At about 1100 Eastern Standard Time on 23 June 2009, a Bell Helicopter Company 206B JetRanger III helicopter, registered VH-CAP commenced agricultural spraying operations at a property located 24 km north-north-east of Albury Aerodrome, New South Wales. At 1223 the pilot repositioned to commence an impromptu spray run that resulted in the helicopter flight path crossing a powerline that was known to the pilot.

The pilot reported that during the impromptu spray run, he was preoccupied with a request from the property owner to modify the planned spray sequence and forgot about the wire until he sighted it a short distance ahead. In response, the pilot initiated a climb to avoid the wire. He heard the helicopter contact the wire and felt the wire arrest the forward movement.

Although the helicopter was fitted with wire-strike protection system (WSPS) equipment, the wirestrike was outside the strike angle and cable span design parameters of the WSPS. The investigation was unable to determine whether the WSPS might have operated as intended, had the wire continued its initial movement towards the cutter blades before itself breaking.

The pilot's last recollection was seeing the ground rapidly approaching. He regained consciousness an unknown period of time later, still securely restrained in the wreckage. He managed to extricate himself and notify his ground crew. The pilot sustained minor injuries.

The investigation found that the inherent difficulty in visually detecting the wire, combined with the operating groundspeed required for chemical application meant that the pilot did not have sufficient time to avoid the wirestrike.

Although no safety issues were identified as a result of this investigation, the protection afforded by the pilot's helmet and the secure restraint offered by the pilot's four-point harness, probably prevented serious, if not fatal injury. Operators and crew would benefit from the consideration of the use of flying helmets, and when feasible, installation of four-point harnesses in their aircraft, particularly during inherently higher risk operations.

On 31 August 2009 at 1344 Eastern Standard Time, the pilot of a Beech Aircraft Corporation B200T, registered VH-LAB, suffered a seizure and was rendered unconscious, while the aircraft was descending from flight level (FL) 2002 to FL150 inbound to the Bindook VOR. The aircraft was being flown using the aircraft's autopilot coupled to the Global Positioning System (GPS). The aircraft crewman attended to the pilot and notified Air Traffic Control (ATC) of the occurrence.

In the ensuing 20 minutes, the pilot gradually regained consciousness and at 1418 initiated and successfully completed an approach and landing at Bankstown airport.

It was later determined that the pilot had a previously undiscovered medical condition that was the likely cause of the in-flight seizure.

On 25 August 2009, a Piper Cherokee PA28-161 aircraft, registered VH-FKU, was approaching Bankstown Aerodrome, New South Wales (NSW) from reporting point 2RN in the south-west to join on a crosswind leg for runway 29 right (29R). At the same time, a Piper Chieftain PA31-350 aircraft, registered VH-HJH, was approaching Bankstown Aerodrome from Cessnock to join on a downwind leg for runway 29R. Both aircraft were being operated under the visual flight rules.

The pilot of the Cherokee was given traffic information by air traffic control and instructed to widen out to the left and told to expect to follow the Chieftain that was tracking to join on a downwind leg for runway 29R. The pilot of the Cherokee acknowledged the instruction but subsequently turned downwind in front of and inside the flightpath of the Chieftain. Traffic information was passed to the pilots of both aircraft, and the pilot of the Chieftain made a steep descending turn to avoid a collision.

On 2 July 2009, the pilot of a Robinson Helicopter Company R22 Beta II, registered VH-OML, was conducting solo circuit training from the Gold Coast Aerodrome, Queensland. Weather conditions in the area at the time were fine, with light and variable winds.

At about 1015 Eastern Standard Time, the helicopter impacted terrain near the southern aerodrome boundary. The pilot was fatally injured and the helicopter seriously damaged.

There was no evidence of a pre-existing mechanical problem with the helicopter. The pilot had extensive previous experience in aeroplanes and the flight was his sixth solo helicopter flight towards his Private Pilot (Helicopter) Licence. The investigation found that the accident may have been a function of the pilot's control inputs.

As a result of this investigation, the helicopter operator has made a number of changes to their induction process, including the annotation in company records of instructors' ratings and their respective validity periods. In addition, the Civil Aviation Safety Authority has advised that it will review the requirements for initial pilot training and endorsement and recurrent training on Robinson R22 helicopters. Included will be a review of the Helicopter Flight Instructor's Manual to ensure that the required competencies are being covered by flight instructors and trained to students.

The Australian Transport Safety Bureau has issued a Safety Advisory Notice suggesting that operators consider action to ensure the validity of pilots' qualifications and ratings, and that competency standards are met.

On 24 June 2009, the pilot of a Robinson Helicopter R22 Beta II, registered VH-HXO, departed Mareeba, Queensland on a private flight to Uaroo, Western Australia (WA) as the helicopter had been contracted to an operator for aerial mustering tasks. After an overnight stay at Alice Springs, Northern Territory, the pilot departed for Uaroo on 25 June 2009. The last known stop for the pilot was the night of 25 June 2009, at Newman, WA. After refuelling, the pilot departed sometime during that night. The following morning, after the expected arrival time of the helicopter, and after several attempts to contact the pilot, Australian Search and Rescue commenced a search for the missing helicopter. The wreckage was located about 120 km west of Paraburdoo, WA. The pilot was fatally injured as a result of the accident.

