On 31 January 2010, an American Aircraft Corporation Grumman Traveller AA-5 aircraft, registered VH-ERP, was being operated on a visual flight rules private flight from Temora, New South Wales to Canberra, Australian Capital Territory. At about 1630 Eastern Daylight-saving Time, on late final approach to runway 12 at Canberra Aerodrome, and at an altitude of about 150 ft above ground level, the aircraft experienced severe turbulence that resulted in a brief loss of control. The pilot recovered control and landed on runway 12.

The investigation determined that it was probable that the severe turbulence was generated by a combination of the wind conditions on the day and the position of the two buildings located about 220 m and 290 m upwind from runway 12. In addition, there were no standard criteria for assessing the potential local wind effect of aerodrome building developments on aviation operations, and no national building codes for aerodrome developments that address the phenomena of building-induced turbulence.

The aerodrome operator had commissioned pre-construction wind impact assessments of the two buildings to the north of runway 12. These reports concluded that the buildings would not result in adverse wind effects on aircraft operations. This conclusion was based in part on the assessment that use of runway 12 was unlikely in northerly wind conditions. However, operations to that runway remained possible in those conditions without any alert to affected pilots about possible risk. By contrast the Canberra Aerodrome information in the En Route Supplement Australia alerted pilots of the possibility of severe turbulence during touchdown on runway 35 in strong westerly winds.

Subsequent to this occurrence, the Department of Infrastructure, Transport, Regional Development and Local Government established the National Airports Safety Advisory Group (NASAG). NASAG's role is to examine airport planning issues, including the potential local wind effects of buildings on aircraft operations, and to develop a set of universal guidelines and policy material for application at state and local levels. In addition, Airservices Australia is progressing the installation of wind shear detection technologies at several aerodromes. There is the potential that one of those installations could be at Canberra Aerodrome.

Overview

At approximately 1650 on 10 February 2010, empty passenger train WP46 was authorised to travel through Manildra Yard on the main line. However, at the same time a freight train was already standing on the main line, having recently completed shunting within the yard limits relating to preparation of train 8938.

The driver of WP46 heard radio chatter relating to the freight train, so he broadcast that train WP46 was approaching and was authorised to travel through Manildra on the main line. The crew of the freight train immediately replied that they were standing on the main line and advised train WP46 to stop. Train WP46 had already passed the yard limit board but the driver had sighted and reacted to a main line indicator (MLI) showing a red (stop) indication. Train WP46 stopped before passing the MLI, which was located more than 530 m before the track occupied by the freight train.

While a number of defences served to avoid a collision in this case, the event posed a serious safeworking irregularity where one train had been authorised to proceed over track occupied by a second train.

The investigation concluded that the ARTC network controller fulfilled a shunt order without entering information into the computer system identifying that both the main line and loop were occupied. The controller had later forgotten about the track occupancies when authorising train WP46 to travel through the Manildra Yard.

The ARTC, Pacific National and the Manildra Group have put processes in place to ensure shunt orders are not fulfilled unless all shunt operations have ceased and either the main line is clear or a form of train protection has been implemented in accordance with the network rules.

On 31 March 2009, the pilot of a Fairchild Metro SA227-AC aircraft, registered ZK-NSS, experienced control difficulties during landing at New Plymouth Aerodrome, New Zealand, with the aircraft subsequently departing the runway. The New Zealand Transport Accident Investigation Commission (TAIC) commenced an investigation into the occurrence on 1 April 2009 (investigation number 09-003).

On 1 February 2010, the TAIC requested assistance from the Australian Transport Safety Bureau (ATSB) in the review and analysis of data recovered from the aircraft's flight data recorder (FDR). To protect the information supplied to the ATSB and the investigative analysis carried out to assist the TAIC, the ATSB initiated an investigation under the Transport Safety Investigation Act 2003 (TSI Act), and appointed an accredited representative to the TAIC investigation, in accordance with clause 5.23 of Annex 13 to the Convention on Civil Aviation (Chicago Convention).

The ATSB has completed its review and analysis of the FDR information from ZK-NSS and has provided feedback to the TAIC.

The TAIC is responsible for releasing a final investigation report regarding this occurrence.

Contact details for the TAIC are at Website: www.taic.org.nz

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

Preliminary report released 17 May 2010

On 29 January 2010, at about 2010 Western Standard Time a single-engine Pilatus PC-12 aircraft, registered VH-NWO, was being operated on a medical evacuation flight from Derby to Kununurra, Western Australia with four persons on board. The flight was being conducted under the Instrument Flight Rules.

At a position about 30 NM (56 km) after take-off, the pilot reported engine problems and turned the aircraft back to the departure aerodrome. The engine subsequently failed, and the pilot glided the aircraft to the aerodrome and landed safely with no reported injuries. A subsequent inspection confirmed that the engine propeller reduction gearbox had seized.

The investigation found that a number of first - stage reduction gearbox carrier bolts had failed. As a result, the engine manufacturer has reviewed a number of issues relating to engine overhaul practices and has recommended withdrawal from service of an engine from one aircraft in the Australian fleet for examination.

On 31 December 2009, a Cessna Aircraft Company model 208, registered VH-UMV, was engaged in parachuting operations from Cairns Airport, Queensland. While climbing through 12,500 ft in preparation for a parachute drop, the engine failed. The parachutists exited the aircraft and the pilot completed a glide approach and uneventful landing at Cairns Airport.

The failure of the Pratt and Whitney PT6A-114 engine was probably precipitated by fracture of the compressor turbine blades. Federal Aviation Administration (FAA) parts manufacturing approval information indicated that part number T-102401-01 compressor turbine blades that had been installed in the engine during the most recent overhaul were not approved for the PT6A-114 model.

