On 25 September 2008, the pilot of a Bell 206L4 helicopter, registered P2-HBC, was conducting sling loading operations in the vicinity of Lake Murray, Papua New Guinea. While conducting a vertical lift, a witness reported hearing a 'different noise' from the helicopter's engine, before observing the pilot jettison the load. The witness then observed the helicopter oscillating from side to side, yawing to the left and then descending through the tree canopy to impact the ground. The pilot was fatally injured and the helicopter seriously damaged.

This accident is being investigated by the Papua New Guinea Accident Investigation Commission (AIC) in accordance with its obligations under Annex 13 to the Convention on International Civil Aviation. The AIC requested the Australian Transport Safety Bureau's (ATSB's) assistance with their investigation by providing forensic engineering examination of a small selection of instruments and some fuel system detritus recovered from the accident helicopter.

The ATSB subsequently received and examined a fuel quantity gauge, turbine outlet temperature (TOT) gauge and an annunciator panel from the helicopter's instrument cluster. Various marks and observations evident on the components were documented and analysed with respect to the possible relevance of those markings to the accident event. In addition, a small sample of dried material from the internal surfaces of the fuel filter check valve that was provided by the AIC was examined and found to be characteristic of the biopolymer films produced by microbial growth.

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

On 9 July 2009, the Transport Accident Investigation Commission (TAIC) of New Zealand requested assistance from the Australian Transport Safety Bureau (ATSB) in the transfer of cockpit voice recorder (CVR) and flight data recorder (FDR) magnetic tape recordings onto  digital media. The transfer was requested to ensure the archival preservation of information obtained during the TAIC's investigation of various accident and incident events.

To protect the information contained on the recordings against unauthorised disclosure, the ATSB performed the work under the provisions of an investigation initiated under the Australian Transport Safety Investigation Act (2003).

On completion of data transfer, the magnetic tapes were returned to the TAIC, together with the digital copies and a technical report outlining the process undertaken. 

Contact details for the TAIC can be found on the web at: www.taic.org.nz

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

During a flight on 21 June 2009, a Gippsland Aeronautics GA-8 Airvan aircraft, registered VH-BFS, sustained a fracture of the right main landing gear axle assembly, resulting in separation and loss of the wheel and brake calliper. To assist their investigation of the occurrence, the Civil Aviation Safety Authority (CASA) requested the assistance of the Australian Transport Safety Bureau (ATSB) in the metallurgical examination of the fractured landing gear leg. While the examination provided some information on the nature and location of the failure, the amount of material abraded and lost from the fracture surface (as a result of landing on the fractured leg), precluded a full determination of the fracture mechanism.

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

On 5 August 2009, an Airborne Edge Trike microlight aircraft was being operated as sports aviation from the owners private airstrip. The aircraft departed from the private airstrip for a planned flight approximately 10 nm to the north. When the aircraft did not arrive at its destination, a search was initiated by friends. The aircraft wreckage was located approximately 0.65 nm from the threshold of the airstrip. The pilot, who was the sole occupant of the aircraft, was fatally injured.

In assisting the Victorian Police in their investigation of this accident, Recreational Aviation Australia Inc (RA-Aus) requested assistance from the Australian Transport Safety Bureau (ATSB) in the recovery of information from a portable Global Positioning System (GPS) unit recovered from the accident site. To protect the information supplied by RA-Aus to the ATSB and investigative work undertaken to assist RA-Aus, the ATSB initiated an investigation under the Transport Safety Investigation Act 2003 (TSI Act).

The ATSB completed its recovery of data from the Garmin® GPS V portable GPS receiver (serial No: 7304194) and provided the data to RA-Aus in the interests of transport safety, under the provisions of section 61 of the TSI Act.

Contact details for RA-Aus are at website: www.raa.asn.au

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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 Fairchild Dornier 328-110, registered PK-TXN, on behalf of the Indonesian National Transportation Safety Committee. The aircraft was operating a flight from Jayapura to Tanah Merah, Indonesia when it was involved in a runway excursion on landing.

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 flight data 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

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

This supplementary report replaces Section 4.7 (Lost) and some conclusions and safety actions recorded in the ATSB Transport Safety Investigation Report No. 222: Independent investigation into the loss of the Department of Immigration and Multicultural and Indigenous Affairs vessel, Malu Sara, in Torres Strait, Queensland, Australia, 15 October 2005, which was released on 19 May 2006. This supplementary report has been published following the release, and subsequent analysis, of significant new information that was provider to the Coroner during the coronial inquest into the loss of Malu Sara and its five occupants on 15 October 2005 and which related to the initial search and rescue response.

