Procedures-related event - VH-VYC, VH-TIX, Townsville Airport, Queensland, on 27 August 2007

Summary

At about 1717 Eastern Standard Time on 27 August 2007, a student pilot and an instructor in a Cessna Aircraft Company C172 (172), registered VH-TIX, were operating in the circuit area as the crew of a Boeing Company B737-838 (737), registered VH- VYC, was conducting a runway 01 instrument landing system (ILS) approach at Townsville Airport, Qld. The pilot of the 172 was cleared for take-off and to make a right circuit on runway 07 from a position about 700 m along the runway. The 737 was about 1.2 NM from the runway 01 threshold and descending through 400 ft at that time.

The 737 landed on runway 01 and, as it crossed the extended centreline of runway 07, the pilot observed the 172 to pass in close proximity. Radar data and pilot estimates indicated that the 172 passed about 150 m behind the 737 at an altitude of about 100 ft. There was no separation assurance.

As a result of this incident, the local procedures at Townsville were amended to require the application of the Manual of Air Traffic Services (MATS) 4.8.9 Take-off Behind Landing or Departing Aircraft on Intersecting Runways separation standard between aircraft departing runway 07 and aircraft landing or departing runway 01/19 at Townsville. In addition, the Royal Australian Air Force (RAAF) implemented an audit project to examine the compliance of Australian Defence Force (ADF) air traffic services, instructions and procedures with civil requirements.

Occurrence summary

Investigation number AO-2007-038
Occurrence date 27/08/2007
Location Townsville Airport
State Queensland
Report release date 01/06/2009
Report status Final
Investigation level Systemic
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Loss of separation
Occurrence class Serious Incident
Highest injury level None

Aircraft details

Manufacturer Cessna Aircraft Company
Model 172
Registration VH-TIX
Serial number 17263483
Sector Piston
Operation type Flying Training
Departure point Townsville
Destination Townsville
Damage Nil

Aircraft details

Manufacturer The Boeing Company
Model 737
Registration VH-VYC
Serial number 33991
Sector Jet
Operation type Air Transport High Capacity
Destination Townsville, Qld
Damage Nil

Smoke Event - 21 NM west of Mildura, New South Wales, on 27 August 2007, VH-SGA, Piper Navajo PA-31P

Summary

On 27 August 2007, a Piper PA-31P Navajo aircraft, registered VH-SGA, with a pilot and a survey equipment operator on board, was being operated on an aerial survey 21 NM west of Mildura, NSW. At 5,000 ft altitude and operating under the visual flight rules, the pilot noticed an electrical burning smell, which was confirmed by the survey equipment operator.

The pilot, although affected by the fumes, was able to conduct a successful landing at Mildura aerodrome and reported to Air Traffic Services when safely on the ground. The aircraft was examined by a Licensed Aircraft Maintenance Engineer at Mildura. The right engine alternator 'inoperative' sensor was replaced.

As a result of this occurrence, the aircraft operator initiated safety actions to prevent a recurrence.

Occurrence summary

Investigation number AO-2007-039
Occurrence date 27/08/2007
Location 39 km W Mildura
State Victoria
Report release date 25/02/2009
Report status Final
Investigation level Systemic
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Smoke
Occurrence class Serious Incident
Highest injury level None

Aircraft details

Manufacturer Piper Aircraft Corp
Model PA-31
Registration VH-SGA
Serial number 31P-7300166
Sector Piston
Operation type Aerial Work
Departure point Mildura, Victoria
Destination Mildura, Victoria
Damage Nil

Collision with terrain - Pacific Aerospace Cresco 08-600, VH-XMN, 24 km south of Tully, Queensland, on 16 August 2007

Preliminary report

Preliminary report released 11 October 2007

The aircraft was reported missing and was subsequently discovered to have collided with terrain.

