Occurrence investigations commenced from 1 July 2003 are initially categorized as level 4 unless agreed by the ATSB Executive to be above this level at the outset. As detailed in Section 21 (2) of the TSI Act 2003, the Executive Director is empowered to discontinue an investigation at any time. Section 21 (3) of the TSI Act 2003 requires the Executive Director to publish a statement setting out the reasons for discontinuing an investigation (commenced from 1 July 2003) within 28 days of discontinuing the investigation.

An investigation was commenced into a level 4 occurrence involving a Piper PA-24 aircraft, registered VH-EKB, that was cleared to conduct an instrument approach to Essendon Airport on 26 October 2007. At the time, air traffic controllers were concerned that the aircraft was below the glide path for the instrument approach. The preliminary investigation found that the aircraft became clear of cloud and the pilot was flying visually, but had not notified air traffic control (ATC) of this. The pilot was only recently rated to fly in Instrument Meteorological Conditions (IMC) and had originally planned for a visual arrival into Essendon Airport, however the weather conditions had deteriorated. During the investigation, the pilot was advised to ensure that he kept air traffic control aware of the progress of the flight and any subsequent changes. As the circumstances were considered not likely to have significant implications for transport safety compared with other priorities, the Executive Director has discontinued the investigation.

Status: Downgraded the occurrence to level 5

At 0715 Coordinated Universal Time on 20 October 2007, a Boeing Company 747-438 aircraft, registered VH-OJB, departed Los Angeles International Airport, USA, on a scheduled passenger flight to Brisbane, Australia. There were four flight crew, 14 cabin crew, and 406 passengers on board the aircraft.

The first officer was the handling pilot for the flight. As the aircraft became airborne, a tyre on the left body landing gear disintegrated and a section of tyre debris impacted a line of the number 1 hydraulics system in the left body landing gear well. That caused fluid and pressure loss from that system.

A short time later, the electronic indicating and crew alerting system (EICAS) screen in the cockpit advised that the number 1 hydraulics system had failed, and a report was received from the cabin crew that a 'bang' was heard in the vicinity of the left main landing gear shortly before the aircraft became airborne. The flight crew completed checklist items, and the flight continued uneventfully to Brisbane.

The operator found some inconsistencies in the aircraft manufacturer's documentation relating to hydraulics failures. The aircraft manufacturer has noted those and has advised that it will examine them as part of its ongoing standardisation program.

On 24 October 2007 at Darwin Aerodrome, an Airbus A330-300, registered VH-QPE, made two unsuccessful attempts to start the right engine. Subsequent inspection of the engine revealed an uncontained failure of the starter turbine and secondary damage to the integrated drive generator.

The starter was returned to the manufacturer to conduct a failure investigation. The investigation revealed damage consistent with 'crash engagement' of the starter resulting in failure of the overrunning bearing. The blades were designed to separate from the turbine disc in this event, however, the starter failed to contain the cut-off blades as designed. The manufacturer proposed corrective actions to prevent further occurrences.

On the evening of 13 October 2007, an Embraer-Empresa Brasilia EMB-120 ER, registered VH-EEB, was taxiing at Sydney Kingsford Smith Airport, NSW, to take off on a freight charter flight to Melbourne, Vic. The aircraft was lined up with the left edge of the runway. Shortly after the take-off roll commenced, the crew reported feeling two or three bumps on the runway, after which time the crew's attention was drawn to an electrical burning smell in the cockpit, followed by a high-speed warning. The smell dispersed and the flight continued as normal to Melbourne.

Pre-flight checks for the return flight to Sydney revealed damage to the aircraft, which was subsequently found to have been caused by impact with the runway edge lighting on the left side of Sydney runway 16R, where the aircraft had started its take-off run. The aircraft was grounded at Melbourne for repair.

Interim factual report released 3 December 2008

On 17 October 2007, the pilot of a Cessna Aircraft Company C210M, registered VH-WXC, was fatally injured when his aircraft impacted terrain about 257 km south-west of Warburton, WA.

The pilot had delivered an item of general freight at Warburton and was returning to Kalgoorlie when the accident occurred. The aircraft was being operated at night under the visual flight rules.

Preliminary report released 12 December 2007

On 18 October 2007, the pilot of a Cessna Aircraft Company C404 Titan aircraft was conducting a charter flight from Adelaide Airport, SA to Parafield Airport, Beverley airstrip, and return to Adelaide. The pilot had commenced descent into Adelaide on the final sector of the flight when the right engine lost power. There were no apparent anomalies, and the fuel quantity gauges were showing adequate fuel in each tank. After securing the right engine, the pilot continued to Adelaide Airport and landed without further incident.

Aircraft maintenance engineers who inspected the aircraft reported that 3 L of fuel was drained from the right tank and 90 L was drained from the left tank. The fuel quantity gauge was indicating 150 lbs (95 L) in the right tank. An engineer found that one of the electrical circuits in the right fuel quantity indicating system had a high resistance. After wiring in the circuit was repaired, the fuel quantity gauge correctly indicated zero fuel in the right tank. Calibration of the fuel quantity indicating system was carried out and during that process, the left and right signal conditioners were found to be unreliable and were replaced or repaired.

