On 9 July 2009, a Cessna 208B Grand Caravan aircraft registered VH-TFS, was being operated on a charter passenger flight from Lizard Island, Queensland (Qld) to Cairns, Qld. The flight was being conducted under instrument flight rules. At about 1250 Eastern Standard Time, the aircraft encountered severe turbulence. The pilot and two of the three passengers sustained minor injuries. The flight continued to Cairns and landed without further incident.

The Australian Transport Safety Bureau publication 'Staying Safe against In-flight Turbulence' (2009) provides some useful information on aircraft turbulence events. A full copy of that publication is available here.

Interim Factual report released 22 November 2005

At 1828 Eastern Standard Time on 11 October 2005, a Kawasaki Heavy Industries BK117 B-2 multi-engine helicopter, registered VH-BKS, was being operated on a night Visual Flight Rules (VFR) flight to Maroochydore, Qld. The pilot had flown the helicopter on a medical flight from Maroochydore to Brisbane's Princess Alexandria Hospital earlier that evening and was repositioning to Maroochydore with the paramedic and crewman on board.

The pilot intended to fly direct to Maroochydore, VFR on top of scattered¹ cloud at 4,500 ft. Soon after reaching 4,000 ft, the pilot noted that the cloud along the intended track was 4 OKTAS below the level of the helicopter. However, shortly after, the pilot observed the weather as solid overcast beneath him. He reported that the Brisbane approach controller subsequently advised him that the weather at Maroochydore had deteriorated to broken cloud at 1,000 ft above ground level (AGL).

The pilot continued with the flight to Maroochydore and conducted a Maroochydore runway 36 VOR/DME² approach in Instrument Meteorological Conditions (IMC). The helicopter was not equipped for single-pilot Instrument Flight Rules (IFR) operations, nor was the pilot the holder of a current Command Multi- Engine Instrument Rating (Helicopters).

The pilot reported that he did not return to Brisbane because the Brisbane Approach controller made a broadcast to all aircraft inbound to Brisbane 'that an Instrument Landing System (ILS) approach was mandatory'. He said that he assumed this to mean he would have to conduct an IFR approach he was unfamiliar with. He did not declare an emergency. The pilot was an experienced ex-military pilot, with extensive IFR experience. He reported entering cloud at 2,600 ft and broke visual during the approach at 760 ft. The IFR minimum descent altitude for that approach was 660 ft. The pilot reported landing with 45 minutes usable fuel remaining.

Area forecasts indicated that, for the planned flight, VFR operations were possible. The pilot planned the flight using a TAF (Terminal Aerodrome Forecast) for Maroochydore that was valid from midday to midnight on the day of the occurrence. That TAF indicated visibility greater than 10 km and scattered cloud at 2,500ft. The pilot assessed this as suitable for VFR.

An amended TAF for Maroochydore valid from 1800 that evening through to 0600 the following morning, was issued by the Bureau of Meteorology at 1626. That TAF indicated visibility greater than 10 km, few³ clouds at 1,000 ft and scattered cloud at 2,500 ft. The pilot reported he did not have the amended TAF and did not access further weather information after 1400 because he had assessed, during the preceding flight to Brisbane, that the weather was suitable for a return VFR flight to Maroochydore.

1. Defined as 3 to 4 OKTAS (unit of visible sky area representing 1/8 of the total area visible to the celestial horizon).
2. VHF Omni-directional radio range/Distance Measuring Equipment.
3. Defined as 1 to 2 OKTAS.

On 21 December 2007, an Evektor Sportstar, Recreational/ Light Sport Aircraft registration 24-4148 was involved in a fatal accident 12 km SE of Bindoon ALA. Recreational Aviation Australia (RA-Aus) staff commenced an investigation into the occurrence. Three Global Positioning System (GPS) units were recovered from the accident site.

On 9 April 2008, RA-Aus requested technical assistance from the Australian Transport Safety Bureau (ATSB) to recover the data from the GPS units. No analysis of the data by the ATSB was sought by RA-Aus. To protect the information supplied by RA-Aus and the investigative work undertaken to assist RA-Aus, the ATSB initiated an investigation under the Transport Safety Investigation Act 2003.

Data was successfully recovered from all three GPS units in May 2008 by ATSB Technical Analysis staff and subsequently provided to RA-Aus investigators.

______________

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

Abstract

At about 0542¹ on Tuesday 22 April 2008, empty southbound manganese ore train 3DM4 derailed four wagons approximately 58 km south of Darwin near Manton Dam in the Northern Territory (NT).

There were no injuries as a result of the derailment but there was minor damage to the track and rolling stock.

The investigation found that the draft key² on the leading end of the 31st wagon had dislodged from the coupler shank, which allowed the coupler to withdraw and fall onto the track. As a result of this the train was separated into two portions; 30 wagons that were still coupled to the locomotives and the 14 following wagons which were detached. The detached portion of the train then almost certainly passed over the dislodged coupler that was lying on the tracks leading to the derailment of four wagons.

_______

1. The 24-hour clock is used in this report to describe the local time of day, Central Standard Time (CST).
2. Also known as 'Murray Key', the draft key is a flat steel bar that passes through the underframe, yoke and coupler. Its primary function is to secure the yoke and coupler as a unit within the underframe.

Rail safety recommendation

[RR2008-006-SR-007]

On 31 December 2007, at about 1600 Eastern Daylight-saving Time, an Airbus Industrie A320-200 aircraft, registered VH-VQT, was being prepared at Bay C8 at Melbourne Airport, Vic. for a scheduled flight to Newcastle, NSW. The flight crew was in the cockpit preparing the aircraft for the flight, the passengers were boarding the aircraft, and the ground handlers were loading and unloading baggage and other items.

