On 26 May 2007 at about 1644 Western Standard Time, a Piper Aircraft Corp PA-28RT-201 aircraft, registered VH-FTT, departed Jandakot Airport for Esperance, WA. On board the private, visual flight rules (VFR) flight were the non-instrument-rated owner-pilot, and two passenger friends.

The flight arrived at Esperance about 1 hour and 40 minutes after last light, and in marginal weather conditions. The aircraft impacted the ground on what appeared to be a right base for runway 11. There were no survivors.

There was no evidence of any technical defect or other failure of the aeroplane, or of its associated systems, prior to the impact with terrain. That, and the normal operation of the approach and landing aids, and apparent activation of the aerodrome lighting, suggested that the most likely factors that contributed to the development of the occurrence related to the operation of the aircraft.

The investigation was unable to conclusively establish the reason for the impact with terrain. The investigation could not exclude the possibility of a sudden incapacitation of the pilot due to a cardiac condition. However, the weather conditions enroute to, and in the vicinity of Esperance were such that the pilot's decision to attempt the flight indicated a low appreciation, or an acceptance, of the associated risks. The attempted approach and landing under those conditions represented a significant level of risk for any flight attempted under the night VFR.

A Raytheon Beech King Air aircraft, registration VH-IWO, was cruising at FL290 on an aero-medical flight from Newman to Fitzroy Crossing, WA with the pilot, a flight nurse and a doctor on board. When approximately 140 NM (259 km) south-south-east of Broome, the right engine inter-turbine temperature indication (ITT) was observed by the pilot to rise without any engine control input. The ITT rise was accompanied by a slight fluctuation in a number of associated engine indications. The pilot reduced power on the right engine.

Shortly after the power reduction, there was a slight right engine surge, with an accompanying rise in ITT. The pilot observed smoke coming from the right engine exhaust. The pilot shut down and secured the right engine and, after briefing the flight nurse and doctor, diverted to Broome Airport where a single-engine landing was completed.

Examination of the right engine revealed extensive damage caused by the separation of one of the compressor turbine blades at mid span.

As a result of this occurrence, the engine manufacturer has modified the alerting feature in the case of the interruption of the supply of electronic trend monitoring (ECTM) information to customers from its automated ECTM program.

At about 1030 Eastern Standard Time on 23 May 2007, a Piper Aircraft Inc. PA-32-260 aircraft, registered VH-PYD (PYD), departed Horn Island, Queensland, for a visual flight rules charter flight to Warraber Island, Queensland, with the pilot and three passengers onboard. Approximately 25 NM from Warraber Island, the aircraft experienced difficulties with the powerplant and was forced to ditch into the waters of the Torres Strait. Having received only minor injuries, the occupants exited the aircraft before it sank. The occupants were located and rescued within an hour of the ditching.

Shortly after commencing the descent into Warraber Island, the pilot noticed that the engine speed had increased beyond the normal range. Several unsuccessful attempts were made to reduce the engine speed, and within a short time the engine stopped producing power. Without engine power, the aircraft was not able to maintain altitude and given the aircraft's distance from land was forced to ditch into the water.

Because the aircraft was not recovered, the factors that resulted in the powerplant failure could not be determined; however, it was probable that they were related to a problem with the forward most crankshaft bearing.

In addition to the favourable sea, the pilot's recently acquired knowledge from the company's emergency procedures training likely contributed to the successful ditching.

On 17 May 2007, a de Havilland Dash 8, registered VH-TQP, and a Beechcraft Baron D55, registered VH-ILS, were operating in the vicinity of the Port Macquarie CTAF(R) Aerodrome. At the same time, the pilot of an Aeroprakt A22 Foxbat, registered 24-4422, was taxiing to conduct circuits from runway 21. The Foxbat was operating under the visual flight rules (VFR).

The pilot of the Baron initiated a go-round from short final approach to runway 03 as the Foxbat took off from runway 21. The crew of the Dash-8 subsequently conducted a go-round from final as the pilot of the Foxbat also turned onto final for runway 21 in front of the Dash-8.

A short time later, the pilot of the Foxbat landed without further incident. A club instructor inspected the Foxbat's radio after engine shutdown and found that the radio volume was at a low setting.

On 8 May 2007 at about 1858 Eastern Standard Time, a Boeing Aircraft Company 767-338 (767), registered VH-OGI, was inbound to Sydney, NSW from Melbourne, Vic. on descent to 6,000 ft and a SAAB Aircraft Company 340B (SAAB), registered VH-OLL, was departing Sydney for Moruya, NSW on climb to FL140. The distance between the aircraft reduced to 1.5 NM horizontal and 400 ft vertical separation. Separation standards as specified in the Manual of Air Traffic Services (MATS) required the provision of either 3 NM horizontal or 1,000 ft vertical separation between the aircraft. There was a breakdown of separation.

The apparent distraction of the controller by his involvement in a non-operational control room discussion would probably have adversely affected his mental 'air picture' and traffic planning. That included unintentionally clearing the flight crew of the SAAB to climb through the assigned level of the inbound 767, rather than the routinely assigned intermediate altitude of 5,000 ft. The traffic manager's preoccupation with administrative duties meant that the monitoring and control of the distraction risk and operational activities in the control room was ineffective.

