On 28 May 2008, a Boeing Company 737-5U3 (737) aircraft, registered PK-GGE was being operated on a scheduled passenger transport service from Jakarta, Republic of Indonesia to Perth, WA. The flight was conducted under the Instrument Flight Rules (IFR) and Perth Airport was affected by low cloud, rain showers and reduced visibility during the aircraft's arrival.

Shortly after clearing the flight crew to make an instrument landing system (ILS) approach to runway 21, the approach controller assessed that the required separation between landing aircraft was not going to be maintained and cancelled the approach clearance. The controller instructed the crew to maintain 2,500 ft, which was the radar minimum vector altitude (MVA) in that area, and to expect radar vectors for an ILS approach to runway 24. Subsequently, while being radar vectored, two-way communication between the controller and the crew ceased.

The late notice change of approach and landing runway represented a significant increase in workload for the crew, and the investigation concluded that the crew probably inadvertently deselected the approach radio frequency soon after being issued a radar vector for the amended approach and landing.

The crew did not follow the published loss of communication procedure, which resulted in the aircraft operating below the published 25 NM (46 km) minimum safe altitude and below the relevant MVA in instrument meteorological conditions (IMC) for just over 1 minute. There were no warnings or alerts from the aircraft's enhanced ground proximity warning system (EGPWS) during the flight, and the aircraft was not less than 1,421 ft above terrain during the loss of communication.

As a result of this incident, the aircraft operator undertook a number of safety actions. Those actions sought to enhance the operator's operations into Australia, and to review the procedures in the case of a communications failure with air traffic control.

On 7 March 2008, a Zenith Zodiac CH601 XL aircraft, registered VH-ZRS, impacted the sea near Surfers Paradise, Qld. The pilot and the passenger were fatally injured. Recreational Aviation Australia (RA-Aus) commenced an investigation into the occurrence.

RA-Aus requested assistance from the Australian Transport Safety Bureau (ATSB) in order to examine several pieces of canopy from the aircraft. The examination revealed that the canopy had sustained an in-flight structural failure. The results of the ATSB examination were subsequently provided to RA-Aus investigators.

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

Preliminary report released 7 July 2008

On 15 May 2008 at approximately 1000 Eastern Standard Time, a Cessna Aircraft Company C210L aircraft, registered VH-IDM, being operated on low-level geophysical survey operations, struck trees prior to impacting the ground 83km north-east of Georgetown, Qld. The pilot, who was the sole occupant of the aircraft, was fatally injured.

The ATSB has completed its technical analysis report on the flight recorder data from the Boeing Co. 737-408, registration PK-KKT, on behalf of the Indonesian National Transportation Safety Committee (NTSC). The aircraft was operating a flight from Jakarta to Batam, Indonesia and experienced a runway excursion during landing.

The NTSC is responsible for investigating this occurrence. The NTSC requested assistance from the Australian Transport Safety Bureau (ATSB) in the examination 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.

On 8 May 2008, the pilot of an American Champion Aircraft (ACA) 'Citabria', model 7GCBC (registered VH-MWY), was returning to Camden Aerodrome, NSW, after a local area flight, when the upper elevator control cable fractured. The pilot was able to maintain control of the aircraft's pitch attitude using wing flaps, and subsequently landed the aircraft safely, with only minor damage to the propeller.

Laboratory examination of the failed cable found the failure (and an adjacent area of significant damage) to have developed from the progressive fatigue cracking of individual cable wires in locations where the cable passed over guide sheaves. The examination also determined that the cable had not been manufactured to conform with the requirements of the accepted standard for aircraft control cables (MIL-DTL-83420).

From 2005, the aircraft manufacturer changed its internal procedures to require that only cable manufactured and certified to MIL-DTL-83420 be used for new aircraft production. Following the cable failure, the Civil Aviation Safety Authority (CASA) published an Airworthiness Bulletin (AWB), highlighting the issues associated with the use of non-MIL standard cables in aircraft control applications, and recommended that owners and maintainers of American Champion Aircraft ensure that periodic inspections are conducted with appropriate veracity.

