On 17 November 2007 a Boeing Company 737-7Q8 aircraft, registered VH-VBC, with two flight crew, four cabin crew and 145 passengers was being operated on a scheduled passenger service from Coolangatta, Queensland to Melbourne, Victoria. During the take-off, the Master Caution system activated and the right BLEED TRIP OFF light illuminated. The pilot in command, who was the pilot flying, elected to continue the take-off. Once airborne the Bleed Trip Off non-normal checklist was actioned. The right engine bleed could not be reset with the effect that, when above flight level (FL) 170 (17,000 ft above mean sea level), only the left engine bleed air was available for air-conditioning and cabin pressurisation.

At FL318 during the climb, the flight crew observed the left PACK TRIP OFF light illuminate, followed by a rapid loss in cabin pressure and the cabin rate of climb indicator showing a rate of climb of about 2,000 ft/min. The crew fitted their emergency oxygen masks, commenced the Emergency Descent checklist and began a rapid descent to 10,000 ft. During the descent, the cabin altitude exceeded 14,000 ft, at which time the passenger oxygen masks deployed automatically. The aircraft was diverted to Brisbane for landing. There were no reported injuries to passengers or crew and no damage to the aircraft.

The investigation found that a combination of technical faults contributed to the loss of pressurisation and identified a number of other safety factors relating to operational procedures and cabin crew knowledge of the passenger oxygen system.

The operator conducted an internal investigation of the incident and carried out a number of safety actions as a result. Those actions included the enhancement of a number of the operator's manuals and the amendment of the operator's cabin safety recurrent training. In addition, the operator's passenger oxygen use in-cabin brief was enhanced to include advice that oxygen would flow to passengers' masks even if the associated bag was not inflated.

Preliminary report released 16 January 2008

Late in the afternoon on 15 November 2007, a Cessna Aircraft Company 172M aircraft, registered VH-TCS, took off from Uaroo Station, in the Pilbara region of WA, for a local flight under the visual flight rules. A witness driving in a northerly direction along the North West Coastal Highway reported seeing a column of 'dark smoke' in the direction of the property between about 1700 and 1730 Western Daylight-saving Time.

Witnesses discovered the aircraft wreckage on the side of a hill located about 500 m from the property landing strip on the morning of 17 November 2007. The aircraft had been destroyed by impact forces and a post-impact fire. The pilot, who was the sole occupant, was fatally injured.

Preliminary report released 27 April 2008

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.

On 17 November 2007, the owner-pilot of a Cessna Aircraft Company C337G (Skymaster), registered VH-CHU, was conducting a private flight in accordance with the visual flight rules from Moorabbin Airport, Vic. to Merimbula, NSW. The pilot, who was accompanied by three passengers, had indicated that he would be tracking along the coast. The aircraft did not arrive at Merimbula and on 19 November 2007 aircraft wreckage and three of the deceased occupants were found on a beach between Venus Bay and Cape Liptrap, Vic. Some wreckage was later found in the sea, off the beach. There were no survivors.

On 25 May 2007, an Indonesian registered Boeing 737-3YO, PK-AWP, touched down heavily while landing at Polonia Airport, Medan, Indonesia. The landing resulted in nosewheel vibration, a deflated left nosewheel tyre and overheated brakes.

The flight data recorder (FDR) was recovered from the aircraft. The Indonesian National Transportation Safety Committee (NTSC) was responsible for investigating this incident. The NTSC requested ATSB assistance in the recovery of data from the FDR tape on 12 December 2007. The Executive Director of the ATSB approved the request. To protect the information supplied by the ATSB to the NTSC and investigation work undertaken to assist this agency, the ATSB initiated an investigation under the Transport Safety Investigation Act 2003.

The FDR tape was provided to the ATSB on 17 December 2007. The tape was found to be damaged and the recovery of data was problematic, however, the ATSB successfully recovered the incident flight data from the damaged FDR tape. A data listing and graphical representation of data recorded during the incident flight and a report describing the recovery procedures, were finalised on the 10 January 2008. This information was provided to the NTSC.

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

On 10 November 2007 at approximately 0830 Central Standard Time, a Cessna Aircraft Company 172N, registered VH-WLQ, with two pilots and a passenger on board departed Katherine, NT on a private, visual flight rules (VFR) flight to Tennant Creek. At about 1030, the aircraft struck a powerline which spanned the Stuart Highway 20 km north of Elliott. The aircraft's tail section was broken rearwards from the aft fuselage, rendering the aircraft uncontrollable and causing it to impact the highway in a steep nose-down attitude. The three occupants were fatally injured. The aircraft was destroyed.