Summary

On 16 August 2007 at 1454 Eastern Standard Time, the pilot of a Pacific Aerospace Corporation Cresco 08-600 aircraft, registered VH-XMN, departed from Ingham, Qld on a ferry flight under the visual flight rules (VFR) to Tully. The aircraft did not arrive at Tully and the next day the pilot and aircraft were reported missing.

Australian Search and Rescue (AusSAR) was notified and a search, based on the last radar observed position of an unidentified aircraft from a replay of recorded radar data, together with witness reports from the area, was initiated. Searchers located the aircraft wreckage on the morning of 18 August 2007. The aircraft had impacted mountainous terrain in a state forest 24 km south of Tully. The pilot was fatally injured, and the aircraft was destroyed.

The circumstances of this occurrence were consistent with controlled flight into terrain resulting from visual flight rules into instrument meteorological conditions. The pilot did not provide a flight notification or SARTIME for the trip required for flight in a designated remote area. As a consequence, there was a delayed search and rescue response.

Following the investigation, the aircraft operator reviewed the company operations manual and added search and rescue procedures.

Occurrence summary

Investigation number AO-2007-037
Occurrence date 16/08/2007
Location 24 km S Tully
State Queensland
Report release date 03/02/2009
Report status Final
Investigation level Systemic
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Occurrence class Accident
Highest injury level Fatal

Aircraft details

Manufacturer Pacific Aerospace Corporation
Model 08-600
Registration VH-XMN
Serial number 36
Sector Turboprop
Operation type Private
Departure point Ingham, Qld
Destination Tully, Qld
Damage Destroyed

Fuel related event - 50 km north-west of Swan Hill, Victoria, on 11 August 2007, VH-TJE, Boeing 737-476

Preliminary report

Preliminary report released 11 October 2007

On 11 August 2007, a Boeing 737-476 aircraft, registered VH-TJE, was being operated on a scheduled passenger service between Perth, WA to Sydney, NSW. The flight crew consisted of a pilot in command, who was the pilot flying, and a copilot. The aircraft took off from Perth at 0544 Western Standard Time. About 2 hours 40 minutes later, the master caution light illuminated associated with low output pressure of the aircraft's main tank fuel pumps. The pilot in command observed that the centre tank fuel pump switches on the forward overhead panel were selected to the OFF position and he immediately selected them to the ON position.

The main fuel tanks were low on fuel and the investigation estimated that there was about 100 kg in each of the main tanks. The centre fuel tank contained about 4,700 kg of fuel when the master caution occurred. The flight continued on the flight planned route and landed at Sydney 51 minutes after the initial illumination of the master caution light.

Summary

On 11 August 2007, a Boeing Company 737-476 aircraft, registered VH-TJE, was being operated on a scheduled passenger service from Perth, WA to Sydney, NSW. The flight crew consisted of a pilot in command, who was the pilot flying, and a copilot. The aircraft departed from Perth at 0544 Western Standard Time. About 2 hours 40 minutes later, the master caution light illuminated associated with low output pressure of the aircraft's main tank fuel pumps. The pilot in command observed that the centre tank fuel pump switches on the forward overhead panel were selected to the OFF position, and he immediately selected them to the ON position.

The main fuel tanks were low on fuel and the investigation estimated that there was about 100 kg in each of the main tanks. The centre fuel tank contained about 4,700 kg of fuel when the master caution occurred. The flight continued on the flight planned route and landed at Sydney 51 minutes after the initial illumination of the master caution light.

The investigation determined that the flight crew had flown the previous two sectors on a B737 aircraft with a different fuel system and fuel control panel. The pilot in command was suffering from chronic stress and it is probable that this stress affected his ability to operate as a pilot in command without him being aware of this. In addition, some checklist procedures were not adhered to by the flight crew, and it was likely that deviations from those checklist items were occurring throughout the operator's fleet of B737 aircraft.

As a result of this investigation, the operator has instigated safety action to change the Before Start and Before Taxi procedures and checklists.

