On 4 April 2007 at about 0809 Eastern Standard Time a Boeing Aircraft Company 737-8FE registered VH-VON was inbound to Sydney, NSW from Melbourne, Vic. on descent to 6,000 ft and an Airbus A330-342X, registered B-HLW was departing Sydney for Hong Kong on climb to 7,000 ft. The distance between the aircraft reduced to 1.9 NM horizontal and 600 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 loss of separation occurred as a result of the separation that was planned by the air traffic control officer being based on an incorrect cleared flight level (CFL) that had been entered into the controller's air situation display (ASD). The investigation concluded that this data entry error occurred within 2 minutes of the air traffic controller assuming responsibility for the control position, and that the reconfiguration of the in-use console by the controller during that time increased the risk of the controller being distracted from the traffic separation task.

On 9 April 2007, at 1703 Western Standard Time, the main landing gear of a Beech Super King Air 200 (registered VH-SGT) collapsed on touchdown at Perth airport. The aircraft was extensively damaged as a result of the collapse. No injuries were sustained by the pilot or passengers from the accident.

The Australian Transport Safety Bureau investigation revealed that two major system components had failed which could have prevented the landing gear from properly retracting/extending; the geared components within the right main landing gear actuator had fractured, and the left torque tube support bearing had seized from contamination and lack of lubrication. Although each component failure was apparently unrelated, the examination was not able to conclusively establish which failure had been the primary contributing factor in this landing occurrence. The Super King Air 200 aircraft landing gear system configuration was such that should either one of these component assemblies cease to function, extension or retraction of the landing gear would not have been possible.

As a result of this occurrence, the operator changed their system of maintenance to introduce an inspection interval and replacement schedule for all landing gear torque tube support bearings within their Super King Air 200 fleet.

The Civil Aviation Safety Authority released airworthiness bulletin 32-07 to all operators of Hawker Beechcraft 65, 70, Queen Air 90 and 200-series King Air aircraft that recommended changes to the maintenance schedule for landing gear components.

Safety Advisory Notice

[SAN20080002]

Dornier Do 228-202, ZK-VIR, was carrying out a positioning flight from Westport to Christchurch on the South Island of New Zealand. At about 50 NM north of Christchurch, while cruising at 10,000 feet, both pilots reported becoming 'giddy' and close to fainting. The pilots turned off the cockpit heating and directed external air into the cockpit. A PAN call was made and the aircraft descended to the area minimum safe altitude of 9,000 feet. The crew elected to continue to Christchurch where they were able to make a safe landing.

The Transport Accident Investigation Commission (TAIC) of New Zealand initiated an investigation into the incident, TAIC reference: 07-002. TAIC investigators obtained the cockpit voice recorder (CVR) from the aircraft and requested assistance from the Australian Transport Safety Bureau (ATSB) to recover any information that may have been recorded. In accordance with clause 5.23 of Annex 13 to the Convention on International Civil Aviation, the ATSB appointed an Accredited Representative to assist TAIC and initiated an investigation under the Transport Safety Investigation Act 2003.

The CVR was transported to the ATSB audio laboratory in Canberra for examination in the custody of a TAIC investigator. The CVR information was downloaded on the 11 April 2007. The CVR and copies of the recovered information were provided to the TAIC investigator to be transported back to New Zealand.

The TAIC is responsible for releasing a final investigation report regarding this occurrence. Once it has been completed, a copy of the TAIC investigation report (07-002) may be found at: www.taic.org.nz or by contacting:

TAIC
PO Box 10-323
Wellington 6036
New Zealand

At 1814 Central Standard Time on 2 April 2007, an Israel Aircraft Industries 1124, Westwind aircraft, registered VH-AJP, with a crew of two, departed Darwin Airport, NT on a scheduled cargo service to Alice Springs, NT. At 1844, during climb, at 34,000 ft, the crew heard a series of loud bangs followed by a loss in cabin pressure. The crew donned oxygen masks, closed the aircraft outflow valves and conducted an emergency descent to 10,000 ft. The aircraft was returned to Darwin.

An inspection of the aircraft revealed a hole in a top rear fuselage skin panel. The examination revealed that approximately 60% of the panel had been damaged by exfoliation corrosion. The damage was most severe at the primary site of rupture, in the centre of the panel.

The panel was clad with a corrosion resistant pure aluminium alloy sheet; however, the aluminium cladding was removed on the chemical milled areas. Over time, the coating protecting of the chemical milled areas had deteriorated, leading to the corrosion on the panel.

The panel was located in an area that was not considered susceptible to corrosion, so there were no detailed inspections required for the area.

As a result of this occurrence, the manufacturer has issued a notice to all 1124 Westwind aircraft operators informing them of the event and the corrosion that was found. The operator has carried out an inspection of the area on their entire fleet of 1124 Westwind aircraft. Where corrosion was present, the operator replaced the panel. The operator has also included an inspection of the area in their Corrosion Control Program.

On 31 March 2007, a Boeing Company B767-338, registered VH-OGN, was being operated on a scheduled passenger service between Jakarta, Indonesia, and Sydney, Australia. Approximately 1 hour after departing from Jakarta, the pilot in command (PIC) began to feel unwell. Over the following 4 hours, the medical condition of the PIC continued to deteriorate, and the copilot was alerted to this. The PIC vacated the pilot control position and handed over responsibilities for command decisions and flying duties to the copilot. With approximately 2 hours and 40 minutes of flight time remaining, the PIC left his control seat and relocated to an observer's seat at the rear of the cockpit.

As a result of this occurrence, the aircraft operator has advised the Australian Transport Safety Bureau that procedures relating to the monitoring of flight crew, following pilot incapacitation, have been reviewed and additional guidance material will be inserted into the operators' pilot documentation.