There was no evidence of an aircraft or operational reason for the flight below 500 ft above ground level (AGL). Based on a lack of evidence to the contrary, the investigation concluded that the descent to, and flight at low level was probably as a result of a conscious decision by the pilots.

The investigation was unable to establish which of the pilots was flying the aircraft at the time of the accident.

Preliminary report released 21 January 2008

On 4 November 2007, a Boeing Company 777-2D7 aircraft, registered HS-TJW, was being operated on a scheduled passenger service from Bangkok, Thailand, to Melbourne, Vic, with 17 crew and 277 passengers on board. During a non-directional beacon (NDB) non-precision approach to runway 16 at Melbourne Airport, the aircraft descended below the segment minimum safe altitude at 6.8 distance measuring equipment (DME, a measure in nautical miles). Soon after, the crew received two enhanced ground proximity warning system (EGPWS) cautions. The crew then levelled the aircraft and conducted a visual approach and landing on runway 16.

Occurrence investigations commenced from 1 July 2003 are initially categorized as level 4 unless agreed by the ATSB Executive to be above this level at the outset. As detailed in Section 21 (2) of the TSI Act 2003, the Executive Director is empowered to discontinue an investigation at any time. Section 21 (3) of the TSI Act 2003 requires the Executive Director to publish a statement setting out the reasons for discontinuing an investigation (commenced from 1 July 2003) within 28 days of discontinuing the investigation.

An investigation was commenced into a level 4 occurrence involving a Piper PA-24 aircraft, registered VH-EKB, that was cleared to conduct an instrument approach to Essendon Airport on 26 October 2007. At the time, air traffic controllers were concerned that the aircraft was below the glide path for the instrument approach. The preliminary investigation found that the aircraft became clear of cloud and the pilot was flying visually, but had not notified air traffic control (ATC) of this. The pilot was only recently rated to fly in Instrument Meteorological Conditions (IMC) and had originally planned for a visual arrival into Essendon Airport, however the weather conditions had deteriorated. During the investigation, the pilot was advised to ensure that he kept air traffic control aware of the progress of the flight and any subsequent changes. As the circumstances were considered not likely to have significant implications for transport safety compared with other priorities, the Executive Director has discontinued the investigation.

Status: Downgraded the occurrence to level 5

At 0715 Coordinated Universal Time on 20 October 2007, a Boeing Company 747-438 aircraft, registered VH-OJB, departed Los Angeles International Airport, USA, on a scheduled passenger flight to Brisbane, Australia. There were four flight crew, 14 cabin crew, and 406 passengers on board the aircraft.

The first officer was the handling pilot for the flight. As the aircraft became airborne, a tyre on the left body landing gear disintegrated and a section of tyre debris impacted a line of the number 1 hydraulics system in the left body landing gear well. That caused fluid and pressure loss from that system.

A short time later, the electronic indicating and crew alerting system (EICAS) screen in the cockpit advised that the number 1 hydraulics system had failed, and a report was received from the cabin crew that a 'bang' was heard in the vicinity of the left main landing gear shortly before the aircraft became airborne. The flight crew completed checklist items, and the flight continued uneventfully to Brisbane.

The operator found some inconsistencies in the aircraft manufacturer's documentation relating to hydraulics failures. The aircraft manufacturer has noted those and has advised that it will examine them as part of its ongoing standardisation program.

On 24 October 2007 at Darwin Aerodrome, an Airbus A330-300, registered VH-QPE, made two unsuccessful attempts to start the right engine. Subsequent inspection of the engine revealed an uncontained failure of the starter turbine and secondary damage to the integrated drive generator.

The starter was returned to the manufacturer to conduct a failure investigation. The investigation revealed damage consistent with 'crash engagement' of the starter resulting in failure of the overrunning bearing. The blades were designed to separate from the turbine disc in this event, however, the starter failed to contain the cut-off blades as designed. The manufacturer proposed corrective actions to prevent further occurrences.

On the evening of 13 October 2007, an Embraer-Empresa Brasilia EMB-120 ER, registered VH-EEB, was taxiing at Sydney Kingsford Smith Airport, NSW, to take off on a freight charter flight to Melbourne, Vic. The aircraft was lined up with the left edge of the runway. Shortly after the take-off roll commenced, the crew reported feeling two or three bumps on the runway, after which time the crew's attention was drawn to an electrical burning smell in the cockpit, followed by a high-speed warning. The smell dispersed and the flight continued as normal to Melbourne.

Pre-flight checks for the return flight to Sydney revealed damage to the aircraft, which was subsequently found to have been caused by impact with the runway edge lighting on the left side of Sydney runway 16R, where the aircraft had started its take-off run. The aircraft was grounded at Melbourne for repair.