On 4 December 2010, a Cessna Aircraft Company 172S aircraft, registered VH-CNW (CNW) and a Piper Aircraft Corp PA-28R-201 aircraft registered VH-AIZ (AIZ), were conducting concurrent training flights at Ballarat Airport, Victoria. A flight instructor and student were on board CNW and had entered the circuit with the intention of conducting a touch-and-go. AIZ was preparing to commence a flying training exercise from Ballarat Airport to the local training area with an instructor and student pilot on board.

CNW joined downwind for runway 05 due to glider activity on runway 36. While AIZ lined up on runway 36 due to the more favourable wind direction.

Following a touch-and-go landing on runway 05, CNW was between 70 and 150 ft above the ground, when the instructor saw an aircraft airborne off runway 36 passing from right to left in front of them, in close proximity. The instructor of AIZ became aware of CNW at about the same time and both instructors took control of their aircraft and carried out evasive action.

One instructor estimated they were within 15-30 m of each other horizontally, at about the same height.

While both aircraft made radio broadcasts, it could not be determined why they could hear other radio traffic in the area, but not each other.

The aircraft operator of AIZ has planned the following safety action in response to this incident:

• Institute a training procedure for trainee pilots to positively identify the location of any aircraft making a radio broadcast on the common traffic advisory frequency (CTAF) at Ballarat Airport.
• Conduct a workshop for all staff and trainees on situational awareness.

The aircraft operator of CNW has alerted their staff and students to be extra vigilant when operating in and around Ballarat Airport and have limited student pilots from entering the circuit at Ballarat.

Preliminary report released 29 March 2011

The information contained in this Preliminary report is released in accordance with section 25 of the Transport Safety Investigation Act 2003 and is derived from the ongoing investigation of the occurrence. Readers are cautioned that new evidence will become available as the investigation progresses that will enhance the ATSB's understanding of the accident as outlined in this Preliminary report. As such, no analysis or findings are included in this report.

Abstract

At about 0153 on 9 December 2010 an Up (northbound) loaded grain train travelling from Barellan, New South Wales (NSW) to Maldon, NSW and numbered as 3234, collided at low speed with the rear of another Up (northbound) loaded grain train, numbered as 8922, on the Down2 Main line at Yass Junction, NSW. The intended operation had been for both trains to wait, one behind the other, on the Down Main line at Yass Junction to enable a third northbound goods train, 4MB2, to pass them both on the adjacent Up Main line.

On 25 May 2011, the draft ATSB investigation report into the incident was provided to directly involved parties for comment. The directly involved parties were asked to provide a submission addressing the report. All submissions will be considered before the report is finalised for public release

On 5 December 2010, at 1422 Eastern Daylight-saving Time, a breakdown of separation occurred between a Boeing Company B737-7Q8 (737), registered VH-VBF, and a Boeing Company B767-338 (767), registered VH-OGU, on departure from Melbourne Airport, Victoria. The flight crew of the 737 had reduced their aircraft's speed in order to meet a height requirement of the Standard Instrument Departure. The following 767 aircraft climbed at a faster speed.

When the aircraft were transferred from the aerodrome controller to a departures controller, there was 3.4 NM (about 6.3 km) separation between them. The departures controller expected them to climb at a similar speed, and did not recognise the loss of separation assurance. The controller's actions to manage the compromised separation were not fully effective. At one point, radar separation had reduced to 1.9 NM (3.5 km) and vertical separation to 500 ft.

On 12 October 2011, a similar breakdown of separation occurred at Melbourne between an Airbus A320-232 and a Boeing Company 737-8BK. This incident involved different controllers to those involved in the 5 December 2010 incident.

The ATSB identified a safety issue in that the procedures for takeoffs at Melbourne Airport allowed for aircraft to depart relatively close to each other, with no documented requirements to ensure jet aircraft would maintain a set climb speed or to require flight crews to advise air traffic control if that speed could not be achieved. Although the Melbourne procedures were based on those used in Sydney, the Sydney procedures specified a minimum climb speed. The safety assessment report for the Melbourne procedures did not include a detailed comparison of the procedures used in the two locations. In response to the identified safety issue, Airservices Australia has commenced action to establish a standard speed profile for use at radar terminal area aerodromes in Australia, and to ensure that pilots of jet aircraft notify air traffic control when operating at a significantly lower speed than stipulated in that profile.

Abstract

At about 0937 on 1 November 2010, the Liberian registered container ship MSC Basel grounded in Moreton Bay, Queensland, while departing the port of Brisbane.

MSC Basel was in the main shipping channel when its rudder unexpectedly moved to starboard without the application of any helm. The ship immediately began turning to starboard.

The main engine was run astern and the port anchor was let go. However, these actions could not prevent the ship from grounding on Yule Banks, just to the north of the channel.

The ATSB investigation found that the ship's rudder probably moved to starboard because of a malfunction of the steering control system.

However, inspections and tests carried out following the grounding did not identify any steering control system faults.

The investigation also found that MSC Basel's steering system had not been tested in accordance with SOLAS2 requirements before the ship departed Brisbane.

The investigation report identifies one safety issue and outlines the safety actions taken by MSC Basel's managers to address it. The report also issues one safety advisory notice.

