On 7 March 2009, an Indonesian registered Fokker 50 aircraft, PK-RAR, on a flight from Batam - Hang Nadim airport to Matak Island, Indonesia, overran the runway during landing. The weather was reportedly poor with heavy rain.

The National Transportation Safety Committee (NTSC) of Indonesia was 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 flight data recorder and 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.

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

The ATSB provided information to the NTSC during the course of the investigation and the ATSB's Technical Analysis Report has now been provided to the NTSC. The NTSC is responsible for releasing a final investigation report on 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.

The ATSB has completed its technical analysis report of the flight recorder data from a British Aerospace BAe146-300 aircraft, registered PK-BRD, on behalf of the Indonesian National Transportation Safety Committee (NTSC). The aircraft was operating a cargo transport flight from Jayapura to Wamena, West Papua, Indonesia when it collided with terrain following a rejected landing approach (go-around) at Wamena on 9 April 2009. All six people on board were fatally injured.

The National Transportation Safety Committee (NTSC) of Indonesia 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 aircraft's flight data recorder and 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.

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

The ATSB provided information to the NTSC during the course of the investigation and the ATSB's Technical Analysis Report has now been provided to the NTSC.

The NTSC is responsible for releasing a final investigation report on 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.

Preliminary report released 30 April 2009.

At 2231 Eastern Daylight-saving Time, an Airbus A340-500 aircraft, registered A6-ERG, commenced the take-off roll on runway 16 at Melbourne Airport on a scheduled, passenger flight to Dubai, United Arab Emirates with 257 passengers, 14 cabin crew and four flight crew. The take-off was planned as a reduced-power take-off and the first officer was the handling pilot for the departure.

At 2231:53, the captain called for the first officer to rotate. The first officer attempted to rotate the aircraft, but it did not respond immediately with a nose-up pitch. The captain again called 'rotate' and the first officer applied a greater nose-up command. The nose of the aircraft was raised, and the tail made contact with the runway surface, but the aircraft did not begin to climb. The captain then selected TOGA on the thrust levers, the engines responded immediately, and the aircraft commenced a climb.

The crew notified air traffic control of the tail strike and that they would be returning to Melbourne. While reviewing the aircraft's performance documentation in preparation for landing, the crew noticed that a take-off weight, which was 100 tonnes below the actual take-off weight of the aircraft, had inadvertently been used when completing the take-off performance calculation. The result of that incorrect take-off weight was to produce a thrust setting and take-off reference speeds that were lower than those required for the actual aircraft weight.

The aircraft subsequently landed at Melbourne with no reported injuries. The tail strike resulted in substantial damage to the tail of the aircraft and damaged some airport lighting and the instrument
landing system.

As a result of the accident, the aircraft operator has advised the Australian Transport Safety Bureau that it is reviewing a number of procedures including human factors involved in take-off performance data entry.

On 6 March 2009, an Airbus A330‑303 aircraft, registered VH-QPJ, was being loaded for dispatch on a scheduled international passenger service between Sydney, New South Wales and Hong Kong. Operational changes prior to the aircraft's dispatch required an adjustment of the planned load, with the load controller electing to offload a pallet of freight originally scheduled for that flight, and substituting it with a lighter pallet in the load management system.

Following the pallet substitution in that system, the load controller did not amend the loading instructions that had been previously issued to the ramp staff loading the aircraft. That resulted in the ramp staff being unaware of the changed loading requirement and the loading proceeded as initially planned.

The discrepancy between the actual aircraft load and operator's load management system was not detected during the completion of the load controller's 'Final Distribution Check' prior to issuing the final load sheet to the flight crew. That resulted in the aircraft exceeding the structural maximum taxi weight by 384 kg and the maximum structural take-off weight by about 884 kg. It also resulted in the flight crew entering inaccurate centre of gravity and zero fuel weight data into a number of the aircraft's systems.

Due to a delay in the notification of the loading error to the operator's relevant departments, the aircraft operated another 10 sectors before maintenance inspections for an overweight taxi were completed.

As a result of this occurrence, the operator implemented several changes to the process for managing load control activities. Those changes included: implementing a procedure to ensure the immediate notification of loading-related incidents and changes to the operating procedures in load control, including the introduction of a read and sign process for important ramp and load control communications; the appointment of a load control standards officer; and the conduct of a training needs analysis for load control officers.

