On 15 December 2009, a De Havilland Canada DHC-8-102 aircraft, registered VH-XFU, departed Perth, Western Australia (WA) on a charter passenger service to Darlot, WA. While cruising at flight level (FL) 230, the aircraft sustained multiple system failures, followed by a depressurisation. The crew actioned the aircraft depressurisation checklist and commenced an emergency descent. During the descent, a number of system cautions and warnings illuminated. The crew elected to return to Perth and a descent to 8,000 ft was made. Shortly after, the majority of the aircraft's systems returned to normal.

A subsequent engineering investigation was unable to replicate the system faults. However, it appeared that the number 1 direct current (DC) generator output was spiking, causing power to the left DC buses to be repeatedly switched between the number 1 transformer rectifier unit and the left DC generator. This repeated power switching resulted in some of the aircraft's systems behaving erratically.

As a precaution, the number 1 generator control unit, number 1 DC generator and left bus tie relay were replaced.

Preliminary report released 11 March 2010

On 8 December 2009 at about 1840 Eastern Daylight-saving Time, an Aerospatiale AS350-B2 helicopter, registered VH-NFO (NFO), and a Kawasaki BK117 helicopter, registered VH-LXC (LXC), were engaged in aerial firebombing operations about 20 km south-east of Orange Airport, New South Wales. The pilots were the only occupants of their respective helicopters. After the pilot of NFO had landed to refuel, he noticed damage to the trailing edge of the helicopter's vertical fin. In addition, the plastic navigation light cover on top of the vertical fin was broken. The pilot reported the damage to the pilot of LXC. Examination of LXC did not reveal any apparent damage. There were no injuries.

On 8 December 2009, at about 1645 Eastern Daylight-saving Time, a Bell Helicopter Company TH-1F, registered VH-LIQ, was conducting aerial fire-fighting operations south-east of Tamworth, New South Wales (NSW). On approach to a water source, the pilot in command (PIC) noted a loss of engine power. The PIC reported that he lowered the collective2 and rolled the throttle on; however, the engine continued to spool down. The PIC manoeuvred the helicopter to a cleared area and carried out an emergency landing. The helicopter landed heavily and sustained serious damage. The PIC sustained a fractured nose, while the other occupant (second pilot) was uninjured.

At the time of writing this report, the reason for the total power loss was unknown.

Abstract

On 10 December 2009, during Maersk Duffield's transit into Brisbane, Queensland, the ship's number four diesel generator (4DG) suffered a catastrophic failure, disabling the generator and starting a fire. The engine room was evacuated, and the ship's fixed carbon dioxide (CO₂) fire extinguishing system was operated. After the fire was extinguished, the crew were able to restart most of the ship's equipment and it berthed the following morning.

The ATSB investigation found that it is possible that one or more of the connecting rod palm nuts or counterweight nuts had not been sufficiently tightened during recent overhauls and that the resultant failure of one of the retaining studs was the initiator of the catastrophic engine failure.

Preliminary report released 8 February 2010

On 9 December 2009, the pilot of a Bell Helicopter Co. 206L-1 LongRanger, registered VH-MJO, was conducting a visual flight rules (VFR) flight at Dorrigo NSW, with one passenger on board. Shortly after takeoff, he encountered reduced visibility conditions due to low cloud. Subsequently, all visual reference with the horizon and the ground was lost. The pilot attempted to conduct a landing but the helicopter impacted the ground with a significant vertical force. As a result, the pilot was seriously injured and the passenger was fatally injured. The helicopter was seriously damaged.

On 1 December 2009 at approximately 0730 EST, the forward, left-side cargo door of a Eurocopter AS350D helicopter (registered VH-PIH) separated from the helicopter fuselage during fire-fighting operations near Maryborough, Queensland. The helicopter subsequently landed safely and there were no injuries.

It was probable that separation of the cargo door occurred as a consequence of replacement of the door seal during a recent overhaul. That replacement resulted in the door sitting proud of the mating surfaces when closed and latched. Elevated air loads acting on the door as a product of its overly proud position would subsequently have led to its fracture.

