On 31 December 2009, a Cessna Aircraft Company model 208, registered VH-UMV, was engaged in parachuting operations from Cairns Airport, Queensland. While climbing through 12,500 ft in preparation for a parachute drop, the engine failed. The parachutists exited the aircraft and the pilot completed a glide approach and uneventful landing at Cairns Airport.

The failure of the Pratt and Whitney PT6A-114 engine was probably precipitated by fracture of the compressor turbine blades. Federal Aviation Administration (FAA) parts manufacturing approval information indicated that part number T-102401-01 compressor turbine blades that had been installed in the engine during the most recent overhaul were not approved for the PT6A-114 model.

As a result of this occurrence, the Civil Aviation Safety Authority (CASA) released Airworthiness Bulletin AWB 72-005, alerting all operators and maintainers of PT6A engines, of the potential for installation of these compressor turbine blades in unapproved PT6A engine variants, and to raise awareness of the restrictions placed on the use of approved after-market blades.

On 22 January 2010, a Victa Airtourer 115/A1, registered VH-MTC, was landed safely on Miles Beach, Bruny Island, Tasmania. The pilot, being the sole occupant, shut down, exited and secured the aircraft before leaving it on the beach and walking away. The pilot was found deceased approximately 300 m from the aircraft. A post-mortem revealed the pilot had died as the result of a heart attack.

On 14 January 2010, a Cessna Aircraft Co. 208B Caravan, registered VH-NTQ, was en-route from Broome to Koolan Island, Western Australia (WA) at an altitude of about 9,500 ft, when the pilot noticed a drop in the engine torque indication, with a corresponding drop in the engine oil pressure indication. The pilot diverted to the nearest airstrip, which was Beagle Bay, WA. The pilot shut the engine down when the low oil pressure warning light illuminated and conducted a landing at Beagle Bay airstrip. The aircraft overran the airstrip, coming to rest upside down after impacting a mound of dirt. The aircraft was seriously damaged. The pilot, who was the only occupant, sustained minor injuries.

Following the accident, the Civil Aviation Safety Authority (CASA) issued an airworthiness bulletin, AWB 72-004 Issue 1, on 8 February 2010 to all Cessna 208 aircraft operators in Australia. The bulletin highlighted previous service difficulty reports on similar failures and the possibility of the accident aircraft having experienced the same problem. The bulletin recommended the inspection of the engine oil transfer tube attachment lugs for cracks and the inspection of the engine vibration isolator mounts for correct installation. Any defects in the area of the vibration mounts and oil tubes were to be reported to CASA post inspection. At the time of writing this report, one case of an oil tube with a loose fit and wear had been reported.

Overview

At about 1856 on 24 January 2010 a loaded freight train designated 2224, travelling from Medway Junction to Berrima Junction, derailed one bogie on the second-last wagon at Exeter, NSW.

It was determined that wagon NPZH 35700U derailed due to a 'screwed journal' as a result of a wheel bearing failure. As the bearing failed, it generated and transmitted sufficient heat to the axle journal, to make it 'plastic' and allow the end carrying the failed roller bearing assembly to 'screw off'.

There was insufficient evidence to determine the cause of the bearing failure.

The investigation identified two safety issues in relation to:

• the in-service condition monitoring of the wheel bearing which was ineffective in detecting the failing bearing before it led to the derailment, and,
• bulk hopper wagons loaded with limestone which have been regularly operated at speeds up to 15 km/h higher than the mandated limit for some classes of track.

In both cases the train operator has taken safety action to address the issue.

On 7 January 2010, the crew of a Convair 580 aircraft, registered VH-PDW, were conducting a training flight from Bankstown to Tamworth, New South Wales (NSW). While on descent to Tamworth, the crew noticed smoke emanating from below the instrument panel. Shortly after, the smoke intensified, and flames appeared. The flight crew declared an emergency and suppressed the flames using a portable fire extinguisher. The crew continued the descent, and the aircraft landed without further incident.

A subsequent engineering inspection revealed that a small amount of insulation material had become detached and fallen onto the right red instrument panel light rheostat and surrounding wires. The rheostat had developed a 'hot spot' and consequently, the insulation absorbed the heat and transferred it to the wires, which produced smoke and flames.

