At approximately 0955 Central Daylight-saving Time on 8 Jan 2007, the flight crew commenced the take-off roll on runway 23 in a Boeing Company 737-838 aircraft, registered VH-VXG, on a scheduled passenger service from Adelaide, SA to Alice Springs NT.

At a speed of approximately 140 kts, the crew reported an abrupt, uncommanded yaw. Corrective action was applied, engine parameters checked, and the takeoff was continued without further incident. The crew advised Air Traffic Control of the uncommanded yaw and contacted the operator's maintenance watch for advice. The crew subsequently returned the aircraft to Adelaide Airport. The wind at the time was reported to be light (approximately 3 kts) from the east.

Data from the aircraft's Flight Data Recorder was recovered and downloaded by the Australian Transport Safety Bureau (ATSB) for review. That review indicated that the input to the aircraft rudder was not uncommanded and that the rudder pedals moved proportionally to the rudder surface deflection at all times. An engineering examination of the aircraft did not identify any reason for the uncommanded yaw and the aircraft was released back to service.

Due to a previous, similar, event at Adelaide Airport on 15 Dec 2006 (ATSB occurrence 200607627), the aircraft operator sought advice from the aircraft manufacturer. The aircraft manufacturer reviewed the data from the Flight Data Recorder and concluded that the recorded event was not a result of an uncommanded aircraft rudder input, asymmetric thrust, nose-wheel steering or asymmetric brake application.

While the nature of the uncommanded yaw could not be positively identified, it is likely that the event was related to an atmospheric disturbance during the take-off run.

The ATSB continues to monitor such reported uncommanded yaw events and has reported similar events in the past (see occurrence reports 200607627, 200500994 and 199703237 available on the ATSB website: www.atsb.gov.au).

At 1200 Eastern Standard Time, on 3 February 2007, after departing Sydney Airport and while in a climb at approximately 4,000 ft above ground level, the flight crew of a Boeing 747-438 aircraft, registered VH-OJM, heard several loud bangs and felt vibration through the aircraft structure. Observing an increase in the exhaust gas temperature indication for the number 3 engine, the crew following the non-normal checklist, shut down the engine, dumped excess fuel and returned the aircraft to Sydney Airport.

A subsequent examination of the engine found that it had sustained a high-pressure compressor (HPC), stage 1, blade failure. The mode of failure was known to the engine manufacturer, who had attributed it to blade tip rubbing, due to distortion of the engines high pressure case (module 41). To address the problem, the engine manufacturer had introduced service bulletin (SB), SB72-F002. The number 3 engine did not have the service bulletin embodied at the time of the failure.

Although the exact time of the blade tip rubbing and subsequent cracking could not be determined, the engine manufacturer believed that crack initiation to blade failure took approximately 50 cycles.

During the investigation, the aircraft operator experienced a subsequent failure, bringing the total number of failures of this type for the operator to five. Similar failures were reported by another aircraft operator, with 16 similar failures reported in total.

As a result of the incident, the operator accelerated its modification embodiment program and expects to have all installed engines modified by early 2010.

On the afternoon of 1 February 2007, a Piper PA-28R Cherokee Arrow, with the pilot, a flight instructor and a passenger was approaching to land on Runway 22 at Leongatha aerodrome, Vic. At the same time the pilot of a Cessna 188B Agwagon was taking off on Runway 18 at Leongatha.

Both aircraft were operating under the visual flight rules (VFR). When the Arrow was on base leg, the pilot of the Agwagon broadcast on the Leongatha common traffic advisory frequency (CTAF) that he intended to conduct aerial spraying operations on a property 2 NM to the north of the aerodrome and that he would depart from Runway 18. The instructor and the pilot of the Arrow heard that transmission but did not visually check the position of the Agwagon on the ground. After turning onto final, the pilot of the Arrow broadcast his intention to make a full stop landing on Runway 22, but that transmission was not heard by the pilot of the Agwagon. The pilot of the Agwagon reported that he visually checked the approach to Runway 22 before commencing his takeoff, but did not see the Arrow.

When the Arrow was on the landing roll on Runway 22 and the Agwagon had just become airborne on Runway 18, the two aircraft collided at the intersection of the runways. Both aircraft were substantially damaged but none of the occupants were injured.

