Preliminary report released 5 January 2009

At about 1115 Central Daylight-saving Time on 19 November 2008, a pilot and two linesmen were operating a McDonnell Douglas 369D helicopter, registered VH-PLJ, to test a high-voltage powerline between Mannum and Mobilong, SA. While manoeuvring to test a conductor joint, the helicopter's main rotors struck a conductor and impacted the ground. One linesman was fatally injured and the other sustained minor injuries, while the pilot sustained serious injuries.

Preliminary report released 4 December 2009

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 0217 on Thursday 12 November 2009, train ST22, an XPT passenger service, was being pathed into the 'Platform Road' at Cootamundra, NSW. The driver of the XPT received a 'PROCEED' indication on signal CA74, signifying that the line into the Platform Road was clear. Shortly after passing over 136B points set reverse, the driver of the XPT observed the last wagon  of freight train 4MB7 to be obstructing the path of his train. He made an emergency brake application and stopped his train just short of train 4MB7.

The driver of the XPT immediately contacted the ARTC Network Controller and advised of the problem. Shortly thereafter, the freight train was moved forward to clear a path for the XPT into the Platform Road.

Preliminary investigation of the event has determined that a signalling design irregularity affecting the 'Up Main Line' at Cootamundra allowed signal CA74 to be cleared for the passage of the XPT even though the route was obstructed by the last wagon of train 4MB7.

On 10 November 2009 at around 1900 EST, a Boeing Company 737-467 aircraft, registered VH-TJY, departed Brisbane Airport, Queensland for Melbourne, Victoria. As the aircraft was climbing through 24,000 ft, the flight crew observed abnormal indications associated with the right engine. The aircraft was returned to Brisbane where it landed without further incident.

Engine disassembly and inspection revealed significant damage to the stage-1 low-pressure turbine (LPT). Analysis of the stage-1 LPT blades showed that some blades had sustained levels of thermally-induced microstructural degradation, which may have affected the creep resistance of the alloy and resulted in the blades being susceptible to failure by creep rupture.

Creep rupture was identified as the likely failure mechanism in previous stage-1 LPT blade failures in this engine type investigated by the Australian Transport Safety Bureau and the engine manufacturer. As a result of this occurrence and at the time of writing this report, the engine manufacturer is revising service bulletin SB 72-1113 to expand the range of blade manufacturing batch numbers that had previously been identified as being predisposed to creep-related failure. Blades in the identified batches are to be withdrawn from service as soon as they are next removed from the engine.

On 12 October 2009, a 'Boorabee' ultralight aircraft, registered 19-1418, being operated on a private flight from Renmark, Vic. to Casino, NSW, impacted the ground approximately 37 km west-south-west of Hay, NSW. The pilot, who was the sole occupant of the aircraft, was fatally injured. In assisting the NSW Police in their investigation of this accident, Recreational Aviation Australia Inc (RA-Aus) requested assistance from the Australian Transport Safety Bureau (ATSB) in the recovery of information from a portable Global Positioning System (GPS) unit recovered from the accident site.

To protect the information supplied by RA-Aus to the ATSB and investigative work undertaken to assist RA-Aus, the ATSB initiated an investigation under the Transport Safety Investigation Act 2003 (TSI Act). The ATSB completed its recovery of data from the Garmin® GPS72 portable GPS receiver (serial No: 82377157) and provided the data to RA-Aus in the interests of transport safety, under the provisions of section 61 of the TSI Act.

Contact details for RA-Aus are at Website: www.raa.asn.au

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

At about 1500 Eastern Standard Time on 9 November 2009, a Bell Helicopter Company 412 helicopter, registered VH‑EMZ and operating as call sign 'Rescue 700', departed Horn Island Aerodrome, Queensland to rendezvous with a container ship located about 132 km to the west of Horn Island. The purpose of the flight was to evacuate an ill crew member and transfer him to hospital.

Prior to arrival, the flight crew had been advised that the patient would need to be recovered via rescue winch from the ship's forecastle. Approaching overhead the winching area, with the rescue crew officer (RCO) and paramedic being lowered by the winch and about 6m above the deck, the pilot lost sight of the ship. Shortly after, the helicopter began drifting back towards a mast that was located on the forecastle. Despite assistance from the winch operator to re-establish the hover, the pilot was unable to arrest the helicopter's movement and the winch cable became fouled on the foremast while the helicopter continued to drift rearwards. The winch cable separated and the paramedic and RCO fell about 10m to the ship's deck, seriously injuring both personnel.

The investigation identified that the requirement to confirm adequate hover reference existed overhead an intended winch area, before deploying personnel on the winch, was left to the pilot's discretion. In this instance the pilot, despite his extensive experience, did not identify the possibility of losing sight of the ship, and therefore the necessary hover reference.

Following the occurrence, the helicopter operator issued an instruction to aircrew emphasising the importance of ensuring that adequate hover reference exists during winching operations. The helicopter operator also commenced a review of its operations manual to ensure that it provides sufficient procedural guidance for winching operations and commenced the development of company-wide aviation risk management training that will commence in early 2011.

At 0735 Eastern Daylight-saving Time on 26 October 2009, VH-OGP, a Qantas Airways Boeing 767-300, initiated a go-around manoeuvre from an approach into Sydney Airport, New South Wales. The aircraft immediately returned for a normal landing. The go-around was initiated due to the crew becoming aware that the aircraft was not properly configured for landing. Almost simultaneously, the 'Too Low Gear' automated warning activated, which indicated that the aircraft's landing gear was not extended.