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

• all of the organisation's aircraft have been examined to ensure that there is sufficient clearance between the rheostats, insulation material and wires
• any insulation material located in close proximity to a rheostat has been removed
• a notice to crew was issued to emphasise the importance of recording defects in the maintenance log.

On 9 January 2010, the pilot of a Cessna Aircraft Company A185E floatplane, registered VH-ELQ, commenced the take-off run in Tippler's Passage on a charter flight around South Stradbroke Island, Queensland (Qld), with four passengers onboard. Immediately after the aircraft's floats came out of the water, the pilot reported 'feeling something hitting and vibrating on the right float'. The pilot rejected the takeoff and landed the aircraft straight ahead. The aircraft struck a sandbank and came to rest inverted. The five occupants exited the aircraft; one passenger received minor injuries.

Shortly after, a crab pot was observed within the immediate vicinity of the aircraft. The pilot reported that it was likely that the crab pot became entangled around the aircraft's right water rudder during taxiing.

An investigation conducted by the Queensland Police Service determined that there was evidence to suggest that the crab pot had come into contact with the aircraft's float. However, where the contact was made, and for how long, was not determined. A number of differences were also identified throughout the course of the investigation relating to the wind conditions at the time of the accident, the position of the aircraft at the time of the takeoff, whether or not the takeoff was commenced into wind, and the location of the crab pots. These differences could not be reconciled.

While the aircraft occupants in this accident were able to don life jackets and exit the aircraft without difficulty, previous ATSB investigations have highlighted the challenges faced when exiting from an inverted, submerged aircraft cabin. In 2009, the Civil Aviation Safety Authority issued a Notice of Proposed Rule Making, proposing that each occupant of a seaplane taking off or landing on water must wear a life jacket. This will ensure that the availability of life jackets after the occupants have exited the aircraft into the water is assured.

Section 21 (2) of the Transport Safety Investigation Act 2003 (TSI Act) empowers the ATSB to discontinue an investigation at any time. Section 21 (3) of the TSI Act requires the ATSB to publish a statement setting out the reasons for discontinuing an investigation.

An investigation was commenced into a pitch down event involving a Fairchild Industries Inc. SA226-AC on a scheduled freight flight from Moree, NSW to Brisbane, Qld on 24 December 2009. Information from tests conducted by the aircraft operator, on the aircraft after the flight, did not reveal any problems with the aircraft and it was returned to service. The ATSB's analysis of flight recorder data did not disclose any additional safety information. The ATSB has assessed that further investigation was unlikely to produce any benefit for transport safety and has elected to discontinue the investigation.

The data collected in the course of the investigation may be used by the ATSB for future statistical analysis and safety research purposes.

On 23 December 2009, a Garlick Helicopters Incorporated TH-1F helicopter, registered VH-UHD, was engaged in aerial firefighting operations in the Nangar National Park, New South Wales. At about 200 ft above ground level, the nose of the helicopter unexpectedly yawed to the right. The pilot made a corrective input on the tailrotor pedals, but was unable to stop the yaw and the helicopter began to rotate. The pilot guided the helicopter to a less-timbered area for an emergency landing. The helicopter descended into the trees and was seriously damaged. The pilot, the sole occupant, was seriously injured.

The loss of directional control was due to a structural failure in the helicopter's tailrotor control system, likely precipitated by the failure of an attachment bolt.

The investigation identified a safety issue with the maintenance and operation of ex-military helicopters being used in repetitive heavy lift operations. In response, on 5 July 2011, the Civil Aviation Safety Authority published Airworthiness Bulletin 02‑40 Issue 1 to advise operators and maintainers to investigate the basis for, and the correct implementation of, the continuing airworthiness requirements of the applicable type certificate data sheet and incorporated supplemental type certificates, particularly in regard to the retirement lives of all life-limited components.

CIRCUMSTANCES

On arrival at Sydney, the helicopter landed near the helipad and ground- taxied to the concrete apron in the general aviation parking area. The pilot intended to park in a confined space, adjacent to buildings and hangars on the north-eastern extremity of the apron. A number of aircraft were parked in close proximity to the west and south of the intended parking position. A grassed area to the east was free of obstacles. Ground marshalling assistance was not available. The surface wind was from the south-east at 10-15 kts.

