On 27 April 2006 at about 1530 Eastern Standard Time, a Cessna Aircraft Company U206G (206) aircraft was being operated on a non-scheduled passenger flight from Warraber Island to Mabuiag Island, in Torres Strait. On board were a pilot, six passengers and luggage. Shortly after touchdown during the landing on runway 15 at Mabuiag Island, the aircraft commenced to veer to the left. The pilot was unable to maintain the aircraft on the runway and it continued to veer left, skidding sideways on the grass verge through a fence and into a lagoon. The pilot and passengers were able to safely vacate the aircraft.

The pilot reported that the aircraft was configured with full flap for the approach and that the aircraft touched down at about 65 kts near the runway threshold. He retracted the flaps on touchdown and as he applied maximum braking, the aircraft turned to the left and started to skid. He applied gentle right rudder in an attempt to straighten the aircraft, but it continued to slide to the left. The aircraft ran off the sealed runway surface and it continued to slide on the grass.

The operator reported that an inspection of the aircraft following its recovery from the lagoon did not reveal any mechanical or system anomalies that may have been a factor in the accident.

The pilot reported that he probably did not apply equal braking effort to both the left and right main landing gear brakes during the landing. While the braking technique may have been a factor, it is more likely that the pilot's limited experience in crosswind conditions and on the aircraft types were the main factors that led to the runway excursion.

On 19 April 2006, a Fairchild Industries Inc SA227-DC (Metro) aircraft was being operated from Newman, WA to Perth, WA at flight level (FL) 200. A Boeing Company 717-200 (717) was being operated from Karratha, WA to Perth at FL320. Both aircraft were in controlled airspace and were on tracks that converged.

The crew of the 717 had been provided with a clearance to descend to FL210 by the air traffic controller managing the airspace the aircraft were operating in. This level provided the required minimum vertical separation standard of 1,000 ft with the Metro.

As the crew of the 717 were approaching FL225 the traffic alert and collision avoidance system (TCAS) provided a traffic advisory relating to the Metro. A few seconds later the crew received a TCAS 'reduce descent rate' resolution advisory (RA). The crew advised the controller 'we've got a TCAS resolution advisory we're leaving F210 on descent'. The controller responded by instructing the crew of the 717 to maintain FL210.

Later analysis of Airservices Australia recorded radar data and audio recordings demonstrated that the crew of the 717 had descended to, and maintained, FL210. There was no infringement of separation standards.

The crew of the 717 maintained a high rate of descent approaching their assigned level, which resulted in the TCAS 'reduce descent rate' resolution advisory. The controller did not recognise the rate of descent of the 717, together with the relative positions of the two aircraft, may have generated a RA.

On 21 April 2006, a Brisbane Airport surface movement controller (SMC) issued a clearance for the driver of an aircraft tow vehicle to cross an active runway in front of a Boeing Company 737 aircraft which had been lined up on the runway ready for departure. The crew of the 737 aircraft had been issued with a take-off clearance by the aerodrome controller (ADC) and subsequently commenced take-off. The SMC and ADC services were being provided on separate radio frequencies.

The crew of the tow vehicle later reported that they were still within the runway strip when the 737 aircraft passed behind them airborne. The flight crew of the 737 had observed the tow vehicle crossing the runway during the take-off roll but had assessed that the vehicle would be clear of the runway prior to them reaching its observed position and decided to continue the take-off. The SMC later reported that he had wrongly believed that he had coordinated and received a clearance for the tug to cross the runway from the ADC.

As a result of this occurrence Airservices Australia has made changes to the coordination of runway crossing clearances, including the content, form and readback requirements and has mandated the use of movement strips for the SMC position at Brisbane. It reported that it has continued with efforts to reduce the number or required runway crossings, in consultation with the airport owner and is also in the early stages of a project to procure an Advanced Surface Movement Guidance System (A-SMGCS). Airservices Australia is also actively considering and pursuing the concept of having all runway crossings occurring on the ADC frequency as recommended by the International Civil Aviation Organization.

