At about 1500 Eastern Standard Time on 9 November 2009, a Bell Helicopter Company 412 helicopter, registered VH‑EMZ and operating as call sign 'Rescue 700', departed Horn Island Aerodrome, Queensland to rendezvous with a container ship located about 132 km to the west of Horn Island. The purpose of the flight was to evacuate an ill crew member and transfer him to hospital.

Prior to arrival, the flight crew had been advised that the patient would need to be recovered via rescue winch from the ship's forecastle. Approaching overhead the winching area, with the rescue crew officer (RCO) and paramedic being lowered by the winch and about 6m above the deck, the pilot lost sight of the ship. Shortly after, the helicopter began drifting back towards a mast that was located on the forecastle. Despite assistance from the winch operator to re-establish the hover, the pilot was unable to arrest the helicopter's movement and the winch cable became fouled on the foremast while the helicopter continued to drift rearwards. The winch cable separated and the paramedic and RCO fell about 10m to the ship's deck, seriously injuring both personnel.

The investigation identified that the requirement to confirm adequate hover reference existed overhead an intended winch area, before deploying personnel on the winch, was left to the pilot's discretion. In this instance the pilot, despite his extensive experience, did not identify the possibility of losing sight of the ship, and therefore the necessary hover reference.

Following the occurrence, the helicopter operator issued an instruction to aircrew emphasising the importance of ensuring that adequate hover reference exists during winching operations. The helicopter operator also commenced a review of its operations manual to ensure that it provides sufficient procedural guidance for winching operations and commenced the development of company-wide aviation risk management training that will commence in early 2011.

At 0735 Eastern Daylight-saving Time on 26 October 2009, VH-OGP, a Qantas Airways Boeing 767-300, initiated a go-around manoeuvre from an approach into Sydney Airport, New South Wales. The aircraft immediately returned for a normal landing. The go-around was initiated due to the crew becoming aware that the aircraft was not properly configured for landing. Almost simultaneously, the 'Too Low Gear' automated warning activated, which indicated that the aircraft's landing gear was not extended.

The incorrect aircraft configuration was the result of several interruptions and distractions during the approach. These interruptions and distractions resulted in a breakdown in the pilots' situational awareness.

The investigation identified a number of minor safety issues in the operator's procedures and monitoring systems and Qantas Airways has advised of safety action in response.

On 28 October 2009, an Airbus A330-202 (A330) aircraft, registered VH-EBA (EBA), was being operated as Jetstar flight 12 on a scheduled passenger service from Narita, Japan to Coolangatta, Australia. Soon after entering cloud at 39,000 ft, there was a brief period of disagreement between the aircraft's three sources of airspeed information. The autopilot, autothrust and flight directors disconnected, a NAV ADR DISAGREE caution message occurred, and the flight control system reverted to alternate law, which meant that some flight envelope protections were no longer available. There was no effect on the aircraft's flight path, and the flight crew followed the operator's documented procedures. The airspeed disagreement was due to a temporary obstruction of the captain's and standby pitot probes, probably due to ice crystals. A similar event occurred on the same aircraft on 15 March 2009.

The rate of unreliable airspeed events involving the make of pitot probes fitted to EBA (Goodrich 0851HL) was substantially lower than for other probes previously approved for fitment to A330/A340 aircraft. However, both of the events involving EBA occurred in environmental conditions outside those specified in the certification requirements for the pitot probes. The French Bureau d'Enquêtes et d'Analyses pour la sécurité de l'aviation civile (BEA) has recommended the European Aviation Safety Agency (EASA) to review the certification criteria for pitot probes in icing environments.

At the time of the occurrence, most of the operator's A330 pilots had not received unreliable airspeed training. Most of these pilots had transferred from the operator's A320 fleet, and the third-party training provider had not included the topic in its A320 endorsement training program, even though it was included in the aircraft manufacturer's recommended program since 2004.

The operator identified the problem and included unreliable airspeed in its recurrent training program for the A320 from May 2009 and the A330 from October 2009. The training provider included the topic in its endorsement program from July 2010. The operator, training provider and the Civil Aviation Safety Authority all initiated safety action to minimise the likelihood of similar problems in the future.

On 2 April 2008, the UK Air Accidents Investigation Branch (AAIB) advised the Australian Transport Safety Bureau (ATSB) that the AAIB had commenced an investigation in response to a number of minor accidents involving aircraft fitted with Australian-manufactured Jabiru engines. In support of its investigation, the AAIB requested the appointment by the ATSB of an accredited representative in accordance with international protocols.

The ATSB appointed an accredited representative under the provisions of clause 5.18 of Annex 13 to the Convention on International Civil Aviation. To protect any work undertaken to assist the AAIB, and any information supplied to the ATSB by the AAIB, on 7 April 2008 the ATSB initiated an investigation under the Transport Safety Investigation Act 2003.

