Abstract

At about 0937 on 1 November 2010, the Liberian registered container ship MSC Basel grounded in Moreton Bay, Queensland, while departing the port of Brisbane.

MSC Basel was in the main shipping channel when its rudder unexpectedly moved to starboard without the application of any helm. The ship immediately began turning to starboard.

The main engine was run astern and the port anchor was let go. However, these actions could not prevent the ship from grounding on Yule Banks, just to the north of the channel.

The ATSB investigation found that the ship's rudder probably moved to starboard because of a malfunction of the steering control system.

However, inspections and tests carried out following the grounding did not identify any steering control system faults.

The investigation also found that MSC Basel's steering system had not been tested in accordance with SOLAS2 requirements before the ship departed Brisbane.

The investigation report identifies one safety issue and outlines the safety actions taken by MSC Basel's managers to address it. The report also issues one safety advisory notice.

On 1 December 2010, at 1412 Eastern Daylight-saving Time, a breakdown of separation occurred between a Beech Aircraft Corporation Barron BE58 (BE58), registered VH-VFG, and a SAAB Aircraft Company S340B (S340), registered VH-SBA, near Taree Airport, New South Wales (NSW).

The BE58 was a private flight from Bankstown to Port Macquarie, NSW and the S340 was a scheduled passenger service from Taree to Sydney, NSW. On departure, the S340 was issued a clearance by air traffic control (ATC), with an altitude requirement intended to establish the S340 above the BE58 on a crossing track. When ATC reassessed the proximity of the aircraft and determined that the altitude requirement would not ensure separation, they issued the BE58 with a vectoring instruction.

The separation between the two aircraft reduced to below the required standards. Separation was re-established when the S340 reached 10,000 ft on climb.

This incident highlights the importance for air traffic controllers to continually monitor and reassess their separation plans and implement changes to assure that the required separation standards will be established and maintained. Furthermore, the provision of timely and appropriate traffic information to flight crew, by air traffic control, can significantly enhance pilots' situational awareness.

Airservices Australia (Airservices) has advised that they are conducting a systemic review of a number of Breakdown of Separation occurrences, with outcomes from that review to be considered in terms of further safety improvement. As a short-term safety intervention, Airservices will be conducting an awareness program for Air Traffic Controllers following the publication of this report.

On 22 October 2010, a replica Supermarine Spitfire MK26 recreational/light sport aircraft (registered 19-4024) collided with terrain near Gympie authorised landing area (ALA), fatally injuring the pilot. Recreational Aviation Australia Inc (RA-Aus) is assisting the Queensland Police in their investigation of the occurrence.

On 17 November 2010, RA-Aus requested technical assistance from the Australian Transport Safety Bureau (ATSB) for the recovery of data from an engine management system (EMS) module recovered from the accident site. To protect the information supplied by RA-Aus and the investigative work undertaken, the ATSB initiated an investigation under the Transport Safety Investigation Act 2003.

Due to the damage to the EMS and the lack of configuration information, the recovery involved extracting the data from the electronic memory components and, using example data provided by the EMS manufacturer, converting the binary extracted data into engineering units.

The full converted data set was provided directly to RA-Aus investigators. This report represents an outline of the process undertaken and a summary of the data obtained.

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

On 14 November 2010, a Piper PA-31-350 aircraft registered VH-MKK was being operated on a passenger charter flight from Marree, South Australia to Broken Hill, New South Wales. During the climb the pilot detected an unusual noise in the right engine followed by a gradual decrease in engine performance. The pilot elected to return to Marree Airport, however during the turn back the aircraft was unable to maintain altitude and the pilot elected to conduct a forced landing about 22 km south-east of the Airport.

The pilot did not feather the right engine as he assessed that the right engine was still producing some power.

The aircraft was substantially damaged during the landing, however all passengers and crew were able to exit the aircraft safely.

A post-flight engine inspection found four bearing retainer plate screws missing from the magneto which allowed oil to enter the magneto. It is probable that this led to a magneto failure and subsequent engine failure.

As a result of the accident, the aircraft operator conducted a brief with all company pilots revising engine failure procedures. They also discussed the symptoms of a windmilling propeller and partial engine failure indications and procedures.

The operator has also amended their procedures to mandate that all IFR renewal flights are to be conducted in the Piper PA-31 Chieftain aircraft type.

Abstract

On 15 November 2010, the engine room fitter/storekeeper (storekeeper) on board the Vanuatu registered bulk carrier Polska Walczaca died as a result of injuries he received when he fell from the ship's number five cargo hold ladder while repairing a section of its hand railing.

The ATSB investigation could not determine why the storekeeper fell from the cargo hold ladder. However, it was found that, at the time, he was not wearing a safety harness, and his hardhat was probably not fastened correctly.

The investigation did not identify any organisational or systemic issues that might adversely affect the future safety of marine operations.

On 12 November 2010, a Qantas Airways operated, Boeing Company 767-338 aircraft, registered VH-OGO, departed Perth Airport, Western Australia, on a scheduled passenger flight to Melbourne, Victoria. During climb the flight crew heard a popping sound followed by vibration from the left engine. The vibration decreased when the engine power lever was retarded to the flight idle position. The crew declared a PAN and requested a return to Perth. Air traffic control alerted emergency services who were in attendance when the aircraft landed.

An initial examination of the aircraft revealed pieces of metal in the engine tail pipe and damage to the low-pressure turbine (LPT) module. The engine was replaced, and the aircraft returned to service.

The engine manufacturer attributed the failure to the LPT stage 3 nozzle. A new nozzle design was released 19 January 2011. The current repair limits and repair procedures are also being re-evaluated by the manufacturer.

The aircraft operator advises that; as many engines have undergone their last full refurbishment before fleet retirement, the operator will replace the nozzles on an attrition basis. In the interim, the operator has introduced additional inspections for preservice bulleting 72-1354 LPT stage 3 nozzles that should detect any signs of air foil cracking well in advance of a potential operational event.

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.