danger. For multiple tug operations, the masters of the tugs should plan the passage and consider the speed of passage and when it is time to release the towline. It is also important that the masters regularly communicate during the passage and that any concern regarding speed is immediately brought to the other master’s attention.

At 0720 Western Standard Time on 15 June 2011, a Piper Aircraft PA-46-310P Malibu, registered VH-FAL, departed from Doolgunna Station, on a private flight to Meekatharra WA, with the pilot and one passenger on board.

While on finals to land at Meekatharra, the pilot initiated a go-around due to another aircraft occupying the runway.

On the downwind leg of the second approach, the engine lost power and the aircraft impacted terrain about 500 m short of the runway threshold. Both occupants sustained injuries.

The pilot stated that his usual actions were to set the aircraft fuel selector to the fullest fuel tank for take-off, then manage the fuel balance by appropriate tank selection during the flight. He stated that as this process was routine for him, he could not actually recall having made a change to the tank selection during the flight

To ensure the safe conduct of a flight, it is crucial that pilots establish a disciplined cockpit routine that covers all critical aspects of in-flight management.

On 14 April 2011, a Christen Eagle aircraft collided with terrain about 60 km north-east of Bangkok, Thailand. Both persons on board, one of whom was Australian and held a Recreational Aviation Australia pilot certificate, were fatally injured.

As the accident took place in Thailand, the Aircraft Accident Investigation Committee (AAIC) of Thailand is responsible for its investigation. As part of its investigation, the AAIC requested assistance from the Australian Transport Safety Bureau (ATSB) to gather details of the Australian pilot's qualifications and experience. In accordance with clause 5.23 of Annex 13 to the Convention on International Civil Aviation (Annex 13), the ATSB appointed an accredited representative to assist the AAIC and initiated an investigation under the Australian Transport Safety Investigation Act 2003. The ATSB provided details of the pilot's qualifications and experience to the AAIC.

In accordance with Annex 13, the AAIC of Thailand is responsible for releasing the final investigation report on this occurrence.

Contact details for the AAIC are:

Acting Chief, Aircraft Accident Investigation Group
(Member & Secretary, the Aircraft Accident Investigation Committee of Thailand)
Flight Standards Bureau
Department of Civil Aviation
71, Soi Ngarmduplee, Rama IV Road
Sathorn, Bangkok, 10120, Thailand
Tel: +66 2286 2933, Fax: +66 2286 2925

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

Qantas Airways Boeing 747-300 (B747) VH-EBT aircraft was towed across the path of Cathay Pacific Airways Boeing 747-300 (B747) VR-HIJ which had commenced take-off on runway 34 on a scheduled flight to Hong Kong.

The incident occurred at Sydney (Kingsford Smith) Airport on Tuesday 11 September 1990 at 1350 hours Eastern Standard Time.

On 1 June 2011, a Bell Helicopter 206B (III), registered VH-BHU (BHU), departed Mossman Sports Ground, Queensland for a local area charter flight. The flight was conducted as a weed spotting operation and there was one pilot and three passengers, acting as weed spotters, on board.

The aircraft was operating about 10-15 ft above the tree top level when the pilot initiated a slow left turn, and the helicopter struck a dual-line powerline. The pilot was unaware that there was a powerline in the vicinity prior to the collision. The pilot applied control inputs to keep the helicopter level as it descended though the tree canopy.

The helicopter landed in an upright position and the pilot and three passengers were able to exit. The pilot and one passenger sustained serious injuries, and the other two passengers sustained minor injuries.

As a result of the accident, the helicopter operator conducted a meeting to discuss the factors that led to the accident and highlight the hazards. They also issued a wire awareness information pack to all current pilots and modified the pilot briefing notifications to specifically highlight hazards when working at low level. The Operations Manual was also being updated to enhance the section on low level reconnaissance and changes were made to the Emergency Response Plan.

On 3 June 2011, a Kawasaki Heavy Industries 369HS helicopter, registered VH-XAA, collided with terrain 42 km west-south-west of Canberra Airport, New South Wales. The helicopter sustained serious damage and both occupants received injuries.

Earlier that day the helicopter had departed from a private helicopter landing site about 22 km north-west of Canberra Airport for defence aircrew currency training in the Brindabella Ranges, New South Wales. Pre-departure checks had been normal, and the weather was clear.

After identifying a suitable landing site in the Ranges, the pilot reported that he brought the helicopter into a high hover of about 50 -70 ft above ground level (AGL). He assessed that an adequate power margin existed prior to commencing a right tail rotor pedal turn through about 180° to position for landing. Approaching the required position, the pilot applied left tail rotor pedal to stop the turn, however, the helicopter continued to turn to the right. The pilot assessed that he had lost tail rotor effectiveness and commenced recovery actions, but this was hampered by the proximity of nearby trees. The helicopter continued the right yaw through a number of 360º turns while slowly descending. At about 30 ft AGL, the pilot assessed that collision with the trees was imminent and decided to conduct an emergency landing in the clearing below. The helicopter descended rapidly towards terrain and landed heavily in a level attitude, striking a large log. After rapidly rolling through trees then down a bank the helicopter came to rest in a creek bed.

Both occupants exited the helicopter and activated the portable emergency locator beacon. They were later airlifted out by a rescue helicopter.

On 16 January 2011, at about 1800 Eastern Standard Time, a De Havilland Aircraft DH-82A (Tiger Moth) aircraft, registered VH-WHW (WHW), departed Toowoomba, Queensland on a private local flight.

On board was the pilot in command (PIC) and a flying instructor from the local Aero Club. The PIC conducted a pre-flight inspection, which included a check of the fuel, oil and control cables. He determined that WHW was serviceable and had sufficient fuel for the flight. There were no loose items in the aircraft's storage locker or in the cockpit.

About 15 minutes after take-off, the flying instructor, who was acting as the handling pilot at the time, initiated a left turn to return to the airport. The PIC recalled that, during the turn, WHW suddenly pitched down followed by a second, even more severe, pitch down motion. Both the PIC and the handling pilot recalled that the control stick did not move when WHW pitched down.

In response to the sudden and uncommanded nose down motion, both pilots attempted to raise the nose by applying back pressure on the control stick. Their actions had no effect and WHW continued to pitch nose down until the aircraft became inverted.

The aircraft was about 100 ft above the trees and inverted when it began to climb. Both pilots felt significant g-force followed by the collision with the trees.

The aircraft came to rest upside down on the side of Mount Davidson in bushland. Both occupants sustained serious injuries.

Preliminary report released 9 October 2011

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

At about 0145 on Saturday 28 May 2011, intermodal freight train 5MP9 was travelling from Melbourne to Perth when it experienced a catastrophic failure of a locomotive wheel at about the 849.700track kilometre mark near Fisher, South Australia. There were no injuries. The locomotive did not derail but separated wheel fragments damaged the locomotive traction motor and associated components. The single-line track incurred four rail breaks and broken sleepers over a distance of about 1 km.