The ATSB has completed its technical analysis report of the flight recorder data from the Airbus A320-231, registration PK-YVE, on behalf of the Indonesian National Transportation Safety Committee (NTSC). The aircraft was operating a flight from Jakarta to Medan, Indonesia when the crew reported brake system problems during the approach to Polonia Airport, Medan. The runway and aircraft landing gear were damaged during the subsequent emergency landing resulting in closure of the airport for several hours. No injuries were reported.

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 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 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 25 July 2008 at 1033 Central Standard Time a Piper PA-31-350 (Chieftain) aircraft, registered VH-ZMK was being operated on a scheduled passenger flight from Darwin to Bathurst Island, Northern Territory (NT). Moments after take-off, the right engine began to surge and shortly afterwards, the left engine also began to surge. The pilot declared an emergency and returned to the airfield, landing short of the runway.

The investigation was unable to reconcile the pilot's report that he had selected the inboard tanks before take-off on the incident flight with the evidence of the fuel remaining in the inboard tanks afterwards. The engine surging and power loss could be explained by fuel starvation resulting from selection of the outboard tanks that contained minimal fuel.

On 17 July 2008, an Airbus Industrie A330-300 (Airbus) aircraft was being operated on a scheduled international passenger service from Sydney, NSW to Melbourne, Vic. with 13 crew and 163 passengers. The aircraft commenced a take-off without having received a take-off clearance by Air Traffic Control. At the same time, a Boeing 737 had been cleared to cross the same runway. The tower controller advised the flight crew of the Airbus that they had not been cleared for take-off, and they discontinued the take-off.

The safety issue identified as a result of this investigation related to the potential confusion arising from the use of a combined line-up and wait instruction with a departure instruction. Airservices Australia has committed to undertake a review of this procedure.

On 17 July 2008, at approximately 0915 Eastern Standard Time, the pilot of a Piper Navajo PA-31 aircraft, registered VH-IHR, was en route from Century Mine, Qld to Mt Isa, Qld when the left engine lost power. Shortly after, the right engine lost power and the pilot attempted to land the aircraft in sparsley wooded bushland about 4 km from the Barkly Highway. The pilot received serious injuries, and the aircraft was seriously damaged.

A subsequent check of the aircraft found that the loss of power to both engines was due to fuel starvation.

On 6 July 2008 at 1345 Eastern Standard Time, a SAAB 340B aircraft, registered VH-ZLC, departed the terminal at Orange aerodrome for a scheduled flight to Sydney. At the point of rotation during take-off, the right outboard wheel was observed to have detached from the aircraft. The crew elected to continue the flight to Sydney where the aircraft landed without further incident.

Examination of the components found that the right outboard wheel detachment occurred as a result of the failure of the outboard wheel bearing. It was possible that the failure was related to a lubrication or setting (installation) issue, however this could not be positively determined due to the degree of damage sustained by the bearing components.

As a result of this occurrence, the aircraft operator undertook a thorough internal safety investigation and implemented a range of safety actions, including a review of wheel bearing maintenance procedures, and an audit of main wheel axle nut torques across the fleet.

On 20 June 2008, a Bombardier DHC-8-402 aircraft, registered VH-QOA, with four crew and 59 passengers on board, departed Horn Island for Cairns, Queensland on a scheduled passenger flight. During the climb, the right propeller electronic control (PEC) caution light illuminated with an associated right propeller overspeed warning. The right engine was shut down in accordance with the operator's Quick Reference Handbook and the crew diverted the aircraft to Weipa.

During the approach to Weipa, the aircraft's right hydraulic system failed requiring the landing gear to be manually lowered. Due to the loss of hydraulic system services, the nosewheel steering was not available and the aircraft required ground crew assistance to tow the aircraft to the parking area.

As a result of a number of similar occurrences experienced by international and domestic operators, the propeller manufacturer developed a number of software changes which, when introduced, will allow the continued operation of an engine by the crew after the primary propeller speed signal is lost. The aircraft operator intends incorporating that modification into its DHC-8 fleet once training and other resource considerations are satisfied.

In addition, the aircraft manufacturer has incorporated a modification in the aircraft to ensure that the power transfer unit is started before the loss of the No. 2 hydraulic system pressure.