The investigation found that the lookout by the pilots of both aircraft was not adequate to ensure that there was no conflicting traffic for their respective operations. Neither aircraft displayed landing lights that may have improved the chance of the pilots seeing each other. Sun glare may have increased the difficulty for the pilots of the Arrow seeing the Agwagon.

On 5 January 2007, a Piper PA-28R-201 Arrow, registered VH-TBB, was approaching Port Macquarie Airport, NSW, in class G airspace under the visual flight rules from the south. The aircraft had descended from 2,500 ft above mean sea level and was approaching to join the circuit on left crosswind for runway 03. At about the same time, a de Havilland Dash 8 aircraft, registered VH-TQZ, and a Piper PA-31 Mojave, registered VH-PGW, both operating under the instrument flight rules, were preparing to depart from the airport. The airspace surrounding Port Macquarie Airport was designated as a common traffic advisory frequency (CTAF) (R), where the carriage and use of very high frequency radio was required.

On short final for runway 03, the pilot of the Arrow reported seeing the Dash 8 enter the runway. He immediately broadcast his position and prepared to initiate a missed approach. The crew of the Dash 8 saw the approaching Arrow at the same time as the Arrow pilot's broadcast. They advised that they would vacate the runway without delay, vacating via taxiway B1 as the Mojave pilot manoeuvred his aircraft to assist the Dash 8's runway departure. The pilot of the Arrow continued his approach and landed.

On 11 January 2007, at about 0718 Eastern Daylight-saving Time, an Airbus A320 aircraft, registered ZK-OJB, departed runway 34L at Sydney Airport, NSW for Auckland, New Zealand and was assigned a radar heading by Air Traffic Control (ATC). The controller noticed that the aircraft turned onto an incorrect heading and informed the flight crew. The crew checked the aircraft's compasses and found that they were reading approximately 40 degrees incorrectly and that a GPS PRIMARY LOST message had appeared on the aircraft's multi-purpose control and display unit and navigational display. The crew advised ATC that they had navigational difficulties and elected to return to Sydney for landing.

When the aircraft returned to the departure gate, the flight crew noticed that the inertial reference system (IRS) had been aligned to the incorrect longitude. The operator's investigation into the incident found that the IRS had been aligned by maintenance staff prior to the crew boarding the aircraft. The incorrect alignment of the IRS was not noticed during a number of subsequent checks prior to departure.

As a result of this incident, the operator has proposed to develop a training program for all company pilots designed to improve discussion and guidance in relation to threat and error management issues.

In the early hours of 22 June 2009, an Airbus Industrie A330 (A330), registered VH-QPI (QPI), encountered an area of severe turbulence associated with convective activity while en route from Hong Kong to Perth, Western Australia. As a result of the incident, a combined total of seven passengers and crew members received minor injuries. After consultation with medical and operational personnel, the pilot in command continued the flight to Perth. The aircraft suffered minor internal damage and, after a maintenance check, was returned to service.

The cloud associated with the convective activity consisted of ice crystals; a form of water that has minimal detectability by aircraft weather radar. Consequently, the convective activity itself was not detectable by QPI's radar. As the event occurred at night with no moon, there was little opportunity for the crew to see the weather.

The operator intends to upgrade the weather radar fitted to its A330 fleet, which will increase the fleet's capability to detect convective turbulence. Two other minor safety issues were identified during the investigation relating to the risks associated with the use of the pilot flight library when turbulent conditions are encountered, and the engagement of the manual latch to the cockpit door preventing timely access to the flight deck by other operational staff. The operator has taken, or is proposing, relevant safety action to address those issues.

The Airbus Industrie A330-303 aircraft was being operated on a scheduled passenger service between Hong Kong and Sydney. The pilot in command and second officer were seated at the aircraft control stations while the copilot was in the crew rest area.

In the course of discussions between the pilot in command and second officer, it became evident to the pilot in command that the second officer was no longer responding to conversation. Upon checking, the pilot in command found the second officer to be suffering from what he believed to be a seizure. He was removed from the operating station and replaced by the aircraft's copilot.

The second officer was removed to the crew rest area and immediately attended by a medical practitioner who was travelling on the flight. The flight continued to Sydney.

