On 25 April 2007, at approximately 1155 Eastern Standard Time (EST), the pilots of a Dornier Werke GMBH DO 228-202 K (Dornier), registered VH-YJD, sighted an aircraft at the same altitude approaching from the opposite direction while flying over Princess Charlotte Bay, Qld. The pilot flying the Dornier immediately climbed and turned the aircraft to the left to avoid the approaching aircraft. The conflicting aircraft passed 50 to 100 ft below the right wing of the Dornier. A Cessna Aircraft Company T210M (Cessna), registered VH-FGW, was subsequently identified as the other aircraft. There had been an Airprox.

On 19 April 2007, the Darwin radar (DNR) airspace was being operated as a non-radar procedural sector due to the removal of the Australian Defence Air Traffic System (ADATS) radar data from the civil Australian Advanced Air Traffic System (TAAATS). That change in arrangements was necessary because of ongoing technical problems with the integration of the ADF data into the civil radar system.

At about 0909 Central Standard Time, the DNR controller identified that an instrument flight rules (IFR) Cessna Aircraft Company C210N, tracking from Darwin to Gove, NT at an altitude of 9,000 ft, was in conflict with an IFR Piper Aircraft Corporation PA31-350 that was tracking from Bathurst Island to Jabiru and that a breakdown of separation standards had occurred. The controller re-established the required separation.

The investigation identified that the safety management system employed by Airservices Australia did not require the conduct of an independent review of the locally conducted hazard assessment process that was utilised to manage the controller's loss of radar surveillance capabilities. This was considered to be a safety issue.

Preliminary report released 24 July 2007

On 15 April 2007, a Boeing Company 747-438 aircraft, registered VH-OJR, was being operating on a scheduled passenger flight from Singapore to Sydney, NSW. At 1923 Eastern Standard Time, the aircraft was positioned on a short final approach for a landing on runway 16R when it encountered rapidly changing wind conditions. The aircraft touched down firmly and the crew conducted a go around.

The investigation is continuing.

On 11 April 2007, shortly after take-off from Wagga Wagga Airport, NSW, the crew of a de Havilland Dash 8 aircraft registered VH-TQY, noticed an unusual popping sound, followed by a slight vibration through the power levers. On passing 3,800 ft there was a significant drop in torque on the left engine, with associated popping noise. The crew shut down the engine and returned to Wagga Wagga Airport. After initial inspection on the wing, the engine was removed and sent to the manufacturer for disassembly and examination.

The examination found that the engine's number 5 bearing, the high pressure (HP) turbine disc and stub-shaft had failed. These components were sent to the Australian Transport Safety Bureau for further examination. That examination determined the number 5 bearing had failed at its roller cage through fatigue cracking, the stub-shaft had failed under overload and the HP turbine disc had suffered blade tip rubbing.

The operator had experienced a previous number 5 bearing failure on another of its engines. That bearing displayed the same failure pattern of its roller cage and was consecutively serial numbered to the VH-TYQ engine's number 5 bearing.

As a result of this investigation, the engine manufacturer identified a batch of 15 bearings that required replacement and introduced procedures to minimise the risk of further number 5 bearing failures.

On 4 April 2007 at about 0809 Eastern Standard Time a Boeing Aircraft Company 737-8FE registered VH-VON was inbound to Sydney, NSW from Melbourne, Vic. on descent to 6,000 ft and an Airbus A330-342X, registered B-HLW was departing Sydney for Hong Kong on climb to 7,000 ft. The distance between the aircraft reduced to 1.9 NM horizontal and 600 ft vertical separation. Separation standards as specified in the Manual of Air Traffic Services (MATS) required the provision of either 3 NM horizontal or 1,000 ft vertical separation between the aircraft. There was a breakdown of separation.

The loss of separation occurred as a result of the separation that was planned by the air traffic control officer being based on an incorrect cleared flight level (CFL) that had been entered into the controller's air situation display (ASD). The investigation concluded that this data entry error occurred within 2 minutes of the air traffic controller assuming responsibility for the control position, and that the reconfiguration of the in-use console by the controller during that time increased the risk of the controller being distracted from the traffic separation task.

On 9 April 2007, at 1703 Western Standard Time, the main landing gear of a Beech Super King Air 200 (registered VH-SGT) collapsed on touchdown at Perth airport. The aircraft was extensively damaged as a result of the collapse. No injuries were sustained by the pilot or passengers from the accident.

The Australian Transport Safety Bureau investigation revealed that two major system components had failed which could have prevented the landing gear from properly retracting/extending; the geared components within the right main landing gear actuator had fractured, and the left torque tube support bearing had seized from contamination and lack of lubrication. Although each component failure was apparently unrelated, the examination was not able to conclusively establish which failure had been the primary contributing factor in this landing occurrence. The Super King Air 200 aircraft landing gear system configuration was such that should either one of these component assemblies cease to function, extension or retraction of the landing gear would not have been possible.

As a result of this occurrence, the operator changed their system of maintenance to introduce an inspection interval and replacement schedule for all landing gear torque tube support bearings within their Super King Air 200 fleet.

The Civil Aviation Safety Authority released airworthiness bulletin 32-07 to all operators of Hawker Beechcraft 65, 70, Queen Air 90 and 200-series King Air aircraft that recommended changes to the maintenance schedule for landing gear components.

