Preliminary report released 14 February 2008

On 1 December 2007 an Avid Flyer ultra-light aircraft and a Cessna 172 aircraft collided in midair within the circuit area of the Latrobe Valley aerodrome. The pilot in the Avid Flyer was fatally injured and the Cessna 172 was safely landed.

Preliminary report released 19 February 2008

On 7 December 2007, the pilot of an Air Tractor Inc. AT-802 aircraft, registered VH-LIS, was conducting a test flight at Lake Liddell, NSW. The purpose of that flight was to test an experimental in-flight water collection system using skis attached to the aircraft's main landing gear.

At about 0910 Eastern Daylight-saving time, the pilot was conducting the second test run of the day. After the aircraft had been in contact with the surface of the lake for about 36 seconds, witnesses observed the aircraft collide with the surface of the lake. The aircraft overturned and sank in about 9 metres of water. The pilot was fatally injured.

Examination of the aircraft wreckage showed impact damage consistent with the aircraft pitching nose down, about its right main landing gear while rotating to the right.

On 25 November 2007, a Gulfstream Aerospace Corporation G-IV aircraft, registered HB-IKR, was being operated on a charter flight from Brisbane Airport, Queensland to Sydney, New South Wales. At about 2225 Eastern Standard Time the pilot in command of the aircraft commenced a take-off run on taxiway Alpha, adjacent to the active runway 01. The aerodrome controller (ADC) instructed the pilot to cancel the take-off clearance. The crew stopped the take-off and the ADC instructed them to taxi to the end of the runway for a take-off using the full runway length. There were no injuries, or damage to the aircraft or airport infrastructure.

The investigation found that a combination of a cockpit equipment failure, inadequate pilot rest, deficient cockpit resource management practices and unfamiliarity with the airport layout were likely factors that lead to the occurrence.

On 23 November 2007, a Boeing Company 767-338, registered VH-OGG, was being operated on a scheduled passenger service between Sydney, NSW and Melbourne, Vic. On board were two flight crew, seven cabin crew and 255 passengers. The aircraft departed Sydney at 1426 Eastern Daylight-saving Time (EDT).

At about 1455, a passenger reported to a flight attendant that he could smell fumes coming from the gasper air vent above his seat. The passenger later reported that the fumes smelled like jet exhaust. The passenger became unconscious and was administered oxygen. He regained consciousness within a few seconds of being administered oxygen. A second passenger, seated in the area, also reported feeling nauseous at the time.

The flight crew declared a state of urgency to air traffic control and began performing the 'Smoke or Fumes - Air Conditioning' checklist. The aircraft landed at Melbourne Airport at 1529.

There were no other reports of adverse effects from any of the other passengers or crew on board the flight. The two affected passengers had travelled extensively by air with no previous adverse reactions. The investigation could not determine whether the passengers' symptoms were as a result of fumes in the aircraft cabin, or whether there were other unidentified medical conditions that may have contributed to the symptoms exhibited by the two passengers.

The investigation identified a non-contributory safety issue related to adherence to curing times following application of corrosion inhibiting compounds in the aircraft's cargo bays. The report details safety action taken by the operator to address this safety issue.

On 17 November 2007 a Boeing Company 737-7Q8 aircraft, registered VH-VBC, with two flight crew, four cabin crew and 145 passengers was being operated on a scheduled passenger service from Coolangatta, Queensland to Melbourne, Victoria. During the take-off, the Master Caution system activated and the right BLEED TRIP OFF light illuminated. The pilot in command, who was the pilot flying, elected to continue the take-off. Once airborne the Bleed Trip Off non-normal checklist was actioned. The right engine bleed could not be reset with the effect that, when above flight level (FL) 170 (17,000 ft above mean sea level), only the left engine bleed air was available for air-conditioning and cabin pressurisation.

At FL318 during the climb, the flight crew observed the left PACK TRIP OFF light illuminate, followed by a rapid loss in cabin pressure and the cabin rate of climb indicator showing a rate of climb of about 2,000 ft/min. The crew fitted their emergency oxygen masks, commenced the Emergency Descent checklist and began a rapid descent to 10,000 ft. During the descent, the cabin altitude exceeded 14,000 ft, at which time the passenger oxygen masks deployed automatically. The aircraft was diverted to Brisbane for landing. There were no reported injuries to passengers or crew and no damage to the aircraft.

The investigation found that a combination of technical faults contributed to the loss of pressurisation and identified a number of other safety factors relating to operational procedures and cabin crew knowledge of the passenger oxygen system.

