The United States National Transportation Safety Board (NTSB) requested assistance from the Australian Transport Safety Bureau (ATSB) in investigating the circumstances of an accident involving a Mooney M20R, with Australian registration, that collided with terrain shortly after takeoff from Hollister Municipal Airport, Hollister, California on 25 November 2010. The Australian pilot, the sole occupant, was fatally injured and the aircraft destroyed.

The NTSB request sought assistance in obtaining details of the pilot's experience and training. In accordance with clause 5.23 of Annex 13 to the Convention on International Civil Aviation, the ATSB appointed an accredited representative to the NTSB investigation and initiated its own investigation under the Australian Transport Safety Investigation Act 2003. Details of the pilot's experience and training were provided to the NTSB.

The NTSB is responsible for releasing the final investigation report (docket WPR11FA059) and has advised that the NTSB investigation is complete, and that the investigation report will be released to the public in due course. When released, that report will be available via the NTSB website at www.ntsb.gov

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

On 20 May 2011, a Qantas Airways Boeing 767-338 aircraft, registered VH OGR, was being operated on a scheduled passenger service from Melbourne, Victoria to Perth, Western Australia.

During the approach to runway 03 at Perth, the aircraft encountered turbulence over a 9 second period, with severe turbulence recorded for 3-4 seconds during that time; a go-around was conducted.

Two passengers, who were reportedly not wearing their seat belts at the time, sustained head injuries from coming into contact with a window reveal and an overhead locker. After landing, both passengers received medical attention, with one being transported to hospital.

As a result of this occurrence, the aircraft operator has advised the ATSB that they intend to present this incident at the Airservices Australia industry participation working group for discussion; to improve the dissemination of information relating to windshear events.

Generally, 99 per cent of people receive no injuries during a turbulence encounter; however, if passengers and cabin crew are not wearing their seatbelts, they can be thrown around without warning. Almost all in-flight turbulence injuries could be avoided by wearing a seatbelt and paying attention to any safety announcements made by the flight crew and cabin crew during the flight.

On 16 May 2011, while in the cruise, on a scheduled passenger flight from Changi Airport, Singapore, to Melbourne, Australia. The crew of the Qantas Airways, Airbus A380-842 (A380) aircraft, registered VH-OQI (OQI), noticed a significant discrepancy between the aircraft's fuel state and the fuel predictions. The crew monitored the fuel over the flight and determined that 3.8 Tonne of excess fuel had been used over a 6-hour period.

The excess fuel usage could not be explained.  Due to the potential for delays at Melbourne, the crew opted to divert to Adelaide Airport, where an uneventful landing was made.

Subsequent examination of the aircraft found no evidence of fuel leaks. Engine ground runs confirmed normal fuel flow to all engines. The flight data recorder was analysed by the Australian Transport Safety Bureau, which confirmed fuel flow during the flight was in accordance with the commanded thrust.

Subsequent investigation by the manufacturer and operator identified that for a period of about 4 hours during the flight, the speed brake lever (SBL) was set away from its stowed position of -5° to the +3.6°position. As a result, the aircraft spoilers were deflected into the airstream increasing drag and consequently fuel burn. The crew were not alerted to this as warnings are only displayed to the crew at or above the +5° SBL position.

As a result of the incident, Airbus plans to reduce the alerting position of the speed brake lever angle from +5° to +2.4°.

Airbus have also updated the standard operating procedures (SOP) to highlight that spoiler extension may occur without a crew alert.

On 13 May 2011, at 1606 Eastern Standard Time, an Aérospatiale Eurocopter AS 350B3 helicopter, registered VH-XXW, impacted terrain at Bankstown Airport, New South Wales. As the result of the post-impact fire, the helicopter sustained serious damage.

The owner-pilot had earlier completed an 'air transit' at about 15-20 ft above ground level (AGL), from outside a hangar, to a grassed area south-west of the main helipad.

While stationary in a hover, with a recorded 15 kt wind onto the right front of the helicopter, and at about 10 ft AGL, the pilot decided to land on the grass. When the helicopter was about 2 ft AGL, the pilot stated that it suddenly rotated to the left in an anticlockwise direction. The pilot was unable to correct the anticlockwise yaw with progressive right pedal input. The pilot then raised the collective lever and climbed to about 10 ft AGL, completing about three to four, 360 º rotations.

At the same time, the pilot noticed the helicopter drifting towards a chain-wire fence adjacent to a freight building. During the uncontrolled anticlockwise yaw, the pilot reported that there were no visual or aural warnings. While still rotating, the pilot decided to conduct a forced landing and slowly lowered the collective lever. The helicopter contacted the ground, rolled onto its right side and was seriously damaged from the post-impact fuel fed fire. The pilot sustained minor injuries.

On 15 February 2011, during a scheduled passenger service from Singapore to London, United Kingdom, the flight crew of an Airbus A380-842 aircraft, registered VH-OQC, observed a decrease in oil quantity on the number-4 engine. The aircraft was about 3 hours into the cruise near Delhi International Airport.

On 25 November 2010, a De Havilland Canada DHC-8-202 aircraft, registered VH-SDA (SDA), was taxied to runway 03 at Port Macquarie, New South Wales for a scheduled passenger service to Sydney.

After lining up on runway 03, the pilot in command (PIC) of SDA observed a traffic return on the aircraft's traffic alert and collision avoidance system (TCAS) indicating that an aircraft was behind them, about 400 ft above and descending. As a precaution, the take-off was expedited.

At the same time, a Beech Aircraft Corporation 58 aircraft, registered VH-VFG (VFG), was on final approach to runway 03. After observing SDA commence the take-off, the crew initiated a go-around and positioned the aircraft to the right of the runway centre line to maintain separation with SDA.

At about 600 ft, the crew of SDA noted that the TCAS was indicating that VFG was about 100 ft above and climbing. The PIC of SDA discontinued the aircraft's climb and turned left onto a westerly heading.

Both crews attempted to contact each other on the Port Macquarie common traffic advisory frequency (CTAF) but received no response. The crews eventually established communications on the Brisbane Centre frequency.

Following the incident, the copilot of SDA reported that he may have mistuned the CTAF prior to taxiing. A subsequent engineering inspection by the operator determined that the aircraft's radio transceiver was faulty.

The operator of SDA has advised the ATSB, that as a result of this incident, a safety alert was issued to pilots emphasising the radio requirements for when operating on the CTAF. In addition, the operator also intends to conduct a review of their CTAF operating procedures.

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.

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.

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.

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.