Action by the controllers to issue traffic information to the flight crew of the 767 and a radar vector and altitude limit to the flight crew of the SAAB quickly re-established the required separation standards.

Although no safety issue was identified as a result of this investigation, in its submission in response to the draft report, Airservices Australia (Airservices) advised of its development of an Air Traffic Control (ATC) Reform initiative. The aim of that initiative was to improve the structure and processes used by Airservices to verify ATC operational performance. At the time of writing this report, the initiative was in the design phase, with implementation planned for early 2009.

On the night of 3 May 2007, a Raytheon Aircraft Company 390, registered N7088S, was enroute to Townsville Airport, Qld on the final leg of a private instrument flight rules (IFR) flight from Avalon, Vic via Sydney, NSW and Brisbane, Qld. The aircraft carried four passengers and a pilot. At about 0049 EST on 4 May, the pilot landed the aircraft on runway 01 while it was closed due to works in progress. There was no damage to the aircraft or injuries to personnel.

On 29 April 2007, a notice to airmen (NOTAM) had been issued which required that pilots requiring the use of runway 01 provide 30 minutes prior notice to the works safety officer (WSO) on duty at the airport. The pilot of N7088S later reported that although he had reviewed the list of NOTAMs for the airport prior to the flight, he did not recall noting the runway closure and did not notify the WSO of his planned arrival. The WSO had been notified of the planned arrival of another aircraft and had selected the runway lighting ON in anticipation of its arrival. At the time of the occurrence, the instrument landing system approach aid for runway 01 was available and the airport's pilot activated lighting and airfield frequency response unit were unavailable.

For a period of several minutes while on approach and final, the pilot was not contactable by radio on either the Brisbane Centre frequency or the Townsville common traffic advisory frequency. During this time the duty supervisor at Brisbane Centre notified the WSO of the approaching aircraft. Workers on the runway noticed the approaching aircraft and vacated the runway before the aircraft landed.

The investigation identified several safety factors that contributed to the occurrence, including pre-flight planning, radio selection and operation, ground works management, and air traffic control. The airport operator, the pilot, and Airservices Australia initiated a number of safety actions in response to some of the issues identified.

On 25 April 2007, at approximately 1155 Eastern Standard Time (EST), the pilots of a Dornier Werke GMBH DO 228-202 K (Dornier), registered VH-YJD, sighted an aircraft at the same altitude approaching from the opposite direction while flying over Princess Charlotte Bay, Qld. The pilot flying the Dornier immediately climbed and turned the aircraft to the left to avoid the approaching aircraft. The conflicting aircraft passed 50 to 100 ft below the right wing of the Dornier. A Cessna Aircraft Company T210M (Cessna), registered VH-FGW, was subsequently identified as the other aircraft. There had been an Airprox.

On 19 April 2007, the Darwin radar (DNR) airspace was being operated as a non-radar procedural sector due to the removal of the Australian Defence Air Traffic System (ADATS) radar data from the civil Australian Advanced Air Traffic System (TAAATS). That change in arrangements was necessary because of ongoing technical problems with the integration of the ADF data into the civil radar system.

At about 0909 Central Standard Time, the DNR controller identified that an instrument flight rules (IFR) Cessna Aircraft Company C210N, tracking from Darwin to Gove, NT at an altitude of 9,000 ft, was in conflict with an IFR Piper Aircraft Corporation PA31-350 that was tracking from Bathurst Island to Jabiru and that a breakdown of separation standards had occurred. The controller re-established the required separation.

The investigation identified that the safety management system employed by Airservices Australia did not require the conduct of an independent review of the locally conducted hazard assessment process that was utilised to manage the controller's loss of radar surveillance capabilities. This was considered to be a safety issue.

Preliminary report released 24 July 2007

On 15 April 2007, a Boeing Company 747-438 aircraft, registered VH-OJR, was being operating on a scheduled passenger flight from Singapore to Sydney, NSW. At 1923 Eastern Standard Time, the aircraft was positioned on a short final approach for a landing on runway 16R when it encountered rapidly changing wind conditions. The aircraft touched down firmly and the crew conducted a go around.

The investigation is continuing.

On 11 April 2007, shortly after take-off from Wagga Wagga Airport, NSW, the crew of a de Havilland Dash 8 aircraft registered VH-TQY, noticed an unusual popping sound, followed by a slight vibration through the power levers. On passing 3,800 ft there was a significant drop in torque on the left engine, with associated popping noise. The crew shut down the engine and returned to Wagga Wagga Airport. After initial inspection on the wing, the engine was removed and sent to the manufacturer for disassembly and examination.

The examination found that the engine's number 5 bearing, the high pressure (HP) turbine disc and stub-shaft had failed. These components were sent to the Australian Transport Safety Bureau for further examination. That examination determined the number 5 bearing had failed at its roller cage through fatigue cracking, the stub-shaft had failed under overload and the HP turbine disc had suffered blade tip rubbing.

The operator had experienced a previous number 5 bearing failure on another of its engines. That bearing displayed the same failure pattern of its roller cage and was consecutively serial numbered to the VH-TYQ engine's number 5 bearing.

As a result of this investigation, the engine manufacturer identified a batch of 15 bearings that required replacement and introduced procedures to minimise the risk of further number 5 bearing failures.