The incorrect aircraft configuration was the result of several interruptions and distractions during the approach. These interruptions and distractions resulted in a breakdown in the pilots' situational awareness.

The investigation identified a number of minor safety issues in the operator's procedures and monitoring systems and Qantas Airways has advised of safety action in response.

On 28 October 2009, an Airbus A330-202 (A330) aircraft, registered VH-EBA (EBA), was being operated as Jetstar flight 12 on a scheduled passenger service from Narita, Japan to Coolangatta, Australia. Soon after entering cloud at 39,000 ft, there was a brief period of disagreement between the aircraft's three sources of airspeed information. The autopilot, autothrust and flight directors disconnected, a NAV ADR DISAGREE caution message occurred, and the flight control system reverted to alternate law, which meant that some flight envelope protections were no longer available. There was no effect on the aircraft's flight path, and the flight crew followed the operator's documented procedures. The airspeed disagreement was due to a temporary obstruction of the captain's and standby pitot probes, probably due to ice crystals. A similar event occurred on the same aircraft on 15 March 2009.

The rate of unreliable airspeed events involving the make of pitot probes fitted to EBA (Goodrich 0851HL) was substantially lower than for other probes previously approved for fitment to A330/A340 aircraft. However, both of the events involving EBA occurred in environmental conditions outside those specified in the certification requirements for the pitot probes. The French Bureau d'Enquêtes et d'Analyses pour la sécurité de l'aviation civile (BEA) has recommended the European Aviation Safety Agency (EASA) to review the certification criteria for pitot probes in icing environments.

At the time of the occurrence, most of the operator's A330 pilots had not received unreliable airspeed training. Most of these pilots had transferred from the operator's A320 fleet, and the third-party training provider had not included the topic in its A320 endorsement training program, even though it was included in the aircraft manufacturer's recommended program since 2004.

The operator identified the problem and included unreliable airspeed in its recurrent training program for the A320 from May 2009 and the A330 from October 2009. The training provider included the topic in its endorsement program from July 2010. The operator, training provider and the Civil Aviation Safety Authority all initiated safety action to minimise the likelihood of similar problems in the future.

On 2 April 2008, the UK Air Accidents Investigation Branch (AAIB) advised the Australian Transport Safety Bureau (ATSB) that the AAIB had commenced an investigation in response to a number of minor accidents involving aircraft fitted with Australian-manufactured Jabiru engines. In support of its investigation, the AAIB requested the appointment by the ATSB of an accredited representative in accordance with international protocols.

The ATSB appointed an accredited representative under the provisions of clause 5.18 of Annex 13 to the Convention on International Civil Aviation. To protect any work undertaken to assist the AAIB, and any information supplied to the ATSB by the AAIB, on 7 April 2008 the ATSB initiated an investigation under the Transport Safety Investigation Act 2003.

The UK AAIB is responsible for releasing a final investigation report. Once completed, a copy of the report can be requested from the AAIB at:

• www.aaib.gov.uk, or at
• Air Accidents Investigation Branch
  Berkshire Copse Road
  Aldershot
  Hampshire
  GU11 2HH
  Tel: 01252 510300
  Fax: 01252 376999
  Email: enquiries@aaib.gov.uk

For AAIB press enquiries: 020 7944 3387

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

On 19 October 2009, a British Aerospace Avro-RJ70 aircraft sustained an in-flight engine failure shortly after taking off from Christmas Island.

The investigation found that the number 2 engine failed due to severe overheating damage to the high-pressure turbine section components. The overheating was most likely related to a defective fuel injector nozzle that exposed the turbine nozzle guide vanes and blades to a sustained over-temperature condition and cumulative thermal damage. Although the engine's operating performance and condition was being monitored as part of the operator's Engine Condition and Trend Monitoring (ECTM) program, no significant indications of the impending failure were detected in the lead up to the failure.

The flight crew reported that while responding to the engine failure they were unable to extend the fire lever in order to operate the engine's fire suppression system. The operator subsequently inspected the system, but could not duplicate the problem.
The ATSB did not identify any safety issues as a result of its investigation that required safety action to be taken.

Following landing at Melbourne Aerodrome on 20 October 2009, the crew of a Boeing 737-8FE aircraft, registered VH-VUI, reported that the aircraft was difficult to taxi, requiring more power and steering input than usual. A subsequent visual inspection revealed the number 4 wheel to be oriented at an angle with respect to the axle and, following disassembly, it was discovered that the inner wheel hub and bearing mount had broken away from the wheel assembly.

Examination of the wheel revealed that the inner hub had failed from fatigue cracking that had initiated in the area adjacent to the bearing cup.

Fatigue cracking of the inboard bearing cup bore was an emerging issue for the 737 wheel type at the time of the failure. In May 2009, the wheel manufacturer issued a temporary revision to the Standard Practices Manual, with an updated inspection method for the susceptible area, and the aircraft manufacturer had issued a service letter in August 2009 with a periodic inspection requirement. The operator was in the process of reviewing and incorporating the changes into their own maintenance schedules at the time of the incident.

Immediately following the occurrence, the operator performed a fleet-wide examination, identifying those wheels potentially at risk of a similar failure. Subsequently, ten wheels were removed from service for immediate inspection. The operator also implemented an ultrasonic inspection program for wheels with over 4,000 cycles at every tyre change.

The manufacturers of both the aircraft and the wheel released updated information to operators and maintainers in early 2010, which included a revision to the recommended inspection interval.