On 4 April 2006 a Bell Helicopter Company 206B III helicopter was being operated on a survey of powerlines in the St Albans area of New South Wales with a pilot, two power supply company personnel and a photographer on board. At about 1000 Eastern Standard Time, the pilot observed a previously unseen single-strand telecommunication cable support wire rubbing against the copilot's door and attempted to manoeuvre the helicopter clear of the wire. The helicopter lost directional control and commenced spinning to the right. However, the pilot cleared the wires and attempted a landing in an adjacent paddock. The helicopter came to rest on its right side and was severely damaged. One of the power supply company personnel received serious head injuries and the remaining occupants received minor injuries.

Safety action undertaken as a result of this accident included:

• by the power supply company, who acted to:
  • immediately suspend helicopter inspections
  • appoint an internal accident investigation team that would make recommendations for the recommencement of helicopter operations
  • engage an aviation risk management consultant to assess the hazards affecting the company's aerial surveillance operations and to assist the internal investigation team
  • implement a number of safety actions that were recommended by the internal investigation team.
• the removal by the telephone company of the single-strand telecommunication cable support wire that was struck by the helicopter.

On 5 April 2006, the pilot of an amateur-built Lancair 360 aircraft, registered VH-ZNZ, was conducting circuits at Bankstown Airport, NSW. It was the aircraft's first flight since being repaired after a landing accident in 2003.

Following an overflight and a touch-and-go, the pilot conducted another touch-and-go and shortly after lift-off, at an altitude estimated by witnesses to be between 100 ft and 400 ft, the engine was heard to malfunction. Almost immediately, while still not above 500 ft, the aircraft rolled into a steep right turn. Engine power was heard to return but sounded intermittent. After turning approximately 90 degrees, the aircraft rolled out of the turn momentarily to about wings level, before the turn steepened again to the right. The aircraft was observed to roll further to the right and descend steeply. The aircraft impacted a taxiway, the pilot was fatally injured, and the aircraft destroyed.

The investigation found that the engine power loss was probably due to interruptions of fuel flow to the engine but could not conclusively determine the reason. The aircraft stalled at a height insufficient to allow the pilot to recover.

The investigation identified a number of safety issues related to stall warning, management of incomplete engine power loss after take-off, pilot transition training and the provision of information to purchasers of amateur-built aircraft.

Following the occurrence, the Civil Aviation Safety Authority and Sport Aircraft Association of Australia implemented a number of safety actions. As a result of this and other occurrences the Australian Transport Safety Bureau initiated a broader investigation into loss of control following engine power loss after take-off.

On 26 March 2006, at about 1800 Eastern Daylight-saving Time, a Cessna 188B Agwagon aircraft, registered VH-ZIP, was reported to have taken off from a field adjacent to a local water-ski area, about 59 km south-west of Narrandera, NSW, with the pilot as the sole occupant. The following morning at about 0900, the aircraft wreckage was found by a passer-by at a position 55 km south of Narrandera and about 8 km from the departure area. The aircraft was destroyed, there was no fire, and the pilot was fatally injured.

There was no evidence that the pilot experienced any physiological condition which could have contributed to the accident. Weather conditions in the area were reported to be fine with little or no wind and there were no overhead powerlines or other obstacles in the vicinity. The aircraft had impacted the ground heavily, in a nose-down, right wing-low attitude, consistent with a low-speed stall or aerobatic manoeuvre. There was no evidence of a flight control or systems problem which could have contributed to the accident and the engine and propeller were producing power at the time of impact.

The pilot was reported to have been known to conduct 'high-risk' aerial activities, including aerobatic flight in agricultural aircraft. A number of photographs taken shortly before the final flight showed him conducting low passes over the water-ski site with the aircraft's main wheels in contact with the surface of the water. During the accident flight he was reported to have conducted very low passes over a departing vehicle, more low passes over the water with the main wheels in contact with the water's surface and what was described to be manoeuvres consistent with aerobatic flight.

The investigation concluded that the pilot was probably conducting an aerobatic flight manoeuvre from which collision with terrain could not be prevented.

Interim Factual report released 22 September 2006

At 0728 Eastern Standard Time on 31 March 2006, an amateur-built Lancair 320 aircraft, registered VH-BST, departed Townsville, Qld, on a private flight to Archerfield Aerodrome, Qld. The pilot, who owned the aircraft and was the sole occupant, had earlier submitted a visual flight rules (VFR) flight plan for the flight.