On 24 February 2009, at 1417 Eastern Standard Time, a Piper Aircraft PA28-180 Cherokee aircraft, registered VH-DAC, departed Normanton Airport, Qld on a visual flight rules private flight to Mount Isa with the pilot as the sole occupant. The aircraft did not arrive at Mount Isa as expected and was later found to have impacted terrain at a location adjacent to the planned track. The aircraft was seriously damaged, and the pilot was fatally injured. Examination of the wreckage did not indicate any pre-existing technical fault that may have contributed to the accident. The pilot was not qualified to fly in instrument meteorological conditions (IMC). He may have inadvertently entered IMC while attempting to avoid rain and cloud associated with a weather system that was moving over the intended route at the time.

On 11 February 2009 at about 1922 Eastern Standard Time, a Bombardier Inc DHC‑8‑315 commenced the take-off roll on runway 01 at Townsville Aerodrome for Cairns, Queensland. During the take-off, the pilot in command realised that the aircraft was aligned with the left runway edge. The aircraft was manoeuvred to the centre of the runway and the take-off rejected. It was later determined that the aircraft's left mainwheel had damaged a runway edge light. There were no injuries to the 34 passengers or five crew members and no damage to the aircraft.

The investigation found a number of factors that may have led to the pilot in command not aligning the aircraft on the runway centreline for the take-off. Those factors included misinterpreting the normal runway cues, time pressure to depart, the weather conditions at Townsville Aerodrome and the associated delays during the aircraft's arrival, landing and departure.

Following this occurrence, the operator amended their operational procedures to ensure aircraft were aligned on the centreline of the assigned runway. In addition, the Australian Transport Safety Bureau (ATSB) has released an Aviation Research and Analysis Report (AR-2009-033) that examined a number of domestic and international occurrences in which pilots commenced the take-off while aligned with the runway edge lighting. In that examination, eight common factors were identified that increased the risk of a misaligned takeoff or landing occurrence, including: the distraction or divided attention of the flight crew; a confusing runway layout; the presence of a displaced threshold or the conduct of an intersection departure; poor visibility or weather; air traffic control clearance(s) issued during runway entry; no runway centreline lighting; flight crew fatigue; and recessed runway edge lighting.

The ATSB has developed a Pilot Information Card that will alert pilots of the increased risk of a misaligned takeoff as a result of those factors, which will be distributed to relevant parts of the industry and will be available from the ATSB on request.

During the post-flight inspection of a Saab 340B passenger aircraft, the number two outboard main landing gear wheel was observed to have sustained noticeable damage. The flight crew reported that there was no prior indication of the failure, as the aircraft had handled normally during the landing and taxiing phase of the flight.

Subsequent examination found that the wheel inner rim had fractured away from the hub for approximately one-half of the total circumference. A circumferential fatigue crack had initiated at a location at the bead seat radius, and had propagated until a final ductile overload failure caused a section of the wheel rim to separate.

During the course of the investigation, it was found that the particular wheel design was being phased out due to recognised fatigue problems identified at the bead seat area.

Both the manufacturer and operator were aware of the increased fatigue susceptibility of the earlier wheel design and had established increased inspection regimes for those wheels remaining in service.

On 7 February 2009, five aircraft were engaged in circuit training and one aircraft was departing runway 03 left (03L) at Parafield Airport, SA. All of the aircraft in the circuit at the time were operated by a local flight school. The control tower was not open and Common Traffic Advisory Frequency - carriage and use of radio required, CTAF (R), procedures were in place.

At about 0736 Central Daylight-saving Time, a S.O.C.A.T.A.-Groupe Aerospatiale TB-10 (Tobago), registered VH-YTG, with an instructor and student on board, was on final approach for a practice short field landing. In the circuit behind the Tobago was a Grob - Burkhaart Flugzeugbau G-115 (Grob), registered VH-TGM, with an instructor and student on board. The Grob was on final approach for a practice flapless approach and landing. The Grob collided with the Tobago from behind, damaging the Tobago‟s rudder with the Grob‟s right wing. Both aircraft remained controllable and were landed on runway 03L and 03 right.

