On 5 November 2010, a Boeing Company 747-438 aircraft, registered VH-OJD departed Changi Airport, Singapore on a scheduled flight to Sydney, New South Wales. When the aircraft was climbing through 2,000 ft, a loud bang was heard accompanied with aircraft yaw and vibration. The crew shut down the number one engine, declared a PAN and received approval from air traffic control for a return to Singapore. The crew then jettisoned fuel for about forty minutes. Emergency services were in attendance when the aircraft landed safely a short time later.

A subsequent examination confirmed that the engine had sustained serious damage as the result of a compressor blade release from the stage 1 high pressure compressor (HPC 1). The engine was replaced, and the aircraft returned to service.

The aircraft operator is continuing to bring their RB211-524G engines to the latest modification status at engine shop visits. However, should the rate of engine failures increase significantly a review of current modification policy will be undertaken.

The ATSB has completed its technical analysis of flight recorder data from several Indonesian aviation accident events that occurred between 2009 and 2011.

The National Transportation Safety Committee (NTSC) of Indonesia is responsible for investigating these occurrences. The NTSC requested technical assistance from the Australian Transport Safety Bureau (ATSB) in the determination of the appropriate data frame layouts for the flight data recorder (FDR) information recovered from the occurrence aircraft. In accordance with clause 5.23 of Annex 13 to the Convention on International Civil Aviation, the ATSB appointed an accredited representative to assist the NTSC and initiated an investigation under the Australian Transport Safety Investigation Act 2003.

In cooperation with NTSC staff, suitable data frame layouts were determined for all recovered FDR data, and the information was provided in a report to the NTSC. The NTSC is responsible for releasing the final investigation reports on these occurrences.

National Transportation Safety Committee
Ministry Of Transportation Republic Of Indonesia
Transportation Building 3^rd Floor
Jalan Medan Merdeka Timur No. 5
Jakarta Pusat 10110
Indonesia

Phone  :  +62 21 384 7601
Email    :  knkt@dephub.go.id

Website: http://knkt.dephub.go.id/knkt/ntsc_home/ntsc.htm

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

Preliminary report released 21 July 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 2016 on Friday 6 May 2011, freight train 4PM6 derailed the trailing bogie of the 49th wagon (RQHY 07069C) at Port Augusta, South Australia near the Carlton Parade level crossing (91.559 km). About 1300 m later, the wagon re-railed itself as it entered the road pavement near the Stirling Road level crossing. There were no injuries as a result of the derailment but there was minor damage to rolling stock and track. The investigation is reviewing a number of factors including the condition of the track and rolling stock, train speed and the interaction of rail wagons and the track through this location.

Preliminary report released 26 April 2011

On 30 March 2011, a Piper Saratoga PA32R-301T aircraft, registered VH-LKI, with a pilot and five passengers on board was returning to Moree Airport, New South Wales, from Brewarrina, which was located 300 km to the west‑south-west of Moree.

The aircraft was reported to have flown overhead the airport at about 2000 Eastern Daylight-saving Time before the pilot conducted what was reported to be a left circuit for a landing on runway 19. The aircraft was observed on a low approach path as it flew toward the runway during the final approach leg, before contacting trees and colliding with level terrain about 550 m short of the runway 19 threshold.

The pilot and three passengers were fatally injured. Two other passengers who were seated in the rear of the aircraft were seriously injured. The aircraft was seriously damaged by the impact forces.

On 11 May 2011, the Indonesian National Transport Safety Committee (NTSC) requested technical assistance from the Australian Transport Safety Bureau (ATSB), in the recovery of information from the flight data recorder (FDR) and cockpit voice recorder (CVR) of a XAC MA60 aircraft that impacted the sea on approach to Kaimana Airport, Papua Barat, Indonesia on 7 May 2011. The 21 passengers and 4 crew on-board the aircraft were fatally injured in the accident.

The NTSC is responsible for investigating this occurrence. In accordance with clause 5.23 of Annex 13 to the Convention on International Civil Aviation, the ATSB appointed an accredited representative to assist the NTSC and initiated an investigation under the Australian Transport Safety Investigation Act 2003.

Download and analysis of the FDR and CVR was successful and both were found to contain good quality data including the entire accident flight. Support and information was provided to the NTSC during the course of the investigation and the ATSB's Technical Analysis Report was provided to the NTSC.

A final investigation report regarding this occurrence will be released by the NTSC.

The National Transport Safety Committee of Indonesia is responsible for releasing the investigation report.

National Transportation Safety Committee
Ministry Of Transportation Republic Of Indonesia
Transportation Building 3^rd Floor
Jalan Medan Merdeka Timur No. 5
Jakarta Pusat 10110
Indonesia

Phone  :  +62 21 384 7601
Email    :  knkt@dephub.go.id

Website: http://knkt.dephub.go.id/knkt/ntsc_home/ntsc.htm

______________

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

On 4 May 2011, at about 0730 Eastern Standard Time, a Bell Helicopter B206, registered VH-BNG, struck a single power line and conducted a precautionary landing in a nearby field.

The pilot had commenced end of the season, agricultural spraying operations of sugar cane fields earlier that day and was on his third chemical spray load. While approaching a paddock of four hectares, he calculated that with the required buffer zone of 100 m from each house, the effective spray coverage would only be one hectare. As the pilot flew over one of the houses, his focus was diverted from looking for powerlines, to a resident walking from the house to his car.