On 1 December 2010, at 1412 Eastern Daylight-saving Time, a breakdown of separation occurred between a Beech Aircraft Corporation Barron BE58 (BE58), registered VH-VFG, and a SAAB Aircraft Company S340B (S340), registered VH-SBA, near Taree Airport, New South Wales (NSW).

The BE58 was a private flight from Bankstown to Port Macquarie, NSW and the S340 was a scheduled passenger service from Taree to Sydney, NSW. On departure, the S340 was issued a clearance by air traffic control (ATC), with an altitude requirement intended to establish the S340 above the BE58 on a crossing track. When ATC reassessed the proximity of the aircraft and determined that the altitude requirement would not ensure separation, they issued the BE58 with a vectoring instruction.

The separation between the two aircraft reduced to below the required standards. Separation was re-established when the S340 reached 10,000 ft on climb.

This incident highlights the importance for air traffic controllers to continually monitor and reassess their separation plans and implement changes to assure that the required separation standards will be established and maintained. Furthermore, the provision of timely and appropriate traffic information to flight crew, by air traffic control, can significantly enhance pilots' situational awareness.

Airservices Australia (Airservices) has advised that they are conducting a systemic review of a number of Breakdown of Separation occurrences, with outcomes from that review to be considered in terms of further safety improvement. As a short-term safety intervention, Airservices will be conducting an awareness program for Air Traffic Controllers following the publication of this report.

On 22 October 2010, a replica Supermarine Spitfire MK26 recreational/light sport aircraft (registered 19-4024) collided with terrain near Gympie authorised landing area (ALA), fatally injuring the pilot. Recreational Aviation Australia Inc (RA-Aus) is assisting the Queensland Police in their investigation of the occurrence.

On 17 November 2010, RA-Aus requested technical assistance from the Australian Transport Safety Bureau (ATSB) for the recovery of data from an engine management system (EMS) module recovered from the accident site. To protect the information supplied by RA-Aus and the investigative work undertaken, the ATSB initiated an investigation under the Transport Safety Investigation Act 2003.

Due to the damage to the EMS and the lack of configuration information, the recovery involved extracting the data from the electronic memory components and, using example data provided by the EMS manufacturer, converting the binary extracted data into engineering units.

The full converted data set was provided directly to RA-Aus investigators. This report represents an outline of the process undertaken and a summary of the data obtained.

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

On 14 November 2010, a Piper PA-31-350 aircraft registered VH-MKK was being operated on a passenger charter flight from Marree, South Australia to Broken Hill, New South Wales. During the climb the pilot detected an unusual noise in the right engine followed by a gradual decrease in engine performance. The pilot elected to return to Marree Airport, however during the turn back the aircraft was unable to maintain altitude and the pilot elected to conduct a forced landing about 22 km south-east of the Airport.

The pilot did not feather the right engine as he assessed that the right engine was still producing some power.

The aircraft was substantially damaged during the landing, however all passengers and crew were able to exit the aircraft safely.

A post-flight engine inspection found four bearing retainer plate screws missing from the magneto which allowed oil to enter the magneto. It is probable that this led to a magneto failure and subsequent engine failure.

As a result of the accident, the aircraft operator conducted a brief with all company pilots revising engine failure procedures. They also discussed the symptoms of a windmilling propeller and partial engine failure indications and procedures.

The operator has also amended their procedures to mandate that all IFR renewal flights are to be conducted in the Piper PA-31 Chieftain aircraft type.

Abstract

On 15 November 2010, the engine room fitter/storekeeper (storekeeper) on board the Vanuatu registered bulk carrier Polska Walczaca died as a result of injuries he received when he fell from the ship's number five cargo hold ladder while repairing a section of its hand railing.

The ATSB investigation could not determine why the storekeeper fell from the cargo hold ladder. However, it was found that, at the time, he was not wearing a safety harness, and his hardhat was probably not fastened correctly.

The investigation did not identify any organisational or systemic issues that might adversely affect the future safety of marine operations.

On 12 November 2010, a Qantas Airways operated, Boeing Company 767-338 aircraft, registered VH-OGO, departed Perth Airport, Western Australia, on a scheduled passenger flight to Melbourne, Victoria. During climb the flight crew heard a popping sound followed by vibration from the left engine. The vibration decreased when the engine power lever was retarded to the flight idle position. The crew declared a PAN and requested a return to Perth. Air traffic control alerted emergency services who were in attendance when the aircraft landed.

An initial examination of the aircraft revealed pieces of metal in the engine tail pipe and damage to the low-pressure turbine (LPT) module. The engine was replaced, and the aircraft returned to service.

The engine manufacturer attributed the failure to the LPT stage 3 nozzle. A new nozzle design was released 19 January 2011. The current repair limits and repair procedures are also being re-evaluated by the manufacturer.

The aircraft operator advises that; as many engines have undergone their last full refurbishment before fleet retirement, the operator will replace the nozzles on an attrition basis. In the interim, the operator has introduced additional inspections for preservice bulleting 72-1354 LPT stage 3 nozzles that should detect any signs of air foil cracking well in advance of a potential operational event.