On 9 May 2008, a Boeing Company 737-8CX aircraft, registered PK-GEF, was being operated on a scheduled passenger service between Denpasar, Republic of Indonesia and Perth, WA. On board were two flight crew, six cabin crew and 76 passengers.

The flight crew reported that, once established in the cruise, they reviewed their briefing material and noted that the threshold for runway 21 at Perth was displaced due to runway works.

On approach to land at Perth, the aerodrome controller issued the flight crew with the landing clearance, '... runway 21 displaced threshold, cleared to land'. When the aircraft was about 15 seconds from touchdown, the flight crew questioned the presence of cars on the runway and conducted a go-around.

On the second approach, the flight crew were again issued the landing clearance '... runway 21, displaced threshold, cleared to land'. The aerodrome controller recalled observing the aircraft on what appeared to be an approach to land on the closed section of the runway and instructed the flight crew to go around. The go-around instruction also included information to assist the flight crew in identifying where the aircraft was to be landed. That additional information, together with the high workload being experienced by the flight crew at that time, may have momentarily confused them, with the effect that they did not assimilate and act on the instruction to go around.

As a result of this incident, the airport operator undertook a number of safety actions. Those actions included: the review of its dispatch of Method of Works Plans (MWOP) to relevant stakeholders; the implementation of a more robust MWOP receipt and acknowledge system; and the establishment of a project safety group in support of all critical airside works.

Interim factual report released 25 July 2008

On 9 April 2008, a Fairchild Industries Metro III aircraft departing Sydney, NSW was observed on radar to be turning contrary to air traffic control instructions. The pilot reported that he had a '...slight technical fault...'. Recorded radar data showed the aircraft then completed a turn to the left before turning back to the right and disappearing from radar at an altitude of 3,900 ft. Searchers later discovered a small amount of aircraft wreckage floating in the ocean, south of the last recorded radar position. The pilot was fatally injured, and the aircraft was destroyed.

On 1 May 2008 at about 2216 Eastern Standard Time, an Airbus Industrie A320 aircraft, registered VH-VQS, was conducting the runway 32L (left) instrument landing system missed approach procedure at Launceston Aerodrome, Tasmania. During the climb, the A320 came into close proximity with a Boeing Company 737 that was manoeuvring at 3,100 ft above mean sea level about 5 NM (9 km) to the north-west of the aerodrome. The lateral separation between the aircraft reduced to within 3 NM (5 km) and zero vertical separation as the A320 climbed through 3,100 ft. No Traffic Alert and Collision Avoidance System alerts were generated during the occurrence.

Both aircraft were operating scheduled passenger services from Melbourne, Victoria and had arrived at Launceston outside the normal operating hours of the Launceston air traffic control tower. Separation between the aircraft was therefore the responsibility of the respective flight crews. In this instance, a breakdown in the communication and interpretation of the respective flight crews' separation planning contributed to the proximity event.

On 9 April 2008, the crew of a McDonnell Douglas Helicopter Company MD369ER helicopter registered VH-PLU, experienced a substantial loss of engine power while conducting low-level powerline stringing operations. The helicopter impacted the ground and was seriously damaged. The two occupants were seriously injured.

The investigation determined that the pilot in command was operating the helicopter with a fuel tank quantity that did not guarantee continuous operation of the engine at the flight attitudes experienced during the powerline stringing operation.

As a result of the accident, the operator revised its fuel management procedures for powerline stringing operations.

On 3 April 2008, a Piper PA-32-300 Cherokee Six aircraft, registered VH-ZMP, lost engine power shortly after take-off from Brampton Island, Qld and ditched into the sea. The pilot and the four passengers evacuated the aircraft before it sank and were later recovered by rescue helicopter. The engine power loss was consistent with fuel starvation.

Following the event, the aircraft operator amended Cherokee Six fuel procedures to require a minimum of 30 L of fuel in the selected fuel tank for any take off.