The helicopter taxied to the intended parking position and stopped on an easterly heading. Witness evidence concerning the events which followed was not consistent. The pilot reported sensing a rocking motion which he interpreted as the onset of ground resonance. The helicopter was lifted off and turned towards the building. During this manoeuvre, an extreme vibration commenced which caused the pilot to experience a loss of vision and led to a loss of control of the helicopter. The passenger later recalled that the helicopter completed a 180 degree turn on the ground onto a westerly heading before the rocking motion was felt and the pilot lifted the helicopter off the ground. A ground witness seated inside the building observed the helicopter come to a halt on an easterly heading. It then became airborne and completed a hover turn left onto a westerly heading, at a height of approximately 8-10 feet. As the helicopter settled momentarily, it appeared to be rocking slightly and touched down on each wheel individually, suggesting the pilot was experiencing minor control difficulties.

The helicopter became airborne a second time and was observed to turn right onto a northerly heading, facing a building adjacent to the apron. Severe pitching oscillations commenced as the helicopter climbed to a height of about 30 ft. After several oscillations, the helicopter yawed and rolled to the left, travelling in a westerly direction towards a parked Learjet. The angle of bank increased to 90 degrees and the nose began to drop at about the time the main rotor blades struck the tailplane of the Learjet and the concrete apron. Debris was scattered over a wide area. The fuselage was propelled forward such that the nose of the helicopter collided with the closed doors of a hangar. The helicopter then impacted heavily with the apron on its left side. The tail boom separated and the extensively damaged fuselage came to rest lying on its left side, with the left engine continuing to run.

An extensive technical investigation, which was hampered by the degree of impact damage, did not reveal any evidence of a pre-existing mechanical fault or defect. The investigation was unable to positively establish the reasons for the oscillations reported by the pilot as being the onset of ground resonance, or the source of the extreme vibration which caused the pilot to lose vision and control of the helicopter. However, it was noted that the helicopter was operated in close proximity to a building in wind conditions which favoured recirculation of airflow through the main rotor disc. A possible source of vibration was the interaction of main rotor downwash and the tail rotor . It was also noted that the helicopter was taxied into a confined area where the manoeuvring options available to the pilot were limited.

SIGNIFICANT FACTORS

The following factors were considered relevant to the development of the accident:

1. The helicopter was ground-taxied to a parking position which was in close proximity to buildings and hangars.

2. The parking position and the wind conditions were conducive to the onset of main rotor recirculation.

3. The pilot reported the suspected onset of ground resonance.

4. During an attempt to recover from suspected ground resonance, an extreme vibration developed which led to the loss of control of the helicopter.

The pilot-in-command is a training captain in the company, and he was supervising the line training of a newly recruited captain. After departing Cairns, the aircraft was cleared to track direct to the first turning point, Cayley Reef (342 deg 107 NM from Townsville). Other tracking instructions were given during the flight to this point.

When the aircraft was identified on Townsville radar the controller formed the opinion that the aircraft was tracking from Cayley Reef to Townsville instead of to the Goblin position (138 deg 97 NM from Cayley Reef). The aircraft crew were satisfied that they were tracking to Goblin.

A standard instrument flight rules flight plan designator had been changed some time before and it appeared as though the crew may have been following the old flight plan track as applied to the designator in use. The pilot reported that this was not the case. The incident was discussed with the pilot in a productive interview, following the relaxation of previously imposed industrial restrictions on co-operation with the Bureau. When he learned that the purpose of the interview was to assist in finding solutions to the problem, a number of ideas were offered.

The following factors were considered relevant to the development of the incident:

1. The aircraft was not tracking as anticipated by the radar controller.

2. Controller's concern regarding the intended track of the aircraft.

Recommendations:

Some changes to standard IFR flight plan designators and routes has taken place recently. On occasions, confusion as to the actual route being flown by an aircraft has arisen. The problem has arisen because totally new designators have not been used. An old name and a new route present the potential for confusion. A similar situation occurred when standard instrument departures were introduced, and it was found necessary to adopt totally mew names when procedures were altered. A further check can be built in with routine radio calls. At present, a pilot is required to state the aircraft's cleared flight level when changing frequency. The route is considered to be as important and the pilot involved in this incident suggested that the next enroute reporting point be stated as well.

1. That the Civil Aviation Authority consider applying unused designator names to altered standard IFR flight plan routes.

2. That the Civil Aviation Authority consider the introduction of a requirement for pilots to state their next enroute reporting point when changing frequency in controlled airspace, particularly when operating to a standard IFR plan