The investigation found no evidence of a pre-existing mechanical problem with the helicopter. After consideration of the available evidence, the investigation concluded that the accident may have been a function of the pilot's control inputs, possibly resulting from pilot fatigue, carburettor icing, night flight, or a combination of these factors.

The investigation did not identify any organisational or systemic issues that might adversely affect the future safety of aviation operations. However, the accident does provide a timely reminder of the need for pilots conducting private operations to consider the impact of fatigue; particularly, during a long flight over a number of days, as was the case in this occurrence.

At Indonesia's request, the Australian Transport Safety Bureau (ATSB) appointed an accredited representative in accordance with Clause 5.23 of Annex 13 to the Convention on International Civil Aviation, to participate in the NTSC's investigation into the fatal accident in the Makassar Strait, Indonesia, involving a Boeing 737 operated by AdamAir.

The aircraft disappeared off radar and crashed into the ocean. The aircraft was destroyed and the two pilots, four flight attendants and 96 passengers on board were fatally injured.

Australia's accredited representative to the investigation worked closely with the NTSC throughout the investigation.

To protect the information supplied by the NTSC to the ATSB and investigative workload undertaken to assist the NTSC, the ATSB initiated an investigation under the Transport Safety Investigation Act 2003.

On 25 March 2008, the NTSC published its final report into the accident on its website.

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.

At approximately 1137 EST on 20 August 2009, a Boeing 737-8BK aircraft, registered VH-VOC, departed Launceston, Tasmania on a scheduled passenger service to Sydney, New South Wales. Following take-off, several loud bangs were heard from the left engine, consistent with a compressor surge. The left engine was reduced to flight idle and the aircraft returned to land at Launceston.

The compressor surge and damage to the left engine was the result of advanced variable stator vane bushing/shroud wear, which caused a seal retainer to dislodge from the inner shroud segment and move into the compressor gas path. The liberated seal segments then progressed downstream, causing significant impact damage to the remaining stages, resulting in a loss of compressor efficiency.

The manufacturer was aware of the propensity for inner bushing wear, and had previously released a number of service bulletins aimed at eliminating the issue.

The operator had incorporated the relevant service bulletins into their inspection and maintenance program as required; however the event occurred prior to the engine reaching the earliest threshold for inspection.

On 4 July 2009, an Airbus A330-202, registered VH-EBB, was being operated on a scheduled passenger/freight flight from Sydney, New South Wales to Denpasar, Indonesia via Melbourne, Victoria. During loading of the aircraft at Sydney International Airport, a unit load device (ULD) was loaded onto the aircraft without the proper authorisation. Prior to the aircraft taxying for departure, loading personnel realised that the ULD had been mistakenly loaded. However, there was confusion in the communication of that information to the flight crew and they operated the flight to Melbourne without knowledge of the misloading.

The investigation found that the pilot in command rejected the loading of the ULD before it was loaded in the forward cargo hold, but the status of that ULD was not clearly communicated to the ground handling team and it was returned to the outgoing freight holding area of the departure bay. Contrary to the aircraft operator's procedures, the ULD was subsequently loaded into the aircraft's aft cargo hold, in the absence of a leading hand and without reference on the loading instruction report or the authorisation of the pilot in command. Contributing to the occurrence was a lack of procedure or guidance for the segregation of freight that had been rejected during loading.

The investigation identified a number of factors that did not contribute to the incident but increased operational risk. Those factors related to the performance of the leading hand role, load-checking and procedures for communicating with flight crew after pushback.

The aircraft operator initiated proactive safety action to improve the training and supervision of loading staff, including guidelines for all staff involved with the training and support of new ports or ground handling agents. The operator also implemented procedures to enable ground handling agents to make emergency contact with the aircraft crew after pushback and incorporated those procedures in the relevant manuals.

Preliminary report released 28 September 2009

At about 1730 Eastern Standard Time on 17 August 2009, a Cessna Company U206G aircraft, registered VH-KVT, was being operated on a local flight on a property 81 km north-east of Winton, Qld. The pilot was the only person on board. Following a steep dive, the aircraft collided with flat, open terrain in a steep nose-low attitude, resulting in serious damage. The pilot received fatal injuries.

At 1447 on Thursday 27 November 2008, the northbound Cairns Tilt Train (CTT) collided with a loaded B-double truck  at the Rungoo level crossing, about 19.5 km north of the township of Ingham in north Queensland. On board the CTT were 81 passengers and seven train crew. The truck driver was the sole occupant of the B-double truck.

The two train drivers were fatally injured as a result of the collision, the truck driver sustained moderate injuries. In addition, injuries were incurred by nine passengers.  The investigation was conducted by the Department of Transport and Main Roads in accordance with provisions of Queensland's Transport Infrastructure Act 1994 (the Act), independently chaired by a senior rail safety investigator of the Australian Transport Safety Bureau.

Rail safety in Queensland is regulated by the Department of Transport and Main Roads. All railway managers and/or railway operators within Queensland are required to be accredited in accordance with the Act. The Department of Transport and Main Roads' role in rail safety also includes the investigation of railway incidents.

The final report is available via Queensland Transport.

• Queensland Transport website