Occurrence summary

Investigation number AO-2007-036
Occurrence date 11/08/2007
Location 50 kms NW of Swan Hill
State Victoria
Report release date 28/07/2009
Report status Final
Investigation level Systemic
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Fuel - Other
Occurrence class Serious Incident
Highest injury level None

Aircraft details

Manufacturer The Boeing Company
Model 737
Registration VH-TJE
Serial number 24430
Sector Jet
Operation type Air Transport High Capacity
Departure point Perth, WA
Destination Sydney Airport
Damage Nil

Engine in-flight shutdown - 926 km north-west of Sydney, New South Wales, on 15 August 2007

Summary

At approximately 1405 Eastern Standard Time on 15 August 2007, an Airbus Industrie A330-300 aircraft, registered PK-GPF, was about 926 km north-west of Sydney, NSW enroute to Denpasar, Indonesia when the right (No-2) engine low oil pressure warning activated. The flight crew shut down the engine and commenced a descent to flight level 240 while they advised air traffic control (ATC) of the event and requested a clearance to return to Sydney. Air traffic control cleared the crew to descend and to track directly to Sydney.

After landing, the operator's contracted maintenance staff inspected the No-2 engine, a Rolls-Royce RB211-Trent 700 series. They found that oil was leaking from the braided section of the flexible oil pressure tube that supplied oil to the oil pressure transmitter for that engine.

The Australian Transport Safety Bureau (ATSB) inspected the oil pressure tube in conjunction with the UK Air Accidents Investigation Branch and the engine manufacturer. That inspection revealed that the tube had fractured, probably due to high cycle fatigue in a stress concentration area.

The aircraft operator has since commenced a modification program on all of its Airbus A330 aircraft to fit an additional retainer bracket and associated hardware to the flexible oil pressure transmitter tube in an effort to prevent similar occurrences.

Occurrence summary

Investigation number AO-2007-035
Occurrence date 15/08/2007
Location 145 km W Cunnamulla
State Queensland
Report release date 02/02/2009
Report status Final
Investigation level Systemic
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Abnormal engine indications
Occurrence class Incident
Highest injury level None

Aircraft details

Manufacturer Airbus
Model A330
Registration PK-GPF
Serial number 153
Sector Jet
Operation type Air Transport High Capacity
Departure point Sydney, NSW
Destination Denpasar, Bali
Damage Nil

Fuel system event - Boeing 737-7BX, VH-VBR, 148 km south-east of Rockhampton Aerodrome, Queensland, on 13 August 2007

Summary

On 13 August 2007, a Boeing 737-700 aircraft, registered VH-VBR, was operating on a scheduled flight from Brisbane to Hamilton Island, Qld. On reaching cruise altitude, the flight crew became aware of a fuel imbalance situation due to fuel loss from the number 2 (right) engine. At 1311 Eastern Standard Time and approximately 148 km SE of Rockhampton, Qld, the crew conducted an in-flight shut down of the right engine. The aircraft was subsequently diverted to Rockhampton where a single-engine approach and landing was completed without further incident.

Examination identified the leak as being from the main fuel return pipe where it connected into the oil/fuel heat exchanger. The pipe connection was of flanged plate design, held in position by four bolts tightened into threaded inserts on the oil/fuel heat exchanger body. The threaded inserts had failed, pulling free of the heat exchanger body.

The investigation found that the failure of the inserts was the result of over tightening that had occurred during previous maintenance. The oil/fuel heat exchanger was subject to two different modification states, each requiring different fuel return pipe bolt torque values.

As a result of this occurrence, the aircraft operator notified the subsequent maintenance provider of the incident and received assurance that their process, procedures and oversight were adequate to prevent a recurrence.

