On 5 June 2009, during a scheduled passenger service from Melbourne, Victoria (Vic.) to Coolangatta, Queensland (Qld), the cabin crew of a Boeing Company 737-800 aircraft, registered VH-VBL, detected a strong intermittent smell in the rear of the cabin. An inspection by the cabin crew did not detect the source of the smell.

On descent prior to landing, cabin crew presented various symptoms. Two of the cabin crew used oxygen before recovering sufficiently to resume their duties. No passengers were affected.

The airport rescue and fire fighting service attended the aircraft at the arrival gate. Paramedics conducted medical checks on the cabin crew. Both the cabin crew and flight crew were taken to the local hospital for further examination and later released.

The cargo holds were opened prior to a precautionary inspection for the source of the fumes. The source and nature of the fumes was not identified.

As a result of the incident, the operator initiated and completed a number of safety actions to improve communications and processes in relation to air contamination events.

While it was not possible to determine the nature or source of the reported fumes, the incident highlights the potential for crew incapacitation from exposure to toxic smoke and fumes.

On 22 May 2009, a temporary modification was made to the runway 11/29 lighting at Darwin aerodrome, Northern Territory (NT), due to runway works being conducted on the runway 11 threshold. At 1840 Central Standard Time1, 10 minutes prior to last light, Darwin air traffic control (ATC) attempted to activate the runway lights; however, the runway 11/29 edge lights failed to turn on. Due to the lighting failure, ATC asked all aircraft intending to land at Darwin to hold. After requesting the reason for holding, the crew of a Boeing Company 717-200 aircraft, registered VH-NXM, on a scheduled passenger service with 117 people on board, advised that they had 30 minutes of holding fuel available (equivalent to 1920).

Just prior to 1910, ATC notified the crew of the 717 the lighting was still unavailable and reported asking the crew if they could divert. Initially the crew
advised ATC that they did not have diversion fuel. However, after further calculations, they determined that they had enough fuel for an immediate diversion to Tindal aerodrome, NT. The aircraft was diverted to Tindal and landed without further incident. The pilot in command (PIC) reported that it landed with 1,000 kg of fuel remaining, equating to the fixed fuel reserve.

The lighting at the aerodrome was subsequently restored and the other aircraft holding landed safely at Darwin.

The aerodrome operator advised the ATSB that, as a result of this incident, it has implemented a number of safety actions, including:

• they introduced standard operating procedures for placing night displaced thresholds
• on the recommendation of an independent consultant, they employed an electrical engineer as the engineering manager
• investigated alternative options for establishing a cross runway primary circuit
• purchased temporary portable lighting which can be pre deployed where similar works on the aeronautical ground lights are proposed.

In addition to having robust practices and procedures in place for conducting runway works, this incident highlights the importance of using clear and consistent radio phraseology to avoid confusion between ATC and crews.

On 18 May 2009, an Airbus Industrie A320-232 aircraft, registered VH-VNC was on a regular public transport flight from Mackay, Queensland (Qld) to Melbourne, Victoria when at about 1249 Eastern Standard Time, the aircraft started to vibrate. Cockpit indications showed that the left aileron was oscillating. The crew diverted the aircraft to the Gold Coast Aerodrome, Qld and landed.

The source of the aileron oscillation was an internal fault in one of the left aileron's hydraulic servos. The fault was introduced during manufacture by an incorrect adjustment of the servo, which caused internal wear in a number of the servo's hydraulic control components. The aileron servo manufacturer has incorporated a new method of adjusting the aileron servos during assembly to minimise the likelihood of a recurrence of the problem.

During the investigation, it was found that an identical fault had occurred to the same aircraft 8 months prior to this incident. The previous incident was not reported to the Australian Transport Safety Bureau by the operator as required by the Transport Safety Investigation Act 2003. The operator has improved the training of its staff and the reportable event requirements in its safety management system manual in an effort to address the non-reporting risk.

On 21 May 2009, the pilot of a Piper PA-31 Navajo, registered VH-WAL, was conducting a flight under the instrument flight rules from Albury, NSW to Canberra, ACT with one passenger on board. Approximately halfway through the flight, the pilot became concerned about the quantity of fuel remaining and subsequently conducted a precautionary landing 50 km south-west of Canberra. There was no reported damage to the aircraft or injuries to the occupants.

The aircraft operator has advised the ATSB that, as a result of this occurrence, it has implemented a requirement for all of its pilots to use a documented fuel plan in all circumstances when flying from one location to another.

On 5 May 2009, two Robinson Helicopter Company R22 Beta II helicopters, registered VH-PHT and VH-HCB collided midair about 15 km south-east of Springvale Station, WA. Both helicopters had departed the station just prior to sunrise that morning to conduct mustering operations.

The first helicopter was observed departing to the east in order to make radio contact with an adjoining station prior to heading for the mustering area. The other helicopter departed about 10 minutes later and was observed heading to the south-east, the general direction to the area that was to be mustered.

The helicopters were due to refuel at about 0830 at a place to be arranged, depending on the progress of the mustering operation. When the pilots failed to respond to radio calls from ground personnel, a pilot from a nearby station was tasked to conduct a search by helicopter. The helicopters were subsequently located about 15km to the south-east of Springvale Station and about 2km north of the planned mustering area.

The circumstances of the accident were consistent with a midair collision while the pilots were positioning to commence the muster. The converging flight paths of the helicopters, pilot fatigue and sun glare from the rising sun are identified as contributing safety factors.