The UK AAIB is responsible for releasing a final investigation report. Once completed, a copy of the report can be requested from the AAIB at:

• www.aaib.gov.uk, or at
• Air Accidents Investigation Branch
  Berkshire Copse Road
  Aldershot
  Hampshire
  GU11 2HH
  Tel: 01252 510300
  Fax: 01252 376999
  Email: enquiries@aaib.gov.uk

For AAIB press enquiries: 020 7944 3387

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

On 19 October 2009, a British Aerospace Avro-RJ70 aircraft sustained an in-flight engine failure shortly after taking off from Christmas Island.

The investigation found that the number 2 engine failed due to severe overheating damage to the high-pressure turbine section components. The overheating was most likely related to a defective fuel injector nozzle that exposed the turbine nozzle guide vanes and blades to a sustained over-temperature condition and cumulative thermal damage. Although the engine's operating performance and condition was being monitored as part of the operator's Engine Condition and Trend Monitoring (ECTM) program, no significant indications of the impending failure were detected in the lead up to the failure.

The flight crew reported that while responding to the engine failure they were unable to extend the fire lever in order to operate the engine's fire suppression system. The operator subsequently inspected the system, but could not duplicate the problem.
The ATSB did not identify any safety issues as a result of its investigation that required safety action to be taken.

Following landing at Melbourne Aerodrome on 20 October 2009, the crew of a Boeing 737-8FE aircraft, registered VH-VUI, reported that the aircraft was difficult to taxi, requiring more power and steering input than usual. A subsequent visual inspection revealed the number 4 wheel to be oriented at an angle with respect to the axle and, following disassembly, it was discovered that the inner wheel hub and bearing mount had broken away from the wheel assembly.

Examination of the wheel revealed that the inner hub had failed from fatigue cracking that had initiated in the area adjacent to the bearing cup.

Fatigue cracking of the inboard bearing cup bore was an emerging issue for the 737 wheel type at the time of the failure. In May 2009, the wheel manufacturer issued a temporary revision to the Standard Practices Manual, with an updated inspection method for the susceptible area, and the aircraft manufacturer had issued a service letter in August 2009 with a periodic inspection requirement. The operator was in the process of reviewing and incorporating the changes into their own maintenance schedules at the time of the incident.

Immediately following the occurrence, the operator performed a fleet-wide examination, identifying those wheels potentially at risk of a similar failure. Subsequently, ten wheels were removed from service for immediate inspection. The operator also implemented an ultrasonic inspection program for wheels with over 4,000 cycles at every tyre change.

The manufacturers of both the aircraft and the wheel released updated information to operators and maintainers in early 2010, which included a revision to the recommended inspection interval.

In response to a fatal Robinson R22 helicopter accident and a number of other occurrences involving failure of Robinson R22 helicopter V-belts, the ATSB has commenced a safety issues investigation regarding the reliability of the Robinson Helicopter Co. model R22 drive belt system.

Update

Since the commencement of this investigation, the ATSB has examined accidents, incidents and occurrences involving Robinson R22 drive belt (V-belt) failures. Stemming from that, no significant safety issues have been identified to date in the manufacture or design of the drive belts that might present an airworthiness issue for continued safe operation of the Robinson R22 helicopter fleet.

Industry feedback indicates that failures have been relatively infrequent since Robinson introduced the 'Revision-Z' drive belt standard. Once the initial break-in period is complete, the final stability of the belt system is reported to be much better than has been the case with earlier revision belts. The 'Revision-Y' belts were prone to stretch that required periodic adjustment of the drive system throughout the life of the belts.

Although no singular issue has been identified with the drive belt construction, it should be recognised that the belts represent a critical link in the main rotor drive system. Belt failures are often rapid and may be preceded by the onset of vibration or the smell of burning rubber. The ATSB reinforces the need for continued vigilance by operators and maintenance organisations during the routine inspection of the R22 drive system. Some of the factors that can influence the reliability of the R22 drive system are:

Regular inspection: It is an Australian regulatory requirement that the daily inspection of the drive belts and sheaves must be performed by a licensed aircraft maintenance engineer, a pilot endorsed on the aircraft type or an approved person, in accordance with the R22 Aircraft Flight Manual. The ATSB advises that particular vigilance should be applied during these inspections as they represent a fundamental opportunity to detect the onset of deterioration of the drive system. Any form of drive belt damage such as blistering, cracking and tie band (webbing) separation indicates that the belts require replacement.

Robinson Service Bulletin SB-66 highlights the importance of inspecting the sheaves. If the wear pattern is noticeably different from groove to groove, it is recommended that the drive belts be immediately replaced. The surface condition of the sheaves should be smooth and uniform.

Another prime inspection opportunity exists prior to installation of the belts. Careful inspection of the drive belts at this time may identify any surface abnormalities.