Occurrence summary

Investigation number AO-2007-034
Occurrence date 13/08/2007
Location 148 km SE Rockhampton
State Queensland
Report release date 14/04/2009
Report status Final
Investigation level Systemic
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Fuel systems
Occurrence class Incident
Highest injury level None

Aircraft details

Manufacturer The Boeing Company
Model 737
Registration VH-VBR
Serial number 30745
Sector Jet
Operation type Air Transport High Capacity
Departure point Brisbane, Qld
Destination Hamilton Island, Qld
Damage Nil

Fumes event - en-route from Sydney to Albury, New South Wales, Saab AB 340B, VH-RXX, on 5 August 2007

Summary

On 5 August 2007 at 1407 Eastern Standard Time, a Saab Aircraft AB 340B, registered VH-RXX, was being operated on a scheduled passenger service from Sydney to Albury, NSW. It was the aircraft's first flight of the day and the first flight after a routine compressor wash carried out on the engines.

An odour, which had been apparent inside the aircraft during the preflight procedure and taxi, and which was described as 'similar to curry', became much stronger from just before rotation until about two minutes after take-off. Believing the fumes were caused by compressor wash fluid and would dissipate, the flight crew elected to continue the flight.

The manufacturer of the compressor wash fluid confirmed that, when heated, it would produce an odour similar to curry.

The operator reported that their compressor wash procedure had been followed and was unable to explain the subsequent ingress of fumes to the cockpit and cabin of the aircraft.

Occurrence summary

Investigation number AO-2007-031
Occurrence date 05/08/2007
Location Sydney Airport
State New South Wales
Report release date 23/09/2008
Report status Final
Investigation level Systemic
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Fumes
Occurrence class Incident
Highest injury level None

Aircraft details

Manufacturer Saab Aircraft Co.
Model 340
Registration VH-RXX
Serial number 340B-209
Sector Turboprop
Operation type Air Transport Low Capacity
Departure point Sydney, NSW
Destination Albury, NSW
Damage Nil

Fuel event - Perth, Western Australia, on 7 August 2007

Summary

On 7 August 2007, a British Aerospace (BAe) 146 aircraft, registered VH-NJT, was holding at the Instrument Flight Reporting point, ROTAP, 95 NM (176 km) north-east of Perth, WA. At 0950 Western Standard Time, the left side inner 'Feed Tank Low Level' warning light illuminated, followed almost immediately by the right side inner 'Feed Tank Low Level' warning light.

A PAN PAN radio broadcast was made to Air Traffic Services (ATS) and the aircraft landed at Perth 26 minutes later without further incident. The crew reported that, after landing, a total of 1,920 kgs of fuel remained on board.

Maintenance inspections carried out by the operator found no faults with the aircraft fuel system. The operator advised that 2 days later, a fault was reported in the left side inner boost fuel pump. The pump was replaced, and no further faults have been reported with the aircraft fuel system.

Occurrence summary

Investigation number AO-2007-032
Occurrence date 07/08/2007
Location Perth
State Western Australia
Report release date 05/11/2008
Report status Final
Investigation level Systemic
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Fuel - Other
Occurrence class Incident
Highest injury level None

Aircraft details

Manufacturer British Aerospace
Model AVRO 146
Registration VH-NJT
Serial number E1228
Sector Jet
Operation type Air Transport High Capacity
Departure point Coondewanna, WA
Destination Perth, WA
Damage Nil

In-flight break-up - Clonbinane, Victoria, on 31 July 2007, VH-YJB, Rockwell Commander 500S

Preliminary report

Preliminary report released 12 October 2007

On 31 July 2007, a Rockwell Commander 500S, with a pilot and passenger on board, was making a night, instrument flight rules, business flight from Essendon Airport, Vic. to Shepparton. While cruising at 7,000 ft and approximately 25 NM (46 km) north-north-east of Essendon, the aircraft disappeared from radar. Attempts by the controller to contact the pilot were unsuccessful. Later that night the aircraft wreckage was found in timbered ranges near the last radar position. There were no survivors.

