On 25 February 2010, a Piper Aircraft Corp Chieftain PA-31-350 aircraft, registered VH-BCQ, was being operated on a charter passenger flight from Mackay to Clermont Aerodrome, Queensland. Unable to land at either Clermont or the planned alternate aerodrome of Mackay due to deteriorating weather conditions, the flight diverted to Proserpine/Whitsunday Coast Aerodrome.

The pilot in command requested air traffic services (ATS) to arrange for a person to be on the ground at Proserpine/Whitsunday Aerodrome to ensure that the aerodrome lighting would be on for their arrival. This request was not actioned, but ATS provided the crew with a frequency for the pilot activated lighting system at the aerodrome. However, that frequency was decommissioned 10 days earlier, and a new frequency introduced.

On approach to Proserpine, the flight crew were unable to activate the aerodrome lighting. With critical fuel, and given weather considerations, the flight crew landed the aircraft without runway lighting at around 1957 Eastern Standard Time.

The investigation identified two minor safety issues; one relating to the practices used within the air traffic control group for the effective review and communication of notices to airmen, and the other the risk of out-of-date operational documentation.

The air navigation service provider advised that in response to this occurrence, it will conduct an internal education program to highlight the effect on safety when relevant information is not considered appropriately or reviewed before being provided to pilots.

The incorrect operational documentation has since been updated and the regional council managing Proserpine Aerodrome has instigated safety action relevant to their organisation.

The ATSB has completed its technical analysis report of the flight recorder data from an Avions de Transport Régional ATR-42-300F aircraft, registered PK-YRP, on behalf of the Indonesian National Transportation Safety Committee (NTSC). The aircraft carried out a forced landing in a rice field, approximately 33 km (18 NM) north-east of Balikpapan-Sepinggan Airport, Indonesia, after reportedly losing power from both engines.  The aircraft was operating a scheduled passenger service from Berau-Kalimaru Airport to Temindung Airport, Indonesia. Two of the 51 passengers on-board sustained serious injuries.

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 aircraft's flight data recorder and cockpit voice recorder.

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's technical analysis report has now been provided to the NTSC, who 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

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

On 16 July 2009 the pilot of a Beechcraft King Air C90 aircraft, registered VH-TAM, departed Perth Airport on a flight to Wiluna, Western Australia with one passenger on board.

Sometime after becoming established at flight level (FL) 210, the pilot became affected by hypoxia, which resulted in him becoming fixated on the 'distance-to-run' figures on the aircraft's Global Positioning System equipment display and incorrectly interpreting those figures as the aircraft's 'groundspeed'. That confusion resulted in the pilot interpreting the lower-than-expected figures as a significant headwind and in him descending the aircraft to escape the winds. Once established at FL150 for a significant period of time, he realised that that he had been affected by hypoxia. The pilot descended further before landing at his destination.

The investigation identified problems with the aircraft's left landing gear squat switch that prevented the aircraft from pressurising in flight. In addition, the cabin altitude warning system was non‑operational due to the incorrect connection of the switch wiring during previous maintenance.

Following this occurrence, the aircraft manufacturer changed the aircraft type's maintenance manuals and documentation and the Civil Aviation Safety Authority (CASA) issued a letter to owners and operators of Australian-registered pressurised aircraft that proposed mandating the fitment of aural cabin pressure warning systems in those aircraft. As a result of that industry consultation, CASA determined that a uniquely Australian installation requirement could not be justified.

Notwithstanding, as a result of the ongoing risk of serious incidents and fatal accidents in which the occupants of single-pilot, turbine‑powered, pressurised aircraft have been affected by, or have succumbed to unrecognised hypoxia in an unpressurised cabin, the Australian Transport Safety Bureau has issued a safety advisory notice. That notice encourages all operators of such aircraft to consider the installation of an aural cabin altitude pressure warning system that operates separately to their aircraft's visual warning system.