Safety Advisory Notice

[SAN20080002]

Dornier Do 228-202, ZK-VIR, was carrying out a positioning flight from Westport to Christchurch on the South Island of New Zealand. At about 50 NM north of Christchurch, while cruising at 10,000 feet, both pilots reported becoming 'giddy' and close to fainting. The pilots turned off the cockpit heating and directed external air into the cockpit. A PAN call was made and the aircraft descended to the area minimum safe altitude of 9,000 feet. The crew elected to continue to Christchurch where they were able to make a safe landing.

The Transport Accident Investigation Commission (TAIC) of New Zealand initiated an investigation into the incident, TAIC reference: 07-002. TAIC investigators obtained the cockpit voice recorder (CVR) from the aircraft and requested assistance from the Australian Transport Safety Bureau (ATSB) to recover any information that may have been recorded. In accordance with clause 5.23 of Annex 13 to the Convention on International Civil Aviation, the ATSB appointed an Accredited Representative to assist TAIC and initiated an investigation under the Transport Safety Investigation Act 2003.

The CVR was transported to the ATSB audio laboratory in Canberra for examination in the custody of a TAIC investigator. The CVR information was downloaded on the 11 April 2007. The CVR and copies of the recovered information were provided to the TAIC investigator to be transported back to New Zealand.

The TAIC is responsible for releasing a final investigation report regarding this occurrence. Once it has been completed, a copy of the TAIC investigation report (07-002) may be found at: www.taic.org.nz or by contacting:

TAIC
PO Box 10-323
Wellington 6036
New Zealand

At 1814 Central Standard Time on 2 April 2007, an Israel Aircraft Industries 1124, Westwind aircraft, registered VH-AJP, with a crew of two, departed Darwin Airport, NT on a scheduled cargo service to Alice Springs, NT. At 1844, during climb, at 34,000 ft, the crew heard a series of loud bangs followed by a loss in cabin pressure. The crew donned oxygen masks, closed the aircraft outflow valves and conducted an emergency descent to 10,000 ft. The aircraft was returned to Darwin.

An inspection of the aircraft revealed a hole in a top rear fuselage skin panel. The examination revealed that approximately 60% of the panel had been damaged by exfoliation corrosion. The damage was most severe at the primary site of rupture, in the centre of the panel.

The panel was clad with a corrosion resistant pure aluminium alloy sheet; however, the aluminium cladding was removed on the chemical milled areas. Over time, the coating protecting of the chemical milled areas had deteriorated, leading to the corrosion on the panel.

The panel was located in an area that was not considered susceptible to corrosion, so there were no detailed inspections required for the area.

As a result of this occurrence, the manufacturer has issued a notice to all 1124 Westwind aircraft operators informing them of the event and the corrosion that was found. The operator has carried out an inspection of the area on their entire fleet of 1124 Westwind aircraft. Where corrosion was present, the operator replaced the panel. The operator has also included an inspection of the area in their Corrosion Control Program.

On 31 March 2007, a Boeing Company B767-338, registered VH-OGN, was being operated on a scheduled passenger service between Jakarta, Indonesia, and Sydney, Australia. Approximately 1 hour after departing from Jakarta, the pilot in command (PIC) began to feel unwell. Over the following 4 hours, the medical condition of the PIC continued to deteriorate, and the copilot was alerted to this. The PIC vacated the pilot control position and handed over responsibilities for command decisions and flying duties to the copilot. With approximately 2 hours and 40 minutes of flight time remaining, the PIC left his control seat and relocated to an observer's seat at the rear of the cockpit.

As a result of this occurrence, the aircraft operator has advised the Australian Transport Safety Bureau that procedures relating to the monitoring of flight crew, following pilot incapacitation, have been reviewed and additional guidance material will be inserted into the operators' pilot documentation.

At Indonesia's request on 7 March 2007, the Australian Transport Safety Bureau appointed an accredited representative in accordance with Clause 5.23 of Annex 13 to the Convention on International Civil Aviation, to participate in the NTSC's investigation into the fatal accident at Yogyakarta, Indonesia, involving a Boeing 737 operated by Garuda Indonesia.

The aircraft overran the runway and crashed into a rice field 252 metres from the end of the runway. The aircraft was destroyed by impact forces and the post-impact fire.

There were two pilots, five flight attendants and 133 passengers on board. One flight attendant and 20 passengers, including five Australians were fatally injured. One flight attendant and 11 passengers, including 3 Australians were seriously injured, and two flight attendants and 98 passengers sustained minor injuries.

The ATSB dispatched a Deputy Director and two senior investigators to assist its Indonesian counterpart with the investigation. The ATSB also cooperated closely with the NTSC in the analysis of the aircraft black box recorders.

Australia's accredited representative to the investigation continued to work closely with the NTSC throughout the investigation.

To protect the information supplied by the NTSC to the ATSB and investigative workload undertaken to assist the NTSC, the ATSB initiated and investigation under the Transport Safety Investigation Act 2003.

On 22 October 2007, the NTSC published its final report into the accident on its website.

National Transportation Safety Committee
Ministry Of Transportation Republic Of Indonesia
Transportation Building 3^rd Floor
Jalan Medan Merdeka Timur No. 5
Jakarta Pusat 10110
Indonesia

Phone  :  +62 21 384 7601
Email    :  knkt@dephub.go.id

Website: http://knkt.dephub.go.id/knkt/ntsc_home/ntsc.htm

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