On 6 January 2007, a TL-2000 Sting Sport ultralight aircraft, registered 24-3770, was found to have impacted the ground approximately 30 km north-west of Goulburn. The aircraft was fitted with a Rotax 912 ULS Engine. The engine disassembly and inspection was conducted by a Rotax engine specialist at the request of the NSW police, during which, the crankshaft was found to have fractured. Recreational Aviation Australia subsequently requested the assistance of the Australian Transport Safety Bureau in conducting technical analysis of the crankshaft. That analysis found no indications that would have prematurely initiated failure or have been detrimental to the fatigue life of the crankshaft.

Preliminary report released 4 August 2009

On 10 June 2009 at 1205 Universal Coordinated Time (UTC), an Airbus Industrie A330-202 aircraft, registered VH-EBF, departed Kansai International Airport, Osaka, Japan on a scheduled passenger transport service to the Gold Coast Airport, Qld., Australia with 182 passengers, 13 cabin crew and four flight crew on board.

At 1523, at approximately 427 km south-west of Guam, the flight crew noticed a burning rubber smell on the flight deck. At about that time, two caution messages were displayed to the crew identifying a fault in the right windshield heating. This was followed by a loud bang along with a flash of light, followed by smoke and fire from the bottom right corner of the right windshield. All flight crew donned oxygen masks, and a crew member used a BCF extinguisher to extinguish the fire.

The flight crew diverted the aircraft to Agana Airport, Guam, and reported that no other systems were affected by the fire. At 1614, the aircraft landed at Guam and there were no reported injuries to any of the passengers or crew.

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Update: 24 March 2011

The Australian Transport Safety Bureau (ATSB) is finalising its investigation into the June 2009 in-flight fire event that occurred in the cockpit of an Airbus A330 aircraft (registered VH-EBF) during a scheduled passenger service between Osaka, Japan and Gold Coast Airport, Queensland, Australia.

As the preliminary report on this incident indicates, the ATSB has identified the source of the fire to have been an electrical fault within a terminal block located at the lower right corner of the cockpit right forward windshield. The terminal block served to direct electrical power into the windshield's heating circuitry; ensuring they remain clear and free of ice and fogging that may otherwise interfere with the pilots' outside visibility.

Terminal block failure

Under the oversight and support of the accredited representative from the French investigation agency (Bureau d'Enquetes et d'Analyses pour la securite de l'aviation civile, BEA), the damaged windshield terminal block was dismantled and examined in detail at the manufacturer's facilities in France. While the analysis of the technical findings will be presented in the final ATSB report, it has been ascertained that the terminal blocks of certain windshields produced between February 2007 and August 2008 were susceptible to overheating in a manner similar to that sustained during this occurrence.

Investigation status

The draft report on this investigation is nearing completion and distribution to directly involved parties for comment. A final report should be published during the second quarter of 2011. However, the following safety actions have already been initiated:

Aircraft operator

Following the occurrence affecting VH-EBF, the aircraft operator inspected all windshield terminal block fittings within the aircraft in its fleet. The inspection centred on identifying any evidence of thermal effects or localised heating that may be precursor indications of a similar overheating mechanism. No such evidence was observed during any of the inspections undertaken.

Aircraft manufacturer

In early 2010 the aircraft manufacturer initiated an ongoing retrofitting program to remove and replace all suspect aircraft windshields.

On 10 June 2009, at about 1545 Eastern Standard Time, the pilot of a Bell Jetranger 206B helicopter, registered VH-JTI, was conducting a 20-minute scenic flight, with four passengers, from a helipad at an entertainment facility at Coomera, Queensland.

After about 15 minutes flying, the fuel boost pump low pressure (FUEL PUMP) warning light illuminated briefly. The pilot believed he had sufficient fuel on board and continued the flight. While the helicopter was descending to land at the helipad, the FUEL PUMP warning light illuminated again and shortly afterwards the engine lost all power.

During the final stages of the autorotative landing, the pilot was unable to arrest the helicopter's descent rate and the helicopter struck the ground heavily, resulting in substantial damage. Two passengers sustained serious injuries; the other two passengers and the pilot were uninjured.

A subsequent check of the helicopter and its fuel system showed that the fuel gauge may have been over reading. The operator's practice when calculating the quantity of fuel to be added during refuelling relied on the fuel gauge reading, without using an independent method to crosscheck that reading against the actual fuel tank quantity.

The investigation found that the helicopter departed with insufficient fuel to complete the flight. The low fuel quantity and manoeuvring combined to uncover the fuel boost pumps and the engine was starved of fuel. The helicopter's low speed, height and rotor RPM at that time precluded a safe landing from the subsequent autorotation.