On 4 March 2010, a Boeing Company 717-200 (717) departed Perth, Western Australia (WA) on a scheduled passenger service to Port Hedland, WA.
The aircraft was tracking on a GURAK 3 standard instrument departure, which involved transiting through Pearce military controlled airspace. While maintaining flight level (FL) 1201 and turning left onto a heading of 330 degrees under the control of Pearce air traffic control (ATC), the crew
received a traffic advisory (TA) warning from the traffic alert and collision avoidance system (TCAS). The crew advised ATC and were instructed to continue the turn onto a heading of 360 degrees. During the turn, the crew received a resolution advisory (RA). The crew responded and climbed the aircraft to FL125.

The crew were advised by ATC that the conflicting aircraft, a military-operated Raytheon Aircraft Company 350 (King Air) descending through FL120 on a reciprocal track, had the 717 in sight and was maintaining separation. By this time, the radar separation standard had reduced below the required distance of 3 NM (5.6 km).

This occurrence reinforces the importance of effective coordination between ATC positions, and highlights the challenges faced by air traffic controllers when managing aircraft operating within the same airspace, but under the control of different ATC positions.

A McCauley Propeller Systems propeller hub with an area of transverse cracking extending through the hub mounting boss was received by the Australian Transport Safety Bureau (ATSB) from the Civil Aviation Safety Authority (CASA). CASA requested assistance from the ATSB to conduct an engineering examination of the cracked region.

The examination determined that the crack was the product of a high-cycle, low-stress fatigue mechanism, with the crack origin centred on a mounting stud hole. There were no associated defects or other anomalous features that may have assisted in the crack initiation.

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

The aircraft was observed shortly after it had taken off towards the south-east, flying at a very low height along the beach towards the Tangalooma resort. The aircraft flew over the resort area and was seen by witnesses to perform a steep climbing manoeuvre. The aircraft then descended steeply, dived into the water whilst heading in a westerly direction away from the resort, and sank.

The aircraft appeared to be operating normally prior to the accident. There was no physiological or mechanical evidence found which may have contributed to the development of the accident. No defect was found which may have precluded normal engine operation; however, the engine appears to have not been delivering power at the time of impact.

The prevailing wind at the time of the accident was a strong south-easterly which is known to cause mechanical turbulence in the lee of the island. This may have affected the pilot's ability to recover from the manoeuvre under the circumstances.

The investigation did not reveal any reason for the unusually low flight path and manoeuvre immediately prior to the accident. The engine could not be functionally tested because of impact damage.

Significant factor

The following factor was considered relevant to the development of the accident: The pilot attempted a manoeuvre at a height from which safe recovery could not be effected.

On 24 February 2010, a Boeing Company 737-800, registered PK-GMG, was being operated on a scheduled passenger service from Denpasar, Republic of Indonesia to Perth, Western Australia (WA). The aircraft was cleared by air traffic control (ATC) to land on runway 03.

During the landing roll, the crew received instructions from ATC to exit runway 03 by taking taxiway November, the second on their right. In complying, the aircraft was turned onto the cross runway 06, which was active. The crew then received instructions to expedite their exit via taxiway S. The aircraft was exited from the active runway and moved to its parking stand.

This incident is a reminder that all radio communications phraseology should be clear, concise and unambiguous and should reflect international practices and standards where possible, particularly with regard to instructions provided to and received from international aircraft, and in safety critical situations. It is also a reminder to crews to seek clarification of ATC instructions should there be any doubt as to the content or intent of any clearance or instruction.

On 25 February 2010, a Piper Aircraft Corp Chieftain PA-31-350 aircraft, registered VH-BCQ, was being operated on a charter passenger flight from Mackay to Clermont Aerodrome, Queensland. Unable to land at either Clermont or the planned alternate aerodrome of Mackay due to deteriorating weather conditions, the flight diverted to Proserpine/Whitsunday Coast Aerodrome.

The pilot in command requested air traffic services (ATS) to arrange for a person to be on the ground at Proserpine/Whitsunday Aerodrome to ensure that the aerodrome lighting would be on for their arrival. This request was not actioned, but ATS provided the crew with a frequency for the pilot activated lighting system at the aerodrome. However, that frequency was decommissioned 10 days earlier, and a new frequency introduced.

On approach to Proserpine, the flight crew were unable to activate the aerodrome lighting. With critical fuel, and given weather considerations, the flight crew landed the aircraft without runway lighting at around 1957 Eastern Standard Time.

The investigation identified two minor safety issues; one relating to the practices used within the air traffic control group for the effective review and communication of notices to airmen, and the other the risk of out-of-date operational documentation.

The air navigation service provider advised that in response to this occurrence, it will conduct an internal education program to highlight the effect on safety when relevant information is not considered appropriately or reviewed before being provided to pilots.

The incorrect operational documentation has since been updated and the regional council managing Proserpine Aerodrome has instigated safety action relevant to their organisation.

The ATSB has completed its technical analysis report of the flight recorder data from an Avions de Transport Régional ATR-42-300F aircraft, registered PK-YRP, on behalf of the Indonesian National Transportation Safety Committee (NTSC). The aircraft carried out a forced landing in a rice field, approximately 33 km (18 NM) north-east of Balikpapan-Sepinggan Airport, Indonesia, after reportedly losing power from both engines.  The aircraft was operating a scheduled passenger service from Berau-Kalimaru Airport to Temindung Airport, Indonesia. Two of the 51 passengers on-board sustained serious injuries.