While observing the resident, the pilot considered where to start the spray run, taking into account, the buffer zone and that he needed to quickly get low over the cane field. After the pilot had assessed that the resident was comfortable with the presence of the helicopter, his focus moved to commencing the spray run and not to looking for powerlines. The pilot quickly descended the helicopter toward the field to begin the spray run and it struck a power line to the house. After a precautionary landing in the field, the pilot observed that the helicopter had sustained damage to the chin view windows and one main rotor blade.

As a result of this accident, the pilot advised that planning for future operations would be carried out by the pilot, not by persons indirectly involved in the operation.

On 2 May 2011, a Boeing 717 aircraft, registered VH-NXE and operated by Cobham Aviation, was on a scheduled flight from Perth to Newman, WA. During the climb, the left engine failed. After completing safety checks and declaring a PAN, the crew returned the aircraft to Perth and landed without incident. An engine inspection identified blade failures in the left engine's high-pressure turbine (HPT) module. After disassembly, it was determined that the loss of a single HPT blade due to a fatigue failure had occurred.

The engine manufacturer had implemented a number of modifications to the HPT blades since 2003; culminating in a new-design blade, designated the Mk II. The subject engine had not been retrofitted with Mk II blades at the time of the occurrence.

The manufacturer had issued three service bulletins (SB) to operators regarding the installation and modification of engines with previous-design HPT blades. The operator is complying with these SB requirements; modifications have been scheduled to the engine fleet and are in progress with the manufacturer.

At about 1410 EST, on 30 April 2011, the crew of an Aerospatiale AS350FX2 helicopter registered VH-RTV (RTV) was replenishing gas well-head inhibitor tanks using sling load operations from Ballera Airport, Queensland. During one such operation to a well-head that was surrounded by water, the tail rotor blades struck two pipes that extended above the other pipework. 

At the time, the pilot was descending the helicopter prior to releasing the sling. Both he and the crewman were focusing on maintaining clearance from other parts of the well-head and neither saw the two pipes that the tail rotor struck.

Immediately following the occurrence, the operator introduced procedures which specifically addressed inhibitor tank replenishment to supplement the external and sling load procedures which were already in place.

On 23 April 2011, at 1644 Eastern Standard Time, a loss of separation assurance (LOSA) occurred between a Boeing B737-8BK (737), registered VH-VOB, and an Airbus Industrie A320-232 (A320), registered VH-VGZ, near Armidale Airport, New South Wales (NSW).

Both aircraft were conducting scheduled passenger services at flight level 320 on the same one-way air route, H62, until position Mount Sandon, where the leading 737 aircraft would continue tracking south for Sydney, while the following A320 aircraft was flight planned to track left to Williamtown.

As the 737 was required to enter a holding pattern for sequencing into Sydney, the air traffic controller approved a speed reduction for the aircraft, but did not identify that the longitudinal separation between it and the following A320, was closing.

When the 737 flight crew provided the controller with their aircraft's speed information for the benefit of the following traffic, the controller identified the potential confliction and issued the A320 with a vectoring instruction to maintain separation. Although the separation between the two aircraft did not reduce below the required standard, a LOSA had occurred due to the closing longitudinal proximity between the two aircraft.

Airservices Australia (Airservices) advised that a review of LOSA and breakdown of separation occurrences would be undertaken to determine whether speed differential and aircraft performance were significant contributing factors and if additional refresher training was required for controllers.

This occurrence highlights the need for awareness of the effects of low workload on performance, identification of lowered vigilance and subsequent action or implementation of strategies to maintain safe operations. It also demonstrates how appropriate flight crew communication enhanced the situational awareness of the controller. In addition, the knowledge and application of effective compromised separation recovery techniques by the controller was integral in managing the situation.

Safety summary

What happened

At 1706 on 29 April 2011, the Panama registered bulk carrier Dumun grounded while departing the port of Gladstone, Queensland.

Prior to the grounding, the ship's steering appeared to stop responding to bridge commands when the linkage between the tiller and rudder angle transmitter became detached. The steering gear continued to operate normally, but the transmitter lost its input signal and, as a result, the bridge mounted rudder angle indicator stopped working.

The bridge team assumed that the steering had failed, so the pilot ordered the main engine stopped and then started astern. However, these actions were not enough to prevent the ship from grounding.

What the ATSB found

The ATSB determined that the ship's builders did not identify that the rudder angle indicator transmitter and tiller linkage were not installed correctly. More broadly, the ATSB found that the analysis of shipping operations in Gladstone, carried out by the relevant authorities, had not appropriately considered all that could be done to prevent the grounding of a ship as a result of steering gear or main engine failure. In addition, it was found that a comprehensive safety management system had not been implemented in Gladstone with the aim of identifying, evaluating and controlling pilotage related risk.

What has been done as a result

Dumun's shipbuilder has sent a bulletin to the owners of all ships built by the company advising that the rudder angle indicator linkage should be checked to ensure that it is correctly fitted. The company has also modified its procedures to ensure that these checks are carried out during the building of all future ships.

Maritime Safety Queensland (MSQ) and its pilots have worked with Gladstone Port Corporation and terminal operators to improve ships' readiness for departure by implementing rigorous pre-departure checks. MSQ is also in the process of developing a single pilotage safety management system covering all of the ports in which the organisation provides pilotage operations.

Safety message

Safety regulators and port authorities should consider all the risks associated with the passage of deep draught ships within their ports and have appropriate contingency plans in place to deal with foreseeable emergencies.