It was considered that the installation of improved door locks per Service Bulletin SB 52.00.25 and SB 52.00.26 would likely address this safety issue and significantly reduce the likelihood of a future AS350 cargo door separation event.

As a result of this occurrence the operator applied the cargo door lock modifications detailed in SB 52.00.25 and SB 52.00.26 to the new door installed on VH-PIH. In addition, the Australian Transport Safety Bureau has issued a Safety Advisory Notice to all operators of Eurocopter AS350 aircraft to consider the implications of the safety issue and take action where considered appropriate.

What happened

On 18 November 2009, an Israel Aircraft Industries Westwind 1124A aircraft, registered VH-NGA, was operated on an air ambulance flight from Apia, Samoa to Norfolk Island, Australia. Two flight crew, a doctor, a flight nurse, a patient and a passenger (the patient’s husband) were on board.

On arrival at Norfolk Island at night, there was low cloud and the aircraft had insufficient fuel to divert to another airport. After four unsuccessful approaches, the flight crew ditched the aircraft 6.4 km west-south-west of the airport.

During the ditching, the aircraft encountered significant impact forces, and the flight nurse and first officer were seriously injured. The aircraft cabin rapidly flooded, and all six occupants evacuated from the aircraft, but with only three of the six life jackets on board and neither of the aircraft’s life rafts. The evacuees were rescued 85 minutes later by personnel on a search vessel launched from Norfolk Island.

What the ATSB found

The flight crew were conducting a long-distance flight to a remote island at night. At the time the flight was planned, the aerodrome forecast for Norfolk Island indicated the weather conditions at the time of arrival would be above the alternate minima.

Contrary to the consistent practice of the operator’s Westwind fleet for such flights, the flight departed with full main tanks (or about 7,200 lb of fuel) rather than full main tanks and tip tanks (about 8,700 lb). The reasons why the captain elected to depart without the maximum fuel load on this occasion were not fully determined. However, the ATSB found the captain’s pre-flight planning did not include many of the elements needed to reduce the risk of a long-distance flight to a remote island. These included miscalculating the total fuel required for normal operations, not calculating the additional fuel required for aircraft system failures, not obtaining relevant forecasts for upper-level winds, and not obtaining current information about potential alternate aerodromes. Although there was no requirement for the flight to depart with alternate or holding fuel, the fuel on board was insufficient to meet operator and regulatory requirements for the flight to allow for aircraft system failures.

Although the operator’s Westwind pilots generally used a conservative approach to fuel planning, the operator’s risk controls did not provide assurance there would be sufficient fuel on board flights to remote islands or isolated aerodromes. Limitations included no explicit fuel planning requirements for such flights, no formal training for planning such flights, no formal guidance information about hazards at commonly-used aerodromes, no procedure for a captain’s calculation of the total fuel required to be checked by another pilot, and little if any assessment during proficiency checks of a pilot’s ability to conduct fuel planning.

There were also limitations with Australian regulatory requirements. Other than requirements for fuel planning of passenger-carrying charter flights to remote islands, there were no explicit fuel planning requirements for other passenger-carrying flights to remote islands, and no explicit requirements for planning flights to isolated aerodromes. In addition, air ambulance flights were classified as ‘aerial work’ rather than ‘charter’. Consequently, they were subject to a lower level of requirements than other passenger-transport operations (including requirements for fuel planning).

During the flight, the weather conditions at Norfolk Island deteriorated below the landing minima. Air traffic services in Nadi and Auckland did not provide the flight crew with all the information that should have been provided. In addition, the flight crew did not request sufficient information prior to passing the point of no return (PNR), and the captain did not use an appropriate method for calculating the PNR. Related to these actions, the operator’s risk controls did not provide assurance that its pilots would conduct adequate in-flight fuel management activities during flights to remote islands or isolated aerodromes. The Civil Aviation Safety Authority (CASA) had also published limited guidance material regarding in-flight fuel management.

After the aircraft passed the PNR, there were opportunities to minimise the risk associated with the developing situation. However, the flight crew did not effectively discuss approach options, and they did not effectively review their fuel situation and consider alternate emergency options prior to ditching the aircraft. The flight crew did not refer to the ditching checklist and the final approach was conducted at an airspeed significantly below the reference landing speed (V_REF), which increased the descent rate just prior to impact. A range of local conditions influenced the performance of the crew during the latter stages of the flight, including workload, stress, time pressure and dark night conditions.