At 1048.30, the pilot contacted the Archerfield Aerodrome Controller and reported that he was 19 miles (35 km) from the aerodrome and inbound. He said that he was new to the area and would appreciate any help. The controller advised the pilot to report at the TV towers, a VFR reporting point 13 km north-west of Archerfield. The aircraft was maintaining about 3,700 ft AMSL (above mean sea level).

The pilot reported at the TV towers but had difficulties finding the aerodrome. Radar data showed that the aircraft was 2 km north of the aerodrome at 1,700 ft AMSL, and tracking south-south-east. At 1058.11, the controller asked the pilot if he had the aerodrome in sight. The pilot said that he did not, and said 'I feel I've overflown it'. The controller advised that radar information indicated that the aircraft was north of the aerodrome, and he suggested that the pilot continue to turn left. The pilot then acknowledged that transmission. No further radio transmissions were received from the pilot.

Witnesses reported seeing the aircraft's left wing drop and the aircraft appeared to enter a spin before descending straight down, colliding with a tree and then a creek running parallel to Kessels Road, Coopers Plains. The aircraft was destroyed and the impact was not survivable.

At 1350 Eastern Standard Time on 19 March 2006, an Airbus A330-303 aircraft, registered VH-QPB, commenced take-off on runway 19 at Brisbane Airport, Qld, on a scheduled passenger service to Singapore. The pilot in command (PIC) was the pilot not flying (PNF) and the copilot was the pilot flying (PF) for the sector. Visual meteorological conditions prevailed at Brisbane.

During the take-off roll, the flight crew noticed a significant discrepancy between the PF and PNF's airspeed indications and the PIC assumed control of the aircraft and rejected the take-off. The PIC elected to not use reverse thrust and attempted to manually disconnect the autobrakes via brake pedal deflection during the rejected take-off.

Shortly after vacating the runway, the flight crew noted increased brake temperatures and selected the brake cooling fans ON. During the taxi, the brake temperatures continued to rise and became excessive. The fusible plugs on six of the eight main landing gear wheels melted and the respective tyres deflated. There were no injuries to the crew or passengers.

A post-flight engineering inspection of the aircraft found what appeared to be wasp-related debris in the PIC's pitot probe and the operator determined that the contamination was a probable contributory factor in the incident.

The operator and airport owner undertook a number of safety actions to minimise the risk of future wasp activity at Brisbane Airport.

On 4 March 2006, McDonnell Douglas Corporation MD-82, registered PK-LMW, was operating a flight from Denpasar to Surabaya, Indonesia. The aircraft was cleared to land on runway 10 with the reported wind calm and the runway wet. During the landing roll, the aircraft veered to the right resulting in a runway excursion.

The National Transportation Safety Committee (NTSC) of Indonesia was responsible for investigating this occurrence. On 8 March 2006 the NTSC requested assistance from the Australian Transport Safety Bureau (ATSB) in the recovery and analysis of information from the flight data recorder and cockpit voice 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 NTSC is responsible for releasing the 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

On 4 August 2005, a Piper PA-31-350 Chieftain aircraft, registration VH-MZM, departed Dubbo Airport, NSW, for a local post-maintenance acceptance flight following an engine change. Shortly after departure, the pilot reported that the right engine manifold pressure fluctuated then dropped and maintained 28 inHg. The aircraft was returned to Dubbo with reduced power to the right engine.

Examination of the aircraft by the overhaul engineers revealed the newly-installed turbocharger turbine wheel had failed. The turbocharger was supplied to the ATSB for further examination and analysis.

During the course of the investigation, a second, similar turbine wheel failure occurred in a Piper PA-31-350, registration VH-TZY. Similarly to the first incident, the pilot observed significant manifold pressure fluctuations during cruise flight of the aircraft and the right engine was shut down. The aircraft was returned to the departure aerodrome. The turbocharger had been in service for approximately 241 hours and was subsequently forwarded to the ATSB.

Analysis of both turbine wheels revealed fracture characteristics indicative of a fatigue cracking mechanism. The failures had both occurred through a sealing ring groove, adjacent to the friction-welded joint between the turbine wheel and shaft components. While the post-failure damage of the fracture surfaces in both instances prevented the identification of the prime factor/s giving rise to the initiation of fatigue cracking, it was likely that the stress-raising effect of the ring groove location, geometry and associated microstructure, when combined with pre-existing cyclic loading conditions, was sufficient to initiate fatigue cracking and consequent turbine wheel failure.