Executive summary

At 0435 on 16 February 2010, the bulk carrier River Embley was at anchor off Gladstone, Queensland, when the ship's fire alarms sounded, alerting the crew to an engine room fire. A few minutes later, while the engineers were investigating the fire, there was an explosion in the engine room.

The crew shut down the running machinery, the engine room vents were closed and the ship's electrical load was transferred to the emergency generator. They monitored the situation and at 0823 confirmed that the fire had been extinguished. By 1105, they had determined that the engine room was safe to enter without the use of breathing apparatus.

The ATSB investigation determined that the fire started inside a screw type air compressor and that the explosion that followed occurred when a cloud of hot oil vapour, which had been expelled from the compressor, ignited.

The investigation found that the compressor did not shut down before the fire occurred because its high temperature alarm/shutdown did not operate. The investigation also found that, during the emergency response, the crew worked as a team and demonstrated how effective a trained response to an unexpected emergency can be.

The investigation identified two safety issues: routine testing of the compressor high temperature alarm/shutdown was not included in the ship's planned maintenance system; and routine testing of the alarm/shutdown was not included in the manufacturer's maintenance manual.

These safety issues have been addressed by the ship's managers and the compressor manufacturer.

On 14 February 2010, the pilot of a Cessna Aircraft Company TU206C (C206), registered ZK-JAO, was being operated on a private ferry flight under the
visual flight rules (VFR) from Lord Howe Island, New South Wales (NSW) to Coolangatta, Queensland (Qld) via Port Macquarie, NSW. Those sectors comprised the final stage of the ferry flight, which had originated from New Zealand. The pilot was the only person on board the aircraft.

The pilot reported that he had experienced intermittent ferry tank fuel flow problems during the flight from Lord Howe Island, NSW to mainland Australia. The pilot consequently selected the aircraft's main fuel tanks to ensure a reliable supply of fuel to the engine. At approximately 19 km east of South West Rocks, NSW, when the fuel was exhausted from the aircraft's main fuel tanks, the pilot selected fuel from the ferry tank, but was unable to restart the engine. The fuel flow from the ferry tank had been disrupted and the remaining 300 L in that tank was unable to be accessed. The pilot conducted a successful forced landing at an airstrip in the vicinity of South West Rocks, NSW. There was no reported damage to the aircraft or injuries to the occupant.

The reason why the ferry tank's fuel flow was disrupted could not be established; however, the pilot stated it was likely that an air pocket somewhere in the fuel system between the ferry tank and the aircraft's main fuel lines starved the engine of fuel.

The pilot had installed the ferry tank in New Zealand without the appropriate regulatory authorisations and qualifications to do so.

Although there was no evidence as to whether the installation of the ferry tank played a role in the incident; it is a reminder that approved modifications, carried out by appropriately qualified and licensed people are likely to reduce risk.

On 31 January 2010, an American Aircraft Corporation Grumman Traveller AA-5 aircraft, registered VH-ERP, was being operated on a visual flight rules private flight from Temora, New South Wales to Canberra, Australian Capital Territory. At about 1630 Eastern Daylight-saving Time, on late final approach to runway 12 at Canberra Aerodrome, and at an altitude of about 150 ft above ground level, the aircraft experienced severe turbulence that resulted in a brief loss of control. The pilot recovered control and landed on runway 12.

The investigation determined that it was probable that the severe turbulence was generated by a combination of the wind conditions on the day and the position of the two buildings located about 220 m and 290 m upwind from runway 12. In addition, there were no standard criteria for assessing the potential local wind effect of aerodrome building developments on aviation operations, and no national building codes for aerodrome developments that address the phenomena of building-induced turbulence.

The aerodrome operator had commissioned pre-construction wind impact assessments of the two buildings to the north of runway 12. These reports concluded that the buildings would not result in adverse wind effects on aircraft operations. This conclusion was based in part on the assessment that use of runway 12 was unlikely in northerly wind conditions. However, operations to that runway remained possible in those conditions without any alert to affected pilots about possible risk. By contrast the Canberra Aerodrome information in the En Route Supplement Australia alerted pilots of the possibility of severe turbulence during touchdown on runway 35 in strong westerly winds.

