A Fokker F27-50 aircraft, registered VH-FKZ, had departed Adelaide Airport, SA, on a scheduled passenger service to Olympic Dam SA. During the initial climb, the cabin crew advised the flight crew that there was smoke haze in the cabin. The flight crew returned the aircraft to Adelaide Airport with no reported injuries.

An examination of the right engine indicated that the number-4 bearing had failed.

On 13 July 2007 at about 1420 Western Standard Time, a Boeing Company 717-200 aircraft, registered VH-NXK, was being operated on a scheduled passenger service from Newman, WA to Perth, WA, when the right engine failed during the climb to cruise. The flight crew disconnected the autopilot, actioned the Engine Fire/Severe Damage checklist, and commenced decent to flight level 140. The flight crew broadcast a PAN to air traffic services and advised the cabin crew and passengers that the aircraft would be returning to Newman Aerodrome. The aircraft landed safely at Newman Aerodrome.

The operator's maintenance organisation carried out an internal inspection of the failed engine and found that all the blades on the high-pressure turbine stage disc had been sheared off.

A subsequent investigation by the engine manufacturer revealed that a high-pressure turbine stage 1 blade had separated from the blade disc below the blade platform due to low-cycle fatigue causing the remaining HPT1 blades to separate from the disc. This led to the subsequent engine in-flight shutdown. This failure was similar to a number of previous engine failures that have occurred since November 2003.

The engine was removed from the aircraft for shipment to the engine manufacturer for investigation and repair. A serviceable engine was fitted, and the aircraft was returned to service.

At the time of the incident the aircraft operator was engaged in replacing all the LIP 3 standard of HPT1 blades in their fleet engines with the new HPT1 blade.

On 14 July 2007, a Boeing 737 NG, registered ZK-PBF, taxied at Sydney Airport on taxiway 'G' to runway 16R for a take-off to Christchurch, New Zealand. The aircraft entered the runway with left engine N1 at 28% RPM and right engine N1 at 20% RPM (idle).

The flight crew commenced the take-off by increasing both engines' thrust and the Take Off / Go Around (TO/GA) button was pressed with the left engine N1 at 41% RPM and the right engine N1 at 24% RPM. As both engines accelerated, asymmetric thrust reduced directional controllability of the aircraft, and it veered off the side of the runway before the crew could bring the aircraft to a halt on the crossing runway 07.

As a result of this occurrence, the aircraft operator has reviewed procedures for initial and recurrent training of flight crews.

Interim Factual report released 20 March 2009

While passing through 400 ft above ground level on final approach, the aircraft drifted left of the runway centreline. The crew decided to go around and on applying power, the aircraft rolled and yawed left, resulting in significant control difficulties for the crew. After the crew regained control of the aircraft, they realised that the left engine had stopped. The crew completed the emergency checks, transmitted a PAN call and diverted to Wiluna. It was later determined that the left fuel tank was empty and that the left engine had sustained a total power loss from fuel starvation.

On 4 July 2007, the pilot of a Beech Aircraft Corporation B58 (Baron), registered VH-VEG, was conducting a charter flight in accordance with the instrument flight rules from Sydney, NSW to Shepparton, Vic. At about 1415 Eastern Standard Time, the pilot departed Sydney Airport with one passenger on board. The flight was planned via overhead Canberra, ACT and Albury, NSW. The weather forecasts obtained by the pilot indicated that in the Canberra area the freezing level would be about 6,000 ft above mean sea level (AMSL) and that broken cumulus or stratocumulus cloud could be expected to extend between 5,000 and 10,000 ft with moderate icing in cloud. The aircraft was not equipped for flight into icing conditions.

The pilot climbed the aircraft to the planned cruise altitude of 10,000 ft AMSL and was generally clear of cloud until over Canberra at 1532. At about 50 km to the south-west of Canberra the aircraft entered cloud with high moisture content at a temperature below 0 degrees C, resulting in the rapid accumulation of clear ice on the airframe. The pilot continued on track, but the build-up of ice eventually forced the pilot to descend below 7,500 ft, the published lowest safe altitude for the route. After maintaining 7,100 ft in cloud for a short time the pilot was cleared to descend to 4,900 ft. The pilot became visual and was able to descend further and to dislodge the ice.

The investigation found that the pilot was inexperienced operating in conditions conducive to icing and had not assimilated the guidance provided by the operator and the aircraft manufacturer.

While on this occasion the aircraft did not get very close to terrain, the circumstances of the occurrence are a salutary reminder of the hazard that winter weather in southern Australia can present to pilots of aircraft not equipped for flight in icing conditions.

A Boeing Company 767-300 aircraft, registered VH-OGP, was being operated on an overnight international passenger flight from Nagoya, Japan to Cairns, Qld. On board the aircraft were a pilot in command (PIC), a copilot, seven cabin crew and 162 passengers. The copilot was the pilot flying for the sector and had just completed a period of crew rest. The PIC handed back the control of the aircraft to the copilot at about 1600 UTC and got up to go to the toilet. The copilot heard a bang and turned to see the PIC had collapsed on the cockpit floor. There was no response from the PIC to the copilot's questioning. The copilot switched on the cockpit lights and saw that the PIC appeared to be staring into space and remained unresponsive. The copilot then alerted the cabin service manager to come to the flight deck.

