On 4 October 2009, at 1217 Eastern Standard Time, the flight crew of a SAAB Aircraft Co 340B aircraft, registered VH-SBA noted abnormal left engine temperature indications during initial climb-out on a scheduled passenger flight from Wagga Wagga Aerodrome, New South Wales to Melbourne, Victoria.

The flight crew later reported that they noticed abnormally high indications from the left engine inter-turbine temperature, before shutting down the left engine and returning to the aerodrome for landing. Subsequent inspection of the left engine indicated internal damage, specifically to the stage 1 compressor section blisk blade.

The left engine damage was the result of the fatigue-related failure and separation of four of the stage 1 compressor blisk blades. There was no evidence that material defects or abnormalities contributed to the failures.

Abstract

On 24 November 2009, the chief mate on board the Hong Kong registered chemical tanker Bow De Jin died after entering a cargo tank which contained hydrocarbon vapours and was deficient in oxygen.

The ATSB investigation was unable to determine why the chief mate, who had sailed on tankers for most of his seagoing career, did not follow industry standard and specific company safety procedures before he entered the cargo tank.

The investigation found that while enclosed space entry checklists were being filled out by the crew members on board the ship, the checklist system was not being used as a proactive means to ensure that the necessary safety requirements were being met prior to tank entries.

As a result of this incident and the ATSB investigation, Bow De Jin's managers have taken action to improve the ship's enclosed space entry checklist system.

On 9 November 2010, the student pilot of a Robinson Helicopter Company R22 Beta II, registered VH-TCG, was engaged in a helicopter aerial stock mustering operation on a private station near Rolleston, Queensland. During the muster, after losing communication with the helicopter, one of the mustering party found the wreckage of the helicopter. The student pilot, who was the sole occupant, was fatally injured and the helicopter seriously damaged as a result of the collision with terrain.

The investigation found that the pilot had not met the competency standards to operate a helicopter solo, and had not received any training towards low flying or aerial stock mustering.

The investigation did not identify any organisational or systemic issues that might adversely affect the future safety of aviation operations. However, the accident does provide a timely reminder of the importance of ensuring that flight crews have the appropriate competencies and currency before engaging in highly-skilled tasks.

On 5 November 2010, a Hawker Beechcraft Corporation B200C aircraft registered VH-MVX departed Dubbo, New South Wales on a positioning flight for a medical charter service from Cobar. Before departure the pilot had set the aircraft altitude on the pressurisation controller for a cabin altitude of 3,000 ft at flight level (FL) of 200. After the aircraft levelled out at FL180 the pilot noticed the cabin altitude was at 10,000 ft instead of 3,000 ft. During a check conducted by the pilot that the cabin pressure control switch was not in the dump position, the aircraft depressurised, and the oxygen masks deployed. The pilot did not immediately don his oxygen mask, before initiating an emergency descent and declaring a PAN. The pilot requested clearance to return to Dubbo and landed without further incident about 0745.

The aircraft pressurisation controller was removed and sent to the manufacture for examination. The controller was found to be out of tolerance, a condition that would affect the rate of cabin pressure change responsiveness. As a result of an internal investigation, the operator decided to include a cabin depressurisation exercise requiring an emergency descent as part of their next proficiency check. The operator also will detail the incident and article in their next flight safety newsletter to increase awareness to all pilots.

What happened

On 4 November 2010, while climbing through 7,000 ft after departing from Changi Airport, Singapore, the Airbus A380 registered VH-OQA, sustained an uncontained engine rotor failure (UERF) of the No. 2 engine, a Rolls-Royce Trent 900. Debris from the UERF impacted the aircraft, resulting in significant structural and systems damage.

The flight crew managed the situation and, after completing the required actions for the multitude of system failures, safely returned to and landed at Changi Airport.

What the ATSB found

The Australian Transport Safety Bureau (ATSB) found that a number of oil feed stub pipes within the High Pressure / Intermediate pressure (HP/IP) hub assembly were manufactured with thin wall sections that did not conform to the design specifications. These non-conforming pipes were fitted to Trent 900 engines, including the No. 2 engine on VH-OQA. The thin wall section significantly reduced the life of the oil feed stub pipe on the No. 2 engine so that a fatigue crack developed, ultimately releasing oil during the flight that resulted in an internal oil fire. That fire led to the separation of the intermediate pressure turbine disc from the drive shaft. The disc accelerated and burst with sufficient force that the engine structure could not contain it, releasing high-energy debris.

What has been done to fix it

Following the UERF, the ATSB, Rolls-Royce plc, regulatory authorities and operators of A380 aircraft with Trent 900 engines took a range of steps to ensure that HP/IP hub assemblies with non-conforming oil feed stub pipes were identified and either removed from service, or managed to ensure their safe continued operation. Rolls-Royce also released an engine control software update that included an IP turbine overspeed protection system (IPTOS) that is designed to shut the engine down before the turbine disc can overspeed, in the unlikely event that a similar failure occurs.