This supplementary report should be read in conjunction with the original ATSB report: Loss of the DIMA vessel Malu Sara in Torres Strait Queensland

This report may contain times that differ from those associated with the same occurrence in the original ATSB report. This is the result of the evidence provided to the coronial inquest.

This report identifies the following safety issues: the lack of follow-up and reporting procedures for immigration response vessels which were not engaged on patrol activities in the Torres Strait; the lack of procedures dealing with an immigration vessel which was overdue at its destination or reported being lost; the absence of training for immigration staff in the reporting and follow-up procedures and general search and rescue overview training; search and rescue coordination responsibility for small Commonwealth vessels; and post search and rescue incident analysis practices.

This report acknowledges the actions taken by the Department of Immigration and Citizenship and the Australian Maritime Safety Authority to address the identified safety issues.

Executive summary

At about 1411 on Wednesday 9 September 2009, scheduled XPT passenger train ST24, en route from Melbourne to Sydney, passed signal JE02 at Junee by about 33 m while that signal was displaying a Stop (red) indication. No injuries or damage resulted from the occurrence.

The driver of ST24 said that signal JE26, the signal before JE02, was displaying a Medium Turnout indication and this meant that signal JE02 would be showing a Proceed aspect. Several other rail employees also said that signal JE26 was displaying a Medium Turnout indication. However, the investigation concluded that it was almost certain that signal JE26 was displaying a Caution Turnout indication rather than a Medium Turnout indication, which would have resulted in signal JE02 displaying a Stop indication. The investigation concluded that the driver's perception of signal JE26 was influenced by expectation, distraction and possibly fatigue, and that the employee witnesses' perception of the signal was influenced by expectation, 'confirmation bias' and 'group think'.

The report identifies three safety issues in relation to prioritisation of operational tasks, signal lamp voltage and signalling design standards.

Preliminary report released 20 November 2009

This preliminary report details factual information established in the investigation’s early evidence collection phase and has been prepared to provide timely information to the industry and public. Preliminary reports contain no analysis or findings, which will be detailed in the investigation’s final report. The information contained in this preliminary report is released in accordance with section 25 of the Transport Safety Investigation Act 2003.

Abstract

At 0151½ on 9 September 2009, in a position about 15 miles east of Point Lookout on North Stradbroke Island, Queensland, the Australian registered, single-handed yacht Ella's Pink Lady collided with the Hong Kong registered bulk carrier Silver Yang.

At the time of the collision, Silver Yang was en-route to China and travelling at a speed of about 9 knots on a northerly heading. Ella's Pink Lady was under sail on a voyage from Mooloolaba, Queensland, to Sydney, New South Wales. The yacht was making good a course of 144°(T) and a speed of about 7 knots.

Ella's Pink Lady was dismasted as a result of the collision, but the skipper was able to cut the headsail free, retrieve the damaged rigging on board and motor the damaged yacht to Southport, Queensland.

On 20 September 2009, at about 1630 Western Standard Time, a Boeing 737-400 (737) aircraft, had been pushed back from the domestic terminal onto the taxiway at Perth Airport, Western Australia (WA), when a technical fault was experienced. The aircraft remained in position to allow the flight crew to examine the fault. At the same time, a Boeing 717- 200 (717) aircraft, located in an adjacent bay, requested a pushback clearance from the surface movement controller (SMC). The SMC advised the 717 flight crew to contact their ground crew to discuss suitable pushback options. The 717 was pushed back with the aircraft kept as close to the terminal as possible. A clearance marshaller was located next to the left wing of the 717.

The flight crew of the 737 and the ground engineer for the 717 estimated that the wing of the 717 and the nose of the 737 were 11 m apart. However, the ground engineer for the 737 reported that the distance between the two aircraft was within 1 m and that as a result, he and another ground engineer with him may have been placed within the inlet and exhaust hazard area of the 717.

It was not possible to reconcile the differing accounts of aircraft proximity. However, the incident highlights the potential dangers associated with ground operations around jet aircraft and the need for particular care and attention when dealing with dynamic traffic situations.

On 3 September 2009 at about 1859 Eastern Standard Time, a Boeing 737-838 aircraft was en route from Sydney, New South Wales to Adelaide, South Australia and a Boeing 777-31H aircraft was en route from Melbourne, Victoria to Singapore. The aircraft were on crossing tracks and both were cruising at flight level 300. The air traffic control separation standard was infringed and there was a breakdown of separation.

The air traffic controller responsible for separation of the aircraft had recently completed the air navigation service provider's approved training, but had not recognised the potential conflict between the two aircraft.

As a result of this incident, Airservices Australia has amended the compromised separation recovery component of an air traffic controller's training, and introduced a compromised separation recovery element into its final controller field training.