The pallet loader operator reported that, after a period of normal operation, an electrical burning smell was detected in the area of the loader's engine compartment. The supervising leading hand noticed a fire in that compartment and alerted the operator to dismount the pallet loader. The pallet loader operator detached the fire extinguisher from the loader and extinguished the fire.

The ignition source for the fire was most probably intense electrical arcing within the pallet loader engine's starter motor solenoid.

As a result of this incident:

• the Aerodrome Emergency Planning Advisory Group undertook to:
• - modify its Aerodrome Emergency Plan format to include relevant on-apron emergencies
  - examine the leadership aspects of turn around operations as they might affect on-apron emergency planning.
• the ground vehicle maintenance provider issued a Service Bulletin requiring the immediate inspection of the condition and routing of the starter motor wiring loom in all similar pallet loaders.

As a result of this, and a second fire in a similar pallet loader that occurred at Adelaide Airport on 27 May 2008, the operator retrofitted all of its affected pallet loaders with a replacement starter motor that significantly reduced the risk of electrical arcing.

Preliminary report released 27 February 2008

After departing Port Moresby, Papua New Guinea, at 0430 Coordinated Universal Time on 31 December 2007, the flight crew of a Boeing 737-229 aircraft, registered VH-OZX, being operated on a scheduled flight from Port Moresby to Brisbane, reported severe vibration through the airframe, resulting in a Mayday broadcast and return to Port Moresby.

A subsequent examination on the ground, found a section of the right elevator balance tab had detached and was missing. Preliminary examination of the tab indicated that a failure of one of the elevator tab hinge blocks had occurred.

On 29 December 2007, a Boeing Company 737-229 aircraft, registered VH-OBN, was being operated on a scheduled passenger service from Brisbane, Qld to Norfolk Island. At 0352 Coordinated Universal Time, the flight crew conducted a missed approach at Norfolk Island due to poor weather.

During the flap retraction, the flight crew felt a high frequency vibration through the airframe, while observing control yoke deflection to the left. Due to the vibration, the aircraft's autopilot system could not be engaged and controlled flight was manually maintained with difficulty. The flight crew elected to continue to the designated alternate airport at Nouméa, New Caledonia. During that diversion flight, the cabin crew prepared the passengers for a possible ditching.

An engineering inspection determined that the number 4 leading edge slat, inboard main track had failed. An examination of the failed track identified fatigue cracking that originated at the intersection of diverging machining marks at the fracture site. Further inspection of the number 4 slat found corrosion damage on the outboard auxiliary track, with the inboard auxiliary track adjacent to the failed main track having failed in overload at the slat attachment.

The investigation also identified a number of cabin safety issues during the diversion flight, and poor passenger handling after the subsequent landing at Nouméa. As a result of this investigation, the aircraft operator advised the Australian Transport Safety Bureau of the implementation of a number of safety actions, including:

• the revision of flight crew flight planning - alternate fuel load provisions
• the revision of cabin crew equipment and procedures
• a review of company emergency response procedures.

At the time of finalising this report, the original operator's air operator's certificate had been taken over by a different organisation. The new organisation does not use the aircraft type involved in this occurrence. It has, however, reviewed its operations to ensure that hazards identified in this investigation are mitigated appropriately.

Preliminary report released 14 March 2008

At about 1905 Eastern Daylight-saving Time, on 29 December 2007, a Robinson Helicopter Company R44 Raven 1 (R44), registered VH-MEB was being operated under the charter category with two pilots on board. Following a passenger scenic flight, the helicopter departed Pier 35 helipad, located adjacent to the Yarra River, Melbourne, Vic. to return to the operator's base. Witnesses nearby reported that shortly following the take-off, in a north-north-west direction, the helicopter banked left and turned to the south-west, passing a marina at a height of about 30-35 ft AMSL. Witnesses reported that the helicopter's forward airspeed decreased and that it 'rocked or wobbled in the air' then pitched nose up, rolled to the left, descended and impacted the water.

The handling pilot was able to exit the helicopter via the right side and was recovered by the crew of a boat. The other pilot did not exit the helicopter and was fatally injured. The body of the pilot was subsequently recovered from the wreckage by Victorian Police Search and Rescue Squad divers.

On 10 December 2007 at about 2143 Eastern Daylight-saving Time a Cessna Aircraft Company 172N (C172) registered VH-WDA entered runway 17 at Essendon Airport, Vic. without an air traffic control clearance. At that time, a Piper Aircraft Corporation PA31, registered VH-BTD, was on final approach and had been cleared to land on runway 17. The pilot queried the landing clearance with the tower controller, who observed the C172's unauthorised entry onto the runway, or runway incursion, and sent the PA31 around in order to maintain separation between the two aircraft.

The pilot of the C172 was appropriately licensed, rated and current for the conduct of the private night visual flight rules (VFR) scenic flight and had notified the tower controller from the runway 17 run-up bays that he was 'ready'. In response, the controller instructed the pilot to 'taxi forward and hold short of runway 17'. That instruction was correctly read back by the pilot. Shortly after, the aircraft crossed the holding point and entered runway 17.

The C172 pilot had 311 hours total experience with 20 hours experience under the night VFR. The pilot was completing commercial pilot training and had been operating regularly at Essendon Airport over the previous 2 months. Most of those operations were reported to have been on runways 17 and 35. The pilot advised that the airport markings, signage and lighting were more than adequate for the planned flight.

The C172 pilot could not explain or rationalise why he had entered the runway when he had acknowledged the instruction to hold short of the runway. The investigation did not identify any operational factors that may have contributed to the development of the runway incursion.