The NTSC is responsible for investigating this occurrence. The NTSC requested assistance from the Australian Transport Safety Bureau (ATSB) in the recovery and analysis of information from the aircraft's flight data recorder and cockpit voice recorder.

To protect the information supplied by the NTSC to the ATSB and investigative work undertaken to assist the NTSC, the ATSB initiated an investigation under the Transport Safety Investigation Act 2003.

The ATSB's technical analysis report has now been provided to the NTSC, who is responsible for releasing a final investigation report on this occurrence.

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.

On 16 July 2009 the pilot of a Beechcraft King Air C90 aircraft, registered VH-TAM, departed Perth Airport on a flight to Wiluna, Western Australia with one passenger on board.

Sometime after becoming established at flight level (FL) 210, the pilot became affected by hypoxia, which resulted in him becoming fixated on the 'distance-to-run' figures on the aircraft's Global Positioning System equipment display and incorrectly interpreting those figures as the aircraft's 'groundspeed'. That confusion resulted in the pilot interpreting the lower-than-expected figures as a significant headwind and in him descending the aircraft to escape the winds. Once established at FL150 for a significant period of time, he realised that that he had been affected by hypoxia. The pilot descended further before landing at his destination.

The investigation identified problems with the aircraft's left landing gear squat switch that prevented the aircraft from pressurising in flight. In addition, the cabin altitude warning system was non‑operational due to the incorrect connection of the switch wiring during previous maintenance.

Following this occurrence, the aircraft manufacturer changed the aircraft type's maintenance manuals and documentation and the Civil Aviation Safety Authority (CASA) issued a letter to owners and operators of Australian-registered pressurised aircraft that proposed mandating the fitment of aural cabin pressure warning systems in those aircraft. As a result of that industry consultation, CASA determined that a uniquely Australian installation requirement could not be justified.

Notwithstanding, as a result of the ongoing risk of serious incidents and fatal accidents in which the occupants of single-pilot, turbine‑powered, pressurised aircraft have been affected by, or have succumbed to unrecognised hypoxia in an unpressurised cabin, the Australian Transport Safety Bureau has issued a safety advisory notice. That notice encourages all operators of such aircraft to consider the installation of an aural cabin altitude pressure warning system that operates separately to their aircraft's visual warning system.

Executive summary

At 0435 on 16 February 2010, the bulk carrier River Embley was at anchor off Gladstone, Queensland, when the ship's fire alarms sounded, alerting the crew to an engine room fire. A few minutes later, while the engineers were investigating the fire, there was an explosion in the engine room.

The crew shut down the running machinery, the engine room vents were closed and the ship's electrical load was transferred to the emergency generator. They monitored the situation and at 0823 confirmed that the fire had been extinguished. By 1105, they had determined that the engine room was safe to enter without the use of breathing apparatus.

The ATSB investigation determined that the fire started inside a screw type air compressor and that the explosion that followed occurred when a cloud of hot oil vapour, which had been expelled from the compressor, ignited.

The investigation found that the compressor did not shut down before the fire occurred because its high temperature alarm/shutdown did not operate. The investigation also found that, during the emergency response, the crew worked as a team and demonstrated how effective a trained response to an unexpected emergency can be.

The investigation identified two safety issues: routine testing of the compressor high temperature alarm/shutdown was not included in the ship's planned maintenance system; and routine testing of the alarm/shutdown was not included in the manufacturer's maintenance manual.

These safety issues have been addressed by the ship's managers and the compressor manufacturer.

On 14 February 2010, the pilot of a Cessna Aircraft Company TU206C (C206), registered ZK-JAO, was being operated on a private ferry flight under the
visual flight rules (VFR) from Lord Howe Island, New South Wales (NSW) to Coolangatta, Queensland (Qld) via Port Macquarie, NSW. Those sectors comprised the final stage of the ferry flight, which had originated from New Zealand. The pilot was the only person on board the aircraft.

The pilot reported that he had experienced intermittent ferry tank fuel flow problems during the flight from Lord Howe Island, NSW to mainland Australia. The pilot consequently selected the aircraft's main fuel tanks to ensure a reliable supply of fuel to the engine. At approximately 19 km east of South West Rocks, NSW, when the fuel was exhausted from the aircraft's main fuel tanks, the pilot selected fuel from the ferry tank, but was unable to restart the engine. The fuel flow from the ferry tank had been disrupted and the remaining 300 L in that tank was unable to be accessed. The pilot conducted a successful forced landing at an airstrip in the vicinity of South West Rocks, NSW. There was no reported damage to the aircraft or injuries to the occupant.

The reason why the ferry tank's fuel flow was disrupted could not be established; however, the pilot stated it was likely that an air pocket somewhere in the fuel system between the ferry tank and the aircraft's main fuel lines starved the engine of fuel.

The pilot had installed the ferry tank in New Zealand without the appropriate regulatory authorisations and qualifications to do so.

Although there was no evidence as to whether the installation of the ferry tank played a role in the incident; it is a reminder that approved modifications, carried out by appropriately qualified and licensed people are likely to reduce risk.