In addition to the rapid flooding of the aircraft cabin, the occupants’ evacuation was hampered by there being no formal, specific procedures and limited training regarding on how to secure life rafts in an appropriate, readily accessible location prior to a ditching, and a designated storage location for the stretchered patient’s life jacket. In very difficult circumstances, the nurse and doctor did an excellent job evacuating the patient, and then assisting the injured first officer and the patient in the water, both of whom did not have life jackets.

Due to the inherent limitations of most emergency locator transmitters (ELTs) for a submerged aircraft, and the limited information provided by the flight crew regarding the location of the ditching, search and rescue personnel initially had no reliable information about where to search for the aircraft. It was fortunate that a firefighter made a chance sighting of the captain’s torch, resulting in the search effort being redirected to the appropriate area and the successful rescue of the evacuees.

In addition to issues associated with fuel planning and in-flight fuel management, the ATSB identified safety issues with the operator’s risk controls for emergency procedures and training, fatigue management, crew resource management training and flight crew training for newly-installed systems on the accident aircraft. The ATSB also identified limitations with the operator’s hazard identification processes and the definition of roles and responsibilities of key management personnel, and the processes used for the operator and air ambulance provider for conducting pre-flight risk assessments. Limitations were also identified with the processes used by CASA for planning surveillance, scoping audits and conducting audits.

What's been done as a result

Following the accident, CASA conducted a special audit of the operator, and this audit involved an extensive assessment of the operator’s air ambulance operations. The operator voluntarily ceased its Westwind operations and collaborated with CASA during the audit. During this process, the operator reviewed and substantially enhanced its risk controls and management oversight of flight/fuel planning and in-flight fuel management. It also enhanced its risk controls and management oversight of many other areas of its air ambulance operations.

In 2014, CASA modified the requirements for operations to Australian remote islands, so that all passenger-carrying transport flights, including air ambulance flights, were required to depart with alternate fuel. In addition, in 2012 CASA initiated action to change the regulatory classification of air ambulance (or medical transport) flights from aerial work to air transport. However, although CASA released a Notice of Proposed Rule Making about this issue in 2013, no changes have yet occurred. Accordingly, the ATSB issued a safety recommendation to CASA to continue reviewing the requirements for air ambulance operations and address the limitations associated with the current classification of these flights. The ATSB also issued two other recommendations to CASA for it to continue its activities to address the limitations with the requirements and guidance for fuel planning of flights to isolated aerodromes and the requirements and guidance of in-flight fuel planning.

In addition to these actions, since 2009 there have been improvements in a range of other areas. These include improvements to CASA’s surveillance processes, weather forecasting processes at Norfolk Island, and the publishing of advisory information about the hazards at remote island aerodromes. In addition, there now exists an enhanced capability for satellites to detect the location of ELT signals from aircraft involved in ditchings and similar impacts where the ELTs are unable to emit signals for extended periods.

Safety message

The investigation report contains 36 safety factors that provide lessons to flight crews, operators, regulators and/or other organisations. Overall, the most fundamental lesson for all flight crew, operators and regulators is to recognise that unforecast weather can occur at any aerodrome. Consequently, there is a need for robust and conservative fuel planning and in-flight fuel management procedures for passenger-transport flights to remote islands and isolated aerodromes.

Additional safety messages include:

• Flight crew should discuss and consider options to manage threats when there is time available to do so.
• Operators should ensure their flight crew proficiency checks assess the performance of all key tasks required of their flight crew.
• Operators should not rely on informal risk controls for managing the performance of safety-critical tasks, particularly when there is significant turnover of pilots in a fleet.
• Operators of air ambulance flights should ensure medical personnel have clearly defined procedures and appropriate practical training for using the emergency equipment on board to ensure they can effectively assist a patient in the event of an emergency.
• All organisations in safety-critical industries should use proactive and predictive processes to identify hazards in their operations.
• Organisations that use a bio-mathematical model of fatigue as part of their fatigue risk management system should ensure they have a detailed understanding of the assumptions and limitations associated with such models.
• Regulators should develop effective methods for obtaining, storing and integrating information about operators and the nature of their operations so that they can develop effective surveillance plans.