As a result of this occurrence, the Civil Aviation Safety Authority (CASA) released Airworthiness Bulletin AWB 72-005, alerting all operators and maintainers of PT6A engines, of the potential for installation of these compressor turbine blades in unapproved PT6A engine variants, and to raise awareness of the restrictions placed on the use of approved after-market blades.

On 22 January 2010, a Victa Airtourer 115/A1, registered VH-MTC, was landed safely on Miles Beach, Bruny Island, Tasmania. The pilot, being the sole occupant, shut down, exited and secured the aircraft before leaving it on the beach and walking away. The pilot was found deceased approximately 300 m from the aircraft. A post-mortem revealed the pilot had died as the result of a heart attack.

On 14 January 2010, a Cessna Aircraft Co. 208B Caravan, registered VH-NTQ, was en-route from Broome to Koolan Island, Western Australia (WA) at an altitude of about 9,500 ft, when the pilot noticed a drop in the engine torque indication, with a corresponding drop in the engine oil pressure indication. The pilot diverted to the nearest airstrip, which was Beagle Bay, WA. The pilot shut the engine down when the low oil pressure warning light illuminated and conducted a landing at Beagle Bay airstrip. The aircraft overran the airstrip, coming to rest upside down after impacting a mound of dirt. The aircraft was seriously damaged. The pilot, who was the only occupant, sustained minor injuries.

Following the accident, the Civil Aviation Safety Authority (CASA) issued an airworthiness bulletin, AWB 72-004 Issue 1, on 8 February 2010 to all Cessna 208 aircraft operators in Australia. The bulletin highlighted previous service difficulty reports on similar failures and the possibility of the accident aircraft having experienced the same problem. The bulletin recommended the inspection of the engine oil transfer tube attachment lugs for cracks and the inspection of the engine vibration isolator mounts for correct installation. Any defects in the area of the vibration mounts and oil tubes were to be reported to CASA post inspection. At the time of writing this report, one case of an oil tube with a loose fit and wear had been reported.

Overview

At about 1856 on 24 January 2010 a loaded freight train designated 2224, travelling from Medway Junction to Berrima Junction, derailed one bogie on the second-last wagon at Exeter, NSW.

It was determined that wagon NPZH 35700U derailed due to a 'screwed journal' as a result of a wheel bearing failure. As the bearing failed, it generated and transmitted sufficient heat to the axle journal, to make it 'plastic' and allow the end carrying the failed roller bearing assembly to 'screw off'.

There was insufficient evidence to determine the cause of the bearing failure.

The investigation identified two safety issues in relation to:

• the in-service condition monitoring of the wheel bearing which was ineffective in detecting the failing bearing before it led to the derailment, and,
• bulk hopper wagons loaded with limestone which have been regularly operated at speeds up to 15 km/h higher than the mandated limit for some classes of track.

In both cases the train operator has taken safety action to address the issue.

On 7 January 2010, the crew of a Convair 580 aircraft, registered VH-PDW, were conducting a training flight from Bankstown to Tamworth, New South Wales (NSW). While on descent to Tamworth, the crew noticed smoke emanating from below the instrument panel. Shortly after, the smoke intensified, and flames appeared. The flight crew declared an emergency and suppressed the flames using a portable fire extinguisher. The crew continued the descent, and the aircraft landed without further incident.

A subsequent engineering inspection revealed that a small amount of insulation material had become detached and fallen onto the right red instrument panel light rheostat and surrounding wires. The rheostat had developed a 'hot spot' and consequently, the insulation absorbed the heat and transferred it to the wires, which produced smoke and flames.

The operator has advised the ATSB that, as a result of this occurrence, it has implemented a number of safety actions, including:

• all of the organisation's aircraft have been examined to ensure that there is sufficient clearance between the rheostats, insulation material and wires
• any insulation material located in close proximity to a rheostat has been removed
• a notice to crew was issued to emphasise the importance of recording defects in the maintenance log.

On 9 January 2010, the pilot of a Cessna Aircraft Company A185E floatplane, registered VH-ELQ, commenced the take-off run in Tippler's Passage on a charter flight around South Stradbroke Island, Queensland (Qld), with four passengers onboard. Immediately after the aircraft's floats came out of the water, the pilot reported 'feeling something hitting and vibrating on the right float'. The pilot rejected the takeoff and landed the aircraft straight ahead. The aircraft struck a sandbank and came to rest inverted. The five occupants exited the aircraft; one passenger received minor injuries.

Shortly after, a crab pot was observed within the immediate vicinity of the aircraft. The pilot reported that it was likely that the crab pot became entangled around the aircraft's right water rudder during taxiing.

An investigation conducted by the Queensland Police Service determined that there was evidence to suggest that the crab pot had come into contact with the aircraft's float. However, where the contact was made, and for how long, was not determined. A number of differences were also identified throughout the course of the investigation relating to the wind conditions at the time of the accident, the position of the aircraft at the time of the takeoff, whether or not the takeoff was commenced into wind, and the location of the crab pots. These differences could not be reconciled.

While the aircraft occupants in this accident were able to don life jackets and exit the aircraft without difficulty, previous ATSB investigations have highlighted the challenges faced when exiting from an inverted, submerged aircraft cabin. In 2009, the Civil Aviation Safety Authority issued a Notice of Proposed Rule Making, proposing that each occupant of a seaplane taking off or landing on water must wear a life jacket. This will ensure that the availability of life jackets after the occupants have exited the aircraft into the water is assured.