Rolls-Royce has also made a range of changes to their quality management system to improve the way in which they manage non-conforming parts, both during the manufacturing process and when it has been identified that parts had unknowingly been released into service with non-conformances.

Safety message

The ATSB identified a number of issues during the manufacture of Trent 900 HP/IP hub assemblies that resulted in their release into service with non-conforming oil feed stub pipes. Those issues highlighted the importance of providing clear procedures during the manufacturing process and of personnel complying with those procedures. Even though modern civil turbine engines are very reliable, and UERFs are very rare events, the resulting damage from such a failure can be significant and the potential effects catastrophic. This accident represents an opportunity for the regulatory authorities to incorporate any lessons learned into their certification advisory material to enhance the safety of future aircraft designs.

Abstract

At about 1303 on Saturday 22 May 2010, freight train 7MP7 collided with a young male child on the track adjacent to a level crossing near Nantawarra in the mid-north of South Australia. The child was fatally injured as a result of the collision. The investigation found that prior to the collision the child had wandered away from the family home and had unknowingly placed himself in a place of extreme danger on the railway track and there was little the train drivers could do to avoid the collision.

On 31 October 2010, a Cessna Aircraft Company TU206C, registered VH-EAL (EAL), was being operated on a parachute flight overhead the South Grafton aeroplane landing area (ALA), New South Wales.

Just prior to the parachute drop, the pilot heard broadcasts from an aircraft on the ground at South Grafton and an inbound aircraft. The pilot of EAL requested that both aircraft remain clear of the drop zone. After the parachute drop was completed, the pilot descended the aircraft and continued to converse with the pilots of the other aircraft until the parachutists were on the ground.

The aircraft joined the circuit on crosswind for runway 08.  Due to a preceding aircraft, the pilot of slowed the aircraft down and conducted a wider circuit. The aircraft was turned onto final and shortly after, the engine went quiet. The pilot changed the fuel tank selection and applied full throttle, but the engine did not respond. The aircraft landed about 300 m from the runway and sustained serious damage.

The pilot reported that he had been distracted by the other aircraft operating in the area at the time and did not change the fuel tank selection during the descent or on downwind, as per his normal procedure.

Pilot distractions occur frequently; some can be minimised or removed, while others cannot be avoided. This accident is a prime example of how distractions impact aircraft operations and a reminder that distractions are not unique to any one type of operation and that no pilot is immune.

After lift off, the helicopter was climbed vertically to a height of about 80 feet. As the pilot attempted to commence forward flight, a main rotor low speed warning alert was received and confirmed by the main rotor tachometer. The pilot attempted to land on a road adjacent to the helipad. After touchdown, the main rotor collided with the wall of a building.

On 1 November 2010, an Airbus A330-302, registered VH-EBF (EBF), departed Phuket, Thailand on a scheduled passenger flight to Sydney, New South Wales.

When the aircraft was approaching overhead Kuala Lumpur International Airport, Malaysia, in icing conditions, the aircraft systems indicated a loss of total air temperature (TAT) data. This resulted in the loss of autopilot and autothrottle capabilities. The crew attempted to resolve the fault but were unable to restore the auto-flight capabilities.

The crew conferred with company operational and maintenance personnel and elected to divert to Singapore. The aircraft landed in Singapore without further incident.

Analysis of the data from the flight data recorder indicated that both TAT probes failed during the incident flight, triggering the loss of autoflight capabilities. The manufacturer suspected that the TAT probes failed due to icing.

A new TAT probe was certified for the A330 aircraft and issued through an optional Service Bulletin in 2008. As of November 2010, there had been no reported events of multiple failures involving the new TAT probes. At the time of the incident, EBF was not fitted with one of the new TAT probes.

On 23 October 2010, a Partenavia P.68B aircraft, registered VH-IYI (IYI) and an Avions Pierre Robin R-2160 aircraft, registered VH-JXY, were inbound to Jandakot Airport, Western Australia. The pilot of IYI made an inbound call at the visual flight rules (VFR) inbound reporting point of Boatyard prior to the pilot of JXY. However, JXY was in front of IYI. Both aircraft then tracked towards the VFR reporting point Adventure World.

Prior to reaching Adventure World the Jandakot Tower Airport controller instructed the pilot of IYI to track as number one and cleared them for runway 24R at Jandakot. The pilot of IYI did not continue to track to Adventure World but headed directly for the downwind leg of the circuit.

The pilot of JXY continued onto Adventure World and was instructed by the controller to track for downwind. The pilot of JXY informed the controller on a number of occasions that they could not see IYI. When both aircraft were on their downwind legs the controller informed the pilot of JXY that IYI was below them.

When IYI turned onto base the pilot observed JXY fly over the top of their aircraft, with about 100 ft separation. The pilot of JXY did not see IYI.

This incident highlights the importance of air traffic control and pilots maintaining situational awareness and an accurate mental picture of the location of other traffic in the alerted see and avoid environment. To assist pilots in maintaining situational awareness air traffic control need to provide timely traffic information to aircraft to ensure they are aware of the proximity of other aircraft.