The operator amended its fuel documentation and fuel planning procedures to include a secondary means of verification of fuel on board to cross-check the electric fuel indication system.

Preliminary Report released 21 November 2007

On 25 September 2007, a Robinson Helicopter Company R22 Beta II helicopter was conducting a stock survey flight in the vicinity of Doongan Station, WA. On board the helicopter were the pilot and one passenger.

After about 5 to 10 minutes into the flight, the passenger notified the pilot that he detected a strong burning smell. The pilot landed in a clear area adjacent to a nearby road to inspect the helicopter and elected to keep the helicopter engine running. Both the pilot and passenger visually inspected the helicopter, focussing on the two rubber drive belts that transfer power to the rotor system.

Following the inspection and discussion of the drive belt serviceability, the pilot elected to continue the flight to Doongan Station, while the passenger elected to walk along the road towards the station, until met by a vehicle which was to be sent back by the pilot for him.

After walking about 11 km along the road in the direction of the station, the passenger saw smoke and flames and, upon reaching the source of the smoke, discovered the wreckage of the helicopter adjacent to the road. The helicopter had been destroyed by impact forces and a post-impact fire. The pilot was fatally injured. The post-impact fire started a bushfire which continued for several days. The investigation is continuing.

On 21 September 2007, a SAAB Aircraft AB, SF-340B (SAAB) registered VH-EKX was inbound to Sydney, NSW on a scheduled passenger service from Wagga Wagga, NSW. The crew was cleared by air traffic control to track direct to short final runway 16R at Sydney Airport. The last assigned altitude issued to the SAAB crew was 2,500 ft. A Eurocopter EC120 helicopter registered VH-CKO had departed Sydney Airport on a Georges River 1 departure and, when identified on radar by air traffic control, was cleared to track direct to Kingsgrove at 1,500 ft for aerial work. Air traffic control had coordinated the positions and intended tracks of both aircraft and established a 1,000 ft vertical separation standard.

At 1058.08 Eastern Standard Time, the short-term conflict alert activated on the display consoles of the air traffic controllers. Two seconds later, the copilot of the SAAB reported that they were responding to a resolution advisory from the aircraft's traffic advisory and collision avoidance system (TCAS). Radar analysis indicated that the separation between the two aircraft reduced to 200 ft vertically and 0.5 NM horizontally. There was an infringement of the vertical separation standard of 1,000 ft.

The helicopter pilot had climbed to 2,000 ft and later reported that he had been distracted from monitoring his assigned altitude by a focus on meeting the client's photographic requirements. The pilot in command and the copilot of the SAAB both reported that they believed that they had been cleared by air traffic control to make a visual approach and had descended their aircraft to 2,000 ft.

The investigation established that there was a safety issue in that there is no requirement for a controller to confirm that descent below a previously assigned altitude has not been given in a clearance to a circuit position that does not include a visual approach clearance. Airservices Australia is examining options to address this safety issue.

Preliminary report released 30 October 2007

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.

History of the flight 

On 21 July 2007, an Airbus A320-232 aircraft, registered VH-VQT, was being operated on a scheduled international regular public transport service between Christchurch, New Zealand and Melbourne, Australia.

Following an uneventful flight from New Zealand, the crew were conducting an instrument landing system (ILS) approach to runway 27 at Melbourne. Weather conditions were forecast to include fog, which had subsequently eventuated and was likely to necessitate an instrument approach to the minimum altitude on the approach. The likelihood of the crew having to conduct a missed approach was high, as aircraft ahead of VQT had already conducted missed approaches because of the low visibility and fog. The crew had been aware of these conditions prior to departure and had flight planned accordingly. They had also conducted a briefing on the likelihood of having to conduct a missed approach prior to commencing the descent into Melbourne.

At the decision height on the ILS approach, the crew did not have the prescribed visual reference and commenced a missed approach. During the initial part of the missed approach, the crew were not aware that the aircraft had not transitioned to the expected flight guidance modes1 for the missed approach. When the aircraft did not respond as expected, the crew took manual control of the aircraft. The crew were subsequently processed by air traffic control (ATC) for another approach to Melbourne Airport. This second approach also resulted in the crew conducting a missed approach and the aircraft was subsequently diverted to Avalon Airport, where it landed uneventfully. During the second missed approach, the aircraft systems functioned correctly.

During cruise at 9,000 ft, the aircraft encountered severe turbulence, and the electrical system failed. The pilot unintentionally lost control of the aircraft when he leaned forward on the control column yoke and used both hands to search in the dark for a torch on the cockpit floor.

After recovering the hand-held torch, the pilot was able to light the instrument panel and return the aircraft to the required heading and altitude. When the battery master switch was turned off, the electrical system returned to full operation on alternators.

Maintenance personnel found that an internal electrical short in one of the 12-volt batteries had contributed to the electrical failure. After replacement of the faulty battery and completion of satisfactory electrical system checks, the aircraft was returned to service.

The pilot of the aircraft now secures his torch to his shirt with a strap to enable him to use both hands to keep control of the aircraft should a similar situation arise.

The aircraft operator now secures torches in all its aircraft with the addition of a quick release strap on the torch container.