The pilot was conducting a night freight operation, carrying newspapers from Darwin to Alice Springs via Tindal and Tennant Creek. The flight from Darwin to Tindal was uneventful and the aircraft subsequently departed Tindal at 0219 am local time.

On departure, the pilot reported that he mistakenly established the aircraft on a track 30 degrees right of the correct track. After the pilot had levelled the aircraft at the intended cruising altitude, he fell asleep. As the flight progressed, the pilot occasionally woke up and made slight corrections to the heading, but he did not identify the 30 degree error. When the pilot realised that he should be on descent to Tennant Creek, he selected the appropriate frequencies, however the aircraft's navigation instruments did not provide any directional information. Believing that the aircraft was west of Tennant Creek, the pilot turned the aircraft and flew east, climbing to 14000 ft in an attempt to improve the range of the aircraft's navigation instruments. The instruments still did not show where Tennant Creek was, so the pilot decided to continue to Alice Springs at his flight planned altitude. At the time that the aircraft should have been approaching Alice Springs, the pilot selected the appropriate frequencies for the Alice Springs navigation aids. The aircraft's navigation instruments did not indicate the direction of Alice Springs, even though the pilot again climbed the aircraft to 14000 ft. The pilot reported that as the aircraft was now running low on fuel, the pilot decided to conduct a precautionary search and landing. The pilot advised Adelaide Flight Service on high frequency radio that he intended to land the aircraft on a dry salt lake.

The aircraft sustained minor damage during the landing however the pilot was not injured. He then activated the Emergency Locater Transmitter, and the aircraft was subsequently located 370 km WSW of Alice Springs. The company reported that its roster for night freight pilots has operated satisfactorily for around four years, with no reported serious fatigue problems. The pilots usually operate a one night shift every eight days, and the three days before the night shift are either days off or standby days. The pilot involved in this incident had done no flying on his rostered standby day, and therefore had had three full days off prior to signing on late in the evening of the day before the accident. He stated that he normally tried to sleep in on the morning before the night shift, and then get a couple of hours sleep in the afternoon. However, on the morning before he signed on for the night flight he was unable to sleep in and was then also unable to sleep in the afternoon. Consequently, by the time he signed on for the flight, the pilot had been awake for approximately 13.5 hours. The aircraft was not equipped with GPS. It is probable that the pilot's lack of sleep prior to signing on for the flight resulted in an increased level of fatigue. The increased fatigue may have contributed to the pilot selecting the incorrect heading on departure from Tindal and his subsequent lapses into sleep. Once the aircraft was out of range of the Tennant Creek and Alice Springs navigation aids and because of the lack of terrain features visible at night, there was no information available to the pilot to help him identify his position. The company is currently ensuring that flight crews have access to GPS equipment. The company is also drafting detailed standard operating procedures regarding sleep management, and these procedures will be included in the operations manual.

Preliminary report released 25 January 2010

At about 0800 Western Standard Time on 17 November 2009, the pilot of a Cessna Aircraft Company A188B Agwagon was fatally injured when his aircraft impacted terrain while conducting spraying operations near Kojonup, WA. The aircraft was destroyed.

Section 21 (2) of the Transport Safety Investigation Act 2003 (TSI Act) empowers the ATSB to discontinue an investigation at any time. Section 21 (3) of the TSI Act requires the ATSB to publish a statement setting out the reasons for discontinuing an investigation.

The ATSB had commenced an investigation into the triggering of GPWS alerts in a Boeing Company 737 during its approach to land at Darwin Airport, NT on 9 November 2009. Information obtained from the aircraft operator and the aircraft manufacturer indicated that the alerts signalled a minor problem with flap settings that the crew rectified without difficulty. The ATSB has assessed that the occurrence was unlikely to have any significant implications for transport safety and has elected to discontinue the investigation.

The data collected in the course of the investigation may be used by the ATSB for future statistical analysis and safety research purposes.