The investigation found that the pilots of the Grob experienced sun glare and background visual clutter on the base leg for runway 03L and were unable to sight the preceding Tobago. The pilots of the Grob did not discern some broadcasts from the Tobago pilots, significantly diminishing their situational awareness. The pilots of the Grob continued the approach without positively identifying the preceding aircraft in the circuit.

Soon after the accident, the aircraft operator's flight safety officer produced a comprehensive accident investigation report that captured the key aspects of the accident. Included in the report were a number of recommendations, which were implemented by the operator.

The investigation identified a safety issue regarding definition of the circuit traffic limit in CTAF(R) and a safety issue related to the positive identification of traffic before turning final.

On 2 February 2009, an Agusta Westland AW139 helicopter, registered VH-ESH, departed under the instrument flight rules from Mackay Aerodrome for Townsville Aerodrome, Queensland. The purpose of the flight was to return the helicopter to Townsville following the passage of a tropical cyclone.

Shortly after departure from Mackay, the crew were presented with an increasing number of alert messages indicating the failure of various helicopter systems. While the crew were focussed on assessing these messages, the autopilot altitude hold function disengaged, leading to a descent that was not detected by either the flight crew or air traffic services (ATS).

The helicopter descended undetected for over 6 minutes while flying towards an area of rising terrain, losing about 3,300 ft of altitude, before ATS observed the descent and alerted the crew.

The investigation determined that the helicopter sustained two independent technical problems; one associated with water and particulate ingress and a second related to the probable susceptibility of the air data system to in-flight turbulence. These failures resulted in multiple erroneous alert messages and uncommanded disengagement of the altitude hold function. The investigation also identified a number of safety factors relating to workload and task management by the crew and monitoring of the aircraft by ATS. That included the lack of an altitude deviation alert within the Australian Defence Air Traffic System (ADATS).

Following the occurrence, the helicopter manufacturer and operator, and the Civil Aviation Safety Authority (CASA) implemented a number of safety actions relating to the identified technical and operational safety issues. In addition, the manufacturer and operator of the helicopter, and CASA undertook proactive safety action in a number of cases for which no safety issues were identified.

A replacement common ATS system for ADATS and the civilian Australian Advanced Air Traffic System (TAAATS) has been announced by the Government that could be expected to include common alert functions, such as the existing cleared level adherence monitoring alert in TAAATS.

At about 1452 Eastern Daylight-saving Time on 24 December 2008, a Cessna Aircraft Company 172L aircraft, registered VH-EKS, with a pilot and one passenger, departed Mudgee on a private visual flight rules (VFR) flight to a property near Glen Innes, New South Wales. About 15 minutes after departure, the pilot encountered increasing cloud and, after climbing to assess the weather ahead, decided to descend visually through the cloud in order to maintain visual meteorological conditions.

The pilot descended the aircraft into a valley that was enshrouded in cloud. After flying up the valley for a short time, the pilot decided to turn back. During the turn-back manoeuvre, the aircraft entered cloud. The pilot became disorientated, and the aircraft collided with terrain.

The pilot and passenger were seriously injured, and the aircraft was seriously damaged. Shortly after, the passenger succumbed to his injuries.

The pilot's decision not to obtain the relevant Bureau of Meteorology forecasts prevented a full understanding of the weather likely to affect the flight and what impact this might have on his flight planning, including alternate routes and fuel requirements. Similarly, the pilot's decision not to submit any form of formal flight notification, and to not replace the normally carried portable Emergency Locator Transmitter, adversely affected the prompt commencement of a search and rescue following the accident.

While not contributory to the accident, the investigation identified an error in the flight planning requirements in the Visual Flight Guide (VFG) for VFR flights away from a departure aerodrome. The Civil Aviation Safety Authority (CASA) has advised that the VFG has been withdrawn for amendment.

The investigation also identified that the optional nature of the navigational component of the Aeroplane Flight Review (AFR) meant that a pilot's navigation skills could remain un-assessed for an extended period. While this did not contribute to the accident, CASA has advised that the optional nature of the navigational component will be amended to being a recommended element of the AFR, and that guidance will be provided on its conduct.