At Indonesia's request on 7 March 2007, the Australian Transport Safety Bureau 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 at Yogyakarta, Indonesia, involving a Boeing 737 operated by Garuda Indonesia.

The aircraft overran the runway and crashed into a rice field 252 metres from the end of the runway. The aircraft was destroyed by impact forces and the post-impact fire.

There were two pilots, five flight attendants and 133 passengers on board. One flight attendant and 20 passengers, including five Australians were fatally injured. One flight attendant and 11 passengers, including 3 Australians were seriously injured, and two flight attendants and 98 passengers sustained minor injuries.

The ATSB dispatched a Deputy Director and two senior investigators to assist its Indonesian counterpart with the investigation. The ATSB also cooperated closely with the NTSC in the analysis of the aircraft black box recorders.

Australia's accredited representative to the investigation continued to work 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 and investigation under the Transport Safety Investigation Act 2003.

On 22 October 2007, 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.

While undertaking a demonstration autorotational descent during an instructional flight test in a Robinson R22 Beta II helicopter, the student pilot and flight instructor noted an unusual mechanical noise, followed by the onset of severe vibrations from the main rotor system. After immediately landing the helicopter, it was found that the skin from the underside of one main rotor blade had disbonded from the leading-edge spar over a length of approximately 450 mm from the blade tip.

The skin separation was found to be associated with abrasion and loss of the rotor blade leading edge paint across the bond line between the skin and leading-edge spar. Erosion along the bond line had produced an undercutting effect and a feathering of the skin edge. Associated with random voids and pores in the adhesive that filled the gap between skin and spar recess edges, it was probable that the erosion had produced localised stresses within the adhesive joint, promoting the lifting of the feathered edges and the subsequent peeling separation of the skin.

As a result of a number of similar failures in both R22 and R44 main rotor blades, the helicopter manufacturer published a series of safety alerts, service letters and service bulletins, recommending the regular inspection of the blades for evidence of skin disbonding and the refinishing of blades showing abrasion of the leading-edge paint to, or beyond, the skin bond line. Airworthiness directives from the US Federal Aviation Administration and the Civil Aviation Safety Authority subsequently mandated the initial and repeat inspection of R22 and R44 main rotor blades for this issue. Those airworthiness directives became effective in January 2008.

On 26 February 2007, while in cruise at flight level (FL) 190 on a scheduled passenger flight from Inverell, to Sydney, NSW, with two pilots and six passengers, the crew of a Fairchild Industries SA227-DC (Metro) aircraft, registered VH-HPB, reported that the cabin altitude increased rapidly. The crew immediately donned their emergency oxygen masks and descended the aircraft to 10,000 ft. The flight continued to Sydney and landed safely. There were no injuries.

This was the second reported in-flight depressurisation on VH-HPB. The aircraft operator reported a prior event on 12 February 2007.

Following the 26 February 2007 event, the aircraft operator conducted extensive troubleshooting of the aircraft's pressurisation system and door seals in an attempt to isolate the reason for the depressurisation. Following maintenance actions, the aircraft was returned to service.

The operator reported that the aircraft again depressurised in-flight on two more occasions on 20 March and 4 April 2007. Despite further troubleshooting and maintenance actions, the operator was unable to ascertain the reason for the depressurisations. As a result, following the 4 April event, the operator issued a Pilot Operations Notice to all flight crew restricting the operating altitude of the aircraft to a maximum of 12,000 ft. Subsequent to this action, the aircraft depressurised again in-flight on 16 August 2007.

On 16 October 2007, as a result of fleet changes, the aircraft operator ceased operating VH-HPB. The aircraft subsequently completed a Phase check, including a thorough inspection of all pressurisation components and systems. The aircraft was subject to several pressurisation ground runs, however no anomalies with the pressurisation system were found.

Preliminary report released 8 May 2007

On 23 February 2007, at approximately 1710 Eastern Daylight-saving Time, a Van's Aircraft Inc. RV-4 aircraft, registered VH-ZGH, took off from Essendon Airport, Victoria, with the owner-pilot and one passenger on board. The flight was to the designated Moorabbin aerobatic area over Clyde North.

At approximately 1740, witnesses reported observing the aircraft descending in a spin after completing an aerobatic manoeuvre. The aircraft engine was heard to gain power during the spin and the aircraft speed rapidly increased. The aircraft was then seen to enter into, what appeared to be, an unstable spiral dive.

At approximately 1,500 ft above the ground, witnesses reported that the engine noise was very high-pitched and loud, and objects were seen to separate from the aircraft. The rapid spiral descent continued and the aircraft was observed to impact the ground almost vertically. The aircraft was destroyed by impact forces and a post-impact fire. The pilot and passenger were fatally injured.

On 14 February 2007 at about 1127 Eastern Daylight-saving Time, the pilot of a Cessna Aircraft Company 182T (182) was positioning to conduct a sector entry for an area navigation (RNAV) global navigation satellite system (GNSS) arrival procedure to runway 06 at Camden Aerodrome, NSW. The aircraft was approaching the aerodrome from the east. At the same time, the pilot of a Cessna Aircraft Company 210L (210) was approaching Camden from the south-west with the intention of conducting a Camden runway 06 straight-in RNAV (GNSS) approach. The two aircraft had similar estimated times of arrival at the approach commencement waypoint. They were both being operated under the instrument flight rules (IFR), in Class G airspace.

The air traffic controller provided the pilots with mutual radar based traffic information. The pilot of the 210 contacted the controller and was provided with traffic information about the 182. The pilot of the 182 climbed the aircraft to minimise the risk of a collision as he was unsure of the intentions of the pilot of the 210. Recorded radar data showed that, when the aircraft passed, there was 500 ft vertically and 2.1 NM laterally between them.