Operation: Pilots must monitor Manifold Air Pressure (MAP) to avoid exceeding the placarded power limits, as listed in the Robinson R22 flight manual. Exceeding the drive system limitations may result in sudden belt failure. Refer to Robinson Safety Notice SN-37.

Environment: Operating the helicopter in environments where dust and grit can contaminate the drive system, or where the ambient temperature is high, can also influence the service life of the belts and sheaves. Helicopters operated in these environments may require additional periodic inspections of the drive system.

Sheave alignment: Correct sheave alignment after installation of the drive belts is critical in ensuring the belt longevity.

High gross weight operation: Pilots must ensure that the approved gross weight limits are not exceeded while operating the helicopter.

Clutch actuator: The electrically-driven clutch actuator automatically controls drive belt tension. A cockpit caution light will illuminate when the actuator is re-tensioning, engaging or disengaging the belts. Robinson Safety Notice SN-33 suggests that a problem with the drive belts may be imminent if during flight the clutch light flickers or stays on for longer than normal. Under these circumstances the pilot is advised to land immediately.

ATSB Safety Advisory Notice AO-2011-060-SAN-001

On 6 July 2011, a fatal Robinson R22 accident (AO-2011-060) occurred near Julia Creek, Queensland. The ATSB found that the helicopter sustained an in-flight failure of the drive belts and in the interests of transport safety, issued a Safety Advisory Notice that urged pilots, operators and maintainers to pay particular vigilance to the R22 helicopter drive belt system.

This information is released in accordance with subsection 25(2) of Part 4 of the Transport Safety Investigation Act 2003.

Following a number of accidents and serious incidents involving Piper Chieftain PA-31-350 aircraft where a failure of one of the engine turbochargers had been central to the occurrence events, the Australian Transport Safety Bureau (ATSB) initiated a safety investigation into the broader issue of PA-31-350 turbocharger operational reliability.

In all of the principal occurrences, the turbocharger turbine wheel had separated from its central shaft.  Metallurgical examination of the separated turbine wheel assemblies did not reveal any material/manufacturing anomalies that may have contributed to the failures.

During the course of the investigation, a number of other turbocharger related occurrences were identified. Most of the occurrences had resulted in a reduction in engine power which led to a range of outcomes, including engine shutdown, air returns, and diversions.

While in some occurrences, failure was the result of the separation of the turbine wheel from the turbine shaft, the investigation showed that turbocharger failure could arise from a number of causes, including lubrication issues and foreign object damage. It is likely that some of these mechanisms are interrelated, i.e. fatigue failure of the turbocharger shaft following bearing damage from an interruption or contamination of the oil supply.

No single contributory factor or common set of factors was identified across the failures examined.

Published literature has shown that turbocharger reliability can be significantly enhanced by ensuring that engine, aircraft and turbocharger manufacturer's operational procedures are closely followed - particularly in respect of the application and/or reduction of engine power levels. Specific maintenance attention to the turbocharger lubrication system is also important to ensure preservation and reliable operation of the turbocharger bearings.

Pilots of aircraft powered by turbocharged powerplants are reminded that a failure of the turbocharger system should not result in the complete loss of power from the affected engine. Attention is drawn to a US Federal Aviation Administration, Special Airworthiness Information Bulletin (SAIB) CE-09-11, which provides information for air crew on what to do in the event of a turbocharger malfunction or failure. A copy of that bulletin is included as Appendix B to this report.

Executive summary

Shortly before 0540 on 28 September 2009, a fire started in the steering gear compartment of the Marshall Islands registered anchor handling tug supply vessel Petra Frontier while it was en route from the Timor Sea to Darwin, Northern Territory.

The ship's crew were unable to extinguish the fire using portable fire extinguishers. By about 0640, all of the compartment's access doors and vents were closed, the electrical power supply to the machinery in the space was isolated and the deck above was boundary cooled. As a result of these actions, the fire eventually burnt itself out.

The investigation found that the fire probably started when rags, which had been soaked in oil that was leaking from a hydraulic unit, were ignited by heat generated by, or a spark emanating from, an electrical solenoid. The investigation also found that the ship's crew had not identified the numerous deficiencies that existed in the ship's emergency equipment, they were not familiar with the use of the emergency equipment and the on board response to the fire was not well managed.

The investigation identified two safety issues: while Petra Frontier had undergone a series of flag State inspections and class surveys, neither authority was aware that the ship was unseaworthy in relation to critical safety equipment; and the ship's safety management system contained some contradictory information relating to the scheduling of fire and abandon ship drills.

Preliminary report released 30 October 2009

At about 1130 Western Standard Time on 3 October 2009, the pilot of an Air Tractor Inc. AT-502 aircraft, registered VH-ODP, took off from a paddock on a property about 5 km north-east of Wickepin, WA to conduct agricultural spraying operations. A short time later, the owner of the property discovered the wreckage of the aircraft, which had impacted the ground in an inverted attitude, fatally injuring the pilot. There were no witnesses to the accident.