The operator conducted an internal investigation of the incident and carried out a number of safety actions as a result. Those actions included the enhancement of a number of the operator's manuals and the amendment of the operator's cabin safety recurrent training. In addition, the operator's passenger oxygen use in-cabin brief was enhanced to include advice that oxygen would flow to passengers' masks even if the associated bag was not inflated.

Preliminary report released 16 January 2008

Late in the afternoon on 15 November 2007, a Cessna Aircraft Company 172M aircraft, registered VH-TCS, took off from Uaroo Station, in the Pilbara region of WA, for a local flight under the visual flight rules. A witness driving in a northerly direction along the North West Coastal Highway reported seeing a column of 'dark smoke' in the direction of the property between about 1700 and 1730 Western Daylight-saving Time.

Witnesses discovered the aircraft wreckage on the side of a hill located about 500 m from the property landing strip on the morning of 17 November 2007. The aircraft had been destroyed by impact forces and a post-impact fire. The pilot, who was the sole occupant, was fatally injured.

Preliminary report released 27 April 2008

This preliminary report details factual information established in the investigation’s early evidence collection phase and has been prepared to provide timely information to the industry and public. Preliminary reports contain no analysis or findings, which will be detailed in the investigation’s final report. The information contained in this preliminary report is released in accordance with section 25 of the Transport Safety Investigation Act 2003.

On 17 November 2007, the owner-pilot of a Cessna Aircraft Company C337G (Skymaster), registered VH-CHU, was conducting a private flight in accordance with the visual flight rules from Moorabbin Airport, Vic. to Merimbula, NSW. The pilot, who was accompanied by three passengers, had indicated that he would be tracking along the coast. The aircraft did not arrive at Merimbula and on 19 November 2007 aircraft wreckage and three of the deceased occupants were found on a beach between Venus Bay and Cape Liptrap, Vic. Some wreckage was later found in the sea, off the beach. There were no survivors.

On 25 May 2007, an Indonesian registered Boeing 737-3YO, PK-AWP, touched down heavily while landing at Polonia Airport, Medan, Indonesia. The landing resulted in nosewheel vibration, a deflated left nosewheel tyre and overheated brakes.

The flight data recorder (FDR) was recovered from the aircraft. The Indonesian National Transportation Safety Committee (NTSC) was responsible for investigating this incident. The NTSC requested ATSB assistance in the recovery of data from the FDR tape on 12 December 2007. The Executive Director of the ATSB approved the request. To protect the information supplied by the ATSB to the NTSC and investigation work undertaken to assist this agency, the ATSB initiated an investigation under the Transport Safety Investigation Act 2003.

The FDR tape was provided to the ATSB on 17 December 2007. The tape was found to be damaged and the recovery of data was problematic, however, the ATSB successfully recovered the incident flight data from the damaged FDR tape. A data listing and graphical representation of data recorded during the incident flight and a report describing the recovery procedures, were finalised on the 10 January 2008. This information was provided to the NTSC.

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

On 10 November 2007 at approximately 0830 Central Standard Time, a Cessna Aircraft Company 172N, registered VH-WLQ, with two pilots and a passenger on board departed Katherine, NT on a private, visual flight rules (VFR) flight to Tennant Creek. At about 1030, the aircraft struck a powerline which spanned the Stuart Highway 20 km north of Elliott. The aircraft's tail section was broken rearwards from the aft fuselage, rendering the aircraft uncontrollable and causing it to impact the highway in a steep nose-down attitude. The three occupants were fatally injured. The aircraft was destroyed.

There was no evidence of an aircraft or operational reason for the flight below 500 ft above ground level (AGL). Based on a lack of evidence to the contrary, the investigation concluded that the descent to, and flight at low level was probably as a result of a conscious decision by the pilots.

The investigation was unable to establish which of the pilots was flying the aircraft at the time of the accident.

Preliminary report released 21 January 2008

On 4 November 2007, a Boeing Company 777-2D7 aircraft, registered HS-TJW, was being operated on a scheduled passenger service from Bangkok, Thailand, to Melbourne, Vic, with 17 crew and 277 passengers on board. During a non-directional beacon (NDB) non-precision approach to runway 16 at Melbourne Airport, the aircraft descended below the segment minimum safe altitude at 6.8 distance measuring equipment (DME, a measure in nautical miles). Soon after, the crew received two enhanced ground proximity warning system (EGPWS) cautions. The crew then levelled the aircraft and conducted a visual approach and landing on runway 16.