Subsequent to this occurrence, the Department of Infrastructure, Transport, Regional Development and Local Government established the National Airports Safety Advisory Group (NASAG). NASAG's role is to examine airport planning issues, including the potential local wind effects of buildings on aircraft operations, and to develop a set of universal guidelines and policy material for application at state and local levels. In addition, Airservices Australia is progressing the installation of wind shear detection technologies at several aerodromes. There is the potential that one of those installations could be at Canberra Aerodrome.

Overview

At approximately 1650 on 10 February 2010, empty passenger train WP46 was authorised to travel through Manildra Yard on the main line. However, at the same time a freight train was already standing on the main line, having recently completed shunting within the yard limits relating to preparation of train 8938.

The driver of WP46 heard radio chatter relating to the freight train, so he broadcast that train WP46 was approaching and was authorised to travel through Manildra on the main line. The crew of the freight train immediately replied that they were standing on the main line and advised train WP46 to stop. Train WP46 had already passed the yard limit board but the driver had sighted and reacted to a main line indicator (MLI) showing a red (stop) indication. Train WP46 stopped before passing the MLI, which was located more than 530 m before the track occupied by the freight train.

While a number of defences served to avoid a collision in this case, the event posed a serious safeworking irregularity where one train had been authorised to proceed over track occupied by a second train.

The investigation concluded that the ARTC network controller fulfilled a shunt order without entering information into the computer system identifying that both the main line and loop were occupied. The controller had later forgotten about the track occupancies when authorising train WP46 to travel through the Manildra Yard.

The ARTC, Pacific National and the Manildra Group have put processes in place to ensure shunt orders are not fulfilled unless all shunt operations have ceased and either the main line is clear or a form of train protection has been implemented in accordance with the network rules.

On 31 March 2009, the pilot of a Fairchild Metro SA227-AC aircraft, registered ZK-NSS, experienced control difficulties during landing at New Plymouth Aerodrome, New Zealand, with the aircraft subsequently departing the runway. The New Zealand Transport Accident Investigation Commission (TAIC) commenced an investigation into the occurrence on 1 April 2009 (investigation number 09-003).

On 1 February 2010, the TAIC requested assistance from the Australian Transport Safety Bureau (ATSB) in the review and analysis of data recovered from the aircraft's flight data recorder (FDR). To protect the information supplied to the ATSB and the investigative analysis carried out to assist the TAIC, the ATSB initiated an investigation under the Transport Safety Investigation Act 2003 (TSI Act), and appointed an accredited representative to the TAIC investigation, in accordance with clause 5.23 of Annex 13 to the Convention on Civil Aviation (Chicago Convention).

The ATSB has completed its review and analysis of the FDR information from ZK-NSS and has provided feedback to the TAIC.

The TAIC is responsible for releasing a final investigation report regarding this occurrence.

Contact details for the TAIC are at Website: www.taic.org.nz

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

Preliminary report released 17 May 2010

On 29 January 2010, at about 2010 Western Standard Time a single-engine Pilatus PC-12 aircraft, registered VH-NWO, was being operated on a medical evacuation flight from Derby to Kununurra, Western Australia with four persons on board. The flight was being conducted under the Instrument Flight Rules.

At a position about 30 NM (56 km) after take-off, the pilot reported engine problems and turned the aircraft back to the departure aerodrome. The engine subsequently failed, and the pilot glided the aircraft to the aerodrome and landed safely with no reported injuries. A subsequent inspection confirmed that the engine propeller reduction gearbox had seized.

The investigation found that a number of first - stage reduction gearbox carrier bolts had failed. As a result, the engine manufacturer has reviewed a number of issues relating to engine overhaul practices and has recommended withdrawal from service of an engine from one aircraft in the Australian fleet for examination.