Wreckage was distributed over a considerable area and the outer wing sections and the tail had separated in flight. Subsequent wreckage reconstruction and examination of the fracture surfaces found no evidence of contributory fatigue cracking, pre-existing defects or structural corrosion.

At the time of the occurrence there was a north to north-westerly wind of 40 kts or greater in the area. The Bureau of Meteorology had issued two concurrent SIGMET warnings for the period of the flight. The first warned of severe mechanical turbulence over and south of the ranges, and the second warned of occasional severe mountain wave turbulence.

The Preliminary report contains factual information that has been obtained for the investigation to date and describes the focus of further investigations.

Summary

On 31 July 2007, a Rockwell International Aero Commander 500-S, registered VH-YJB, departed Essendon Airport, Vic. on a business flight to Shepparton that was conducted at night under the instrument flight rules (IFR). On board were the pilot and one passenger. At 1958 Eastern Standard Time, while in the cruise at 7,000 ft above mean sea level in Class C controlled airspace, radar and radio contact with the aircraft was lost when it was about 25 NM (46 km) north-northeast of Essendon.

The wreckage was found in the area of the last radar position and both occupants had been fatally injured. At the time, special weather reports for severe turbulence and severe mountain waves were current for that area. Wind speeds on the ground were reported to be 50 kts. Calculations made using the recorded radar data and forecast wind showed that the aircraft had been in cruise flight at speeds probably greater than its published manoeuvring speed, prior to disappearing from radar.

The wreckage and its distribution pattern were consistent with an in-flight breakup during cruise flight. The breakup most likely resulted from an encounter with localised and intense turbulence, or from an elevator control input, or from a combination of both. As a result of its investigation, the Australian Transport Safety Bureau reissued the publication Mountain Wave Turbulence (available for download at www.atsb.gov.au), distributed the investigation report to all Australian operators of the Aero Commander aircraft, and issued a safety advisory notice to aircraft operators and pilots. That notice encouraged aircraft operators to review their procedures to ensure an appropriate awareness amongst operating personnel of the implications for aircraft performance of the combination of aircraft weights and speed, and of the ambient conditions; in particular, when flying in, or near areas of forecast severe turbulence.

Occurrence summary

Investigation number AO-2007-029
Occurrence date 31/07/2007
Location 37 km NNE Melbourne
State Victoria
Report release date 09/11/2009
Report status Final
Investigation level Systemic
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category In-flight break-up
Occurrence class Accident
Highest injury level Fatal

Aircraft details

Manufacturer Rockwell International
Model 500
Registration VH-YJB
Serial number 3299
Sector Piston
Operation type Business
Departure point Essendon, Vic
Destination Shepparton, Vic
Damage Destroyed

Operational Event, 120 km south-west of Cooktown, Queensland, on 22 July 2007, VH-ESB, Bell 412

Summary

On 22 July 2007, the crew of a Bell 412 helicopter was conducting a night approach as part of a search for the source of transmissions from an emergency locator beacon. During the approach to a landing site, the pilot of the helicopter lost situational awareness and allowed the forward speed of the helicopter to decrease to zero. The helicopter developed a high rate of descent and, during an attempt to arrest the rate of descent, the helicopter was subjected to an over-torque condition. The Australian Transport Safety Bureau did not conduct an onsite investigation into the occurrence. However, the operator's internal investigation identified a number of safety issues. Following the investigation, the operator took safety actions to address the identified issues.

Occurrence summary

Investigation number AO-2007-028
Occurrence date 22/07/2007
Location Near Palmer River HLS
State Queensland
Report release date 30/03/2009
Report status Final
Investigation level Systemic
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Unstable approach
Occurrence class Incident
Highest injury level None

Aircraft details

Manufacturer Bell Helicopter Co
Model 412
Registration VH-ESB
Serial number 36087
Sector Helicopter
Operation type Aerial Work
Departure point Cairns, Qld
Destination Palmer River HLS
Damage Nil