On 20 April 2009, a Robinson Helicopter Company R44 (Raven II) helicopter, registered VH-EZT (EZT), was conducting aerial spraying operations near Langkoop, Victoria. Spraying commenced at 0800 Central Standard Time with a load of 300 L of foliar fertiliser. There were two helicopters spraying the pine paddocks that morning and the operating crews were to break for lunch at about 1300 at a pre-arranged meeting place. Just prior to lunch, the pilot of EZT was tasked with a number of unplanned spray runs and a cleanup run to complete the morning's spraying. When the helicopter did not arrive at the pre-arranged meeting place, the pilot of the second helicopter commenced searching and located the wreckage of EZT in a paddock, near a powerline. The pilot of EZT was fatally injured.

Helicopter EZT contacted a powerline that intersected the northern half of the final spray paddock before colliding with the ground. An examination of the wreckage of the helicopter did not find any mechanical abnormalities that might have contributed to the accident.

Recorded data from the helicopter's satellite navigation system showed that after completing the planned spray runs, the pilot did not conduct a reconnaissance of the unfamiliar area to the south of the plantation to identify any hazards. A reconnaissance flight may have alerted the pilot to the presence of the previously-identified powerline.

The investigation found that an additional hazard identification check prior to the conduct of a cleanup run was not routinely practiced by the pilots, or monitored by the operator. In response to that safety issue, the operator has advised that they will enhance the wire avoidance procedures in their operations manual and mandate that an additional hazard identification check shall be completed prior to any cleanup run.

In addition, the investigation determined that there were no fluid quantity markings on the helicopter's spray tank, and that the spray system included unapproved modifications that increased the risk of overweight operations.

On 3 May 2009 at approximately 0620 Eastern Standard Time, a Bell Helicopter Company model 47G-2A-1 helicopter departed Rolleston aircraft landing area, Queensland, on a private flight. At an altitude of approximately 200 ft above ground level during the climbout, the pilot reported hearing a very loud bang and feeling a jolt through the airframe. The helicopter immediately started descending and the pilot noted that the forward/aft cyclic control was unresponsive. The helicopter subsequently landed heavily, resulting in the main rotor blades severing the tail boom and causing some structural damage to the airframe. The pilot reported suffering a minor back injury as a result of the heavy landing.

The Australian Transport Safety Bureau's (ATSB) examination of the helicopter revealed that two blades had separated from the engine cooling fan as a result of fatigue fracture. The fan cowling had fractured and separated from the engine and there was impact damage to the flight control linkages.

The ATSB examination determined that the fan unit had not been correctly assembled in accordance the Bell 47 aircraft maintenance manual, and that this probably had an effect on the vibration and resonance characteristics of the fan, which in turn may have increased the susceptibility of the fan to fatigue failure.

As a result of this occurrence, the Civil Aviation Safety Authority released Airworthiness Bulletin AWB 63-007, reminding operators and maintainers of the importance of adhering to all current manufacturer's approved data for sheet metal cooling fans and their drive assemblies.

On 7 April 2009, at about 1210 Eastern Standard Time, the flight crew of a Boeing 737-800 aircraft, registered VH-VYL, received an enhanced ground proximity warning system alert during an approach to land at Sydney Airport, NSW. At the same time, the autopilot disconnected, and the engine thrust levers moved towards idle. The handling pilot corrected the engine thrust levers immediately and conducted an uneventful landing.

The investigation determined that spurious data from the left radio altimeter (RA) provided an indicated altitude of minus 7 ft, resulting in the autopilot disconnecting and the thrust lever movement.

An examination found that the left RA receive antenna displayed rubbing wear adjacent to the attachment screw inserts. A bonding check of the antenna indicated that the antenna's resistance was outside the aircraft manufacturer's limits. The antenna was replaced, and the aircraft was returned to service.

Three months after the occurrence, a further RA warning flag event was experienced by another crew in this aircraft. As a result of that event, the left and right RA transceivers were removed and tested with internal faults found on the left unit.

The ATSB has completed its technical analysis report of the cockpit voice recorder download from Boeing 747-4U3 aircraft, registration PK-GSH, on behalf of the Indonesian National Transportation Safety Committee (NTSC). The aircraft was operating a scheduled international flight between Jeddah, Saudi Arabia and Jakarta, Indonesia. When the undercarriage was extended for landing at Jakarta, the left wing landing gear failed to extend. Following a number of flypasts, the crew landed the aircraft smoothly on runway 07R. The aircraft canted to the left during the landing and an emergency evacuation was carried out.

The NTSC is responsible for investigating this occurrence. The NTSC requested assistance from the Australian Transport Safety Bureau (ATSB) in the recovery and analysis of information from the cockpit voice recorder. In accordance with clause 5.23 of Annex 13 to the Convention on International Civil Aviation, the ATSB appointed an Accredited Representative to assist the NTSC and initiated an investigation under the Transport Safety Investigation Act 2003.

The ATSB's Technical Analysis Report has been sent to the NTSC to assist its ongoing investigation. The NTSC is responsible for releasing a final investigation report regarding this occurrence.

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

______________

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

On 2 April 2009, a flight instructor and student pilot in a Robinson Helicopter Company R22, registered VH-YDA, were conducting normal circuit and autorotation training at Proserpine/Whitsunday Coast Airport, Qld. At 1400 Eastern Standard Time, the helicopter collided with terrain on the grass at the side of the departure end of runway 11. The helicopter was seriously damaged, and the instructor was seriously injured.

After the accident, neither pilot could recall any of the flight sequence immediately before the impact. There were no witnesses to the accident and no relevant recorded data. An examination of the helicopter wreckage indicated that there were no pre-impact defects. Due to a lack of information, the investigation was unable to determine why the helicopter collided with terrain.

The investigation found that the use of safety helmets would reduce the risk of pilot injury during door(s)-off operations.

The investigation also found that the helicopter was about 11 kg overweight on take-off for the flight.