At approximately 1650 UTC, the PIC had recovered sufficiently to return to the cockpit, where he remained for the duration of the flight. A PAN call was transmitted by the PIC when the aircraft entered the Australian Flight Information Region and emergency services were placed on standby for the aircraft's arrival and landing at Cairns.

The PIC was subsequently examined and cleared to return to flight duties by a Designated Aviation Medical Examiners (DAME). The DAME determined that the PIC probably had been affected by a gastro-intestinal illness that had previously been experienced by members of the PIC's family. A Norovirus gastro-intestinal disorder was prevalent in the Queensland region at the time.

On 20 June 2007, at approximately 0615 Western Standard Time, a Cessna Aircraft Company C208 Caravan float plane, registered VH‑NRT, departed Broome Airport, WA on a Visual Flight Rules (VFR) charter flight to Talbot Bay. On board the aircraft were the pilot and 10 passengers.

About 35 to 40 minutes into the flight, the weather conditions deteriorated, and the pilot elected to discontinue the flight and return to Broome. During the return flight, the aircraft entered an area of reduced in-flight visibility that resulted in the loss of the visual horizon.

Whilst manoeuvring the aircraft to regain visual meteorological conditions (VMC), the pilot became disoriented. The pilot made a general radio broadcast requesting assistance, which was intercepted by the crew of another aircraft who then provided advice and reassurance to the pilot. The pilot was able to regain control of the aircraft and, shortly after, resume the remainder of the flight.

The approach to Broome required the non-instrument-rated pilot to descend through cloud before becoming visual and landing.

This incident highlighted the risks of inadvertent flight into Instrument Meteorological Conditions (IMC) and of the recovery from those conditions, particularly in respect of a pilot that does not hold an instrument rating.

Aviation Safety Recommendations

[ R2007014SR029 ] [ R2007014SR030 ]

On 13 June 2007 at about 1335 Eastern Standard Time, a Bell Helicopter B206B helicopter registered VH-JWM (JWM) departed Mackay, Qld on a charter flight to a container ship, located about 180 km offshore. The helicopter was engaged in the transfer of a marine pilot to an offshore ship. On board were the pilot and the marine pilot. The flight was operated under the visual flight rules (VFR). The pilot later reported that at about 1423, while about midway between Mackay and the ship at about 1,500 ft above mean sea level, the helicopter sustained an engine power loss. The pilot reported that the first indication was a slight yaw kick in the helicopter. He reported that he immediately lowered the collective control and configured the helicopter descent profile for an auto-rotation emergency landing. The pilot reported that he broadcast a MAYDAY on both the operator's and air traffic control radio frequencies. The pilot reported that he then reduced the forward airspeed of the helicopter, confirmed the inflation of the pop-out floats on the helicopter's skids, flared the helicopter and landed in the ocean. He reported that at this point, the helicopter was floating on the ocean and the main rotor blades had nearly stopped rotating.

The 2 to 3 m sea swells caused the helicopter to roll to its left and become inverted. The two occupants sat on the overturned helicopter until they could inflate and enter a four-person life raft.

About one and one-half hours after ditching, they recovered by another company helicopter and transported to the Mackay Base Hospital. They sustained only minor injuries. After several weeks floating, the helicopter eventually submerged and was not recovered until 26 September 2007. The damage to the wreckage prevented the investigation from obtaining any additional information in relation to the engine failure.

On 31 May 2007, the pilot of a Beech Aircraft Corp. Super King Air, registered VH-XCB, was conducting an Area Navigation (RNAV) Global Navigation Satellite System (GNSS) non-precision approach (NPA) to runway 36 at Ballarat, Vic. in instrument meteorological conditions (IMC) as part of a check flight for renewal of a command instrument rating. While conducting the approach, the check pilot on board visually determined that the aircraft was displaced outside the permitted lateral tolerances of the published final approach track. The pilot's primary flight display showed that the aircraft was within permitted tolerances and there were no associated messages or alerts.

An examination of the aircraft's navigation equipment by an avionics technician found that the installation was not approved for the procedure and a technical problem prevented the equipment from meeting approval standards.

The operator of the aircraft annotated the aircraft's maintenance release to reflect that the Global Positioning System (GPS) was not approved for use in the conduct of RNAV (GNSS) NPAs.

During the Australian Transport Safety Bureau investigation into the accident at Lockhart River, Qld on 7 May 2005, involving the Metro 23 aircraft registered VH-TFU, it was established that it was possible to receive ground proximity warning system (GPWS) warnings while conducting the Runway 12 RNAV (GNSS) non-precision approach, even when the aircraft was on the correct profile and track. After several reports of crews receiving such warnings, an investigation into the potential safety implications of these 'nuisance' warnings' was commenced. It was found that nuisance warnings could condition flight crews to ignore the warnings in order to complete the approach procedure, rendering the warning system ineffective in preventing controlled flight into terrain.

The safety issue identified as a result of this investigation related to the generation of 'nuisance' GPWS warnings while conducting the Runway 12 RNAV (GNSS) non-precision approach at Lockhart River. Airservices Australia have commenced designing a revised approach using new approach design criteria, and the Civil Aviation Safety Authority has undertaken to flight validate the revised approach when available.