At 1026 Eastern Standard Time on 18 June 2008, a Robinson Helicopter Company R44 Clipper II helicopter, registered VH-RYW, departed Cairns Airport, Qld, to film a residential development site that was located in the vicinity of False Cape, about 10 km east of the airport. On board the helicopter were the pilot and three passengers.

The occupants of the helicopter reported that while conducting the second period of filming, there was a sudden and violent movement of the nose of the helicopter to the right, which continued into a rapid rotation of the helicopter. The pilot's reported attempt to reduce the rate of right yaw was unsuccessful, and he entered autorotation and attempted to reach a clear area. The helicopter subsequently collided with trees before impacting the ground, seriously injuring the pilot and front seat passenger.

This accident highlighted the risk of loss of tail rotor effectiveness associated with the conduct of aerial filming/photography and other similar flights involving high power, low forward airspeed and the action of adverse airflow on a helicopter.

The investigation also identified that the lack of the nomination of a search and rescue or scheduled reporting time for the flight, decreased the likelihood of a timely response in the case of an emergency.

In response to this accident, the helicopter manufacturer advised that it was considering a revision to the aerial survey and photography flights safety notice that was contained in the R44 Pilot's Operating Handbook. That revision would, if adopted, include a discussion of the risk of unanticipated right yaw associated with the conduct of those flights.

The Australian Transport Safety Bureau (ATSB) has completed its technical analysis report of the flight recorder data recovery from the Transall C160-NG, registration PK-VTQ, on behalf of the Indonesian National Transportation Safety Committee (NTSC). The aircraft was destroyed by fire after landing at Wamena Airport, Irian Jaya, Indonesia.

The NTSC of Indonesia is responsible for investigating this occurrence. The NTSC requested assistance from the 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 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.

Following the construction of a new hangar adjacent to runway 28 right (28R) at Archerfield Airport, Queensland, the Australian Transport Safety Bureau (ATSB) received a number of submissions asserting that the building infringed safety standards or reduced flight safety.

Drawing on an independent third-party review, the ATSB determined that the building does not breach obstacle limitation surfaces. The ATSB also conducted an initial examination of the instrument departure procedure from runway 28R. The ATSB found that the procedure complied with the extant instrument departure design requirements, but identified an ambiguity in the guidance for designing instrument departure procedures.

The ATSB assessed that this ambiguity could lead to inconsistent expectations about the extent of clearance from obstacles provided to aircraft when pilots were following an instrument departure procedure. This had the potential to increase the risk of a collision with an obstacle. In response, on 30 May 2008, the (then) Executive Director of the ATSB commenced a safety issue investigation in accordance with sections 21 and 23 of the Transport Safety Investigation Act 2003.

As a result of that investigation, the Civil Aviation Safety Authority and Airservices Australia have, in consultation, reviewed their understanding of how the design standards for instrument departure procedures should apply in Australia. They have also re-examined the runway 28 instrument departure procedure at Archerfield in the light of that review and have advised that they intend to amend the requirements for instrument departures from runway 28R.

The potential for inconsistent interpretation of the instrument departure procedure design requirements has also been notified to the International Civil Aviation Organization instrument flight procedures panel, which monitors the international standards for the design of instrument procedures.

On the morning of 11 June 2008, a Bell 412 helicopter, registered VH-UAH, was being used to conduct training operations from Wollongong Aerodrome, New South Wales. Shortly after landing on the runway, the helicopter developed severe vertical airframe vibrations that resulted in reduced pilot control. In an attempt to mitigate the vibrations, the pilot raised the helicopter into the hover, however, the vibrations continued to increase in severity. In response, the pilot lowered the collective to set the helicopter back down onto the runway. The resulting heavy landing caused serious damage to the helicopter, but the crew were not injured.

A subsequent examination of the helicopter's flight control system revealed an anomaly with the collective hydraulic actuator. Excessive free play was found to have developed in the bolted joint between the pivot bolt and the pilot input lever, which then allowed vertical vibrations and controllability issues to develop. It is likely that free play at the bolted joint was introduced when the collective actuator was last overhauled.

As a result of this occurrence, the collective actuator manufacturer revised the tensioning procedures and requirements for the pivot bolt assembly during the overhaul process. In addition, the helicopter operator changed its inspection regime of the collective servo-hydraulic actuator units in its fleet of Bell 412 helicopters and issued a 'flight staff instruction' to provide guidance to pilots on what actions to take if they experienced unusual or excessive vibrations during flight.