On 11 January 2007, at about 0718 Eastern Daylight-saving Time, an Airbus A320 aircraft, registered ZK-OJB, departed runway 34L at Sydney Airport, NSW for Auckland, New Zealand and was assigned a radar heading by Air Traffic Control (ATC). The controller noticed that the aircraft turned onto an incorrect heading and informed the flight crew. The crew checked the aircraft's compasses and found that they were reading approximately 40 degrees incorrectly and that a GPS PRIMARY LOST message had appeared on the aircraft's multi-purpose control and display unit and navigational display. The crew advised ATC that they had navigational difficulties and elected to return to Sydney for landing.

When the aircraft returned to the departure gate, the flight crew noticed that the inertial reference system (IRS) had been aligned to the incorrect longitude. The operator's investigation into the incident found that the IRS had been aligned by maintenance staff prior to the crew boarding the aircraft. The incorrect alignment of the IRS was not noticed during a number of subsequent checks prior to departure.

As a result of this incident, the operator has proposed to develop a training program for all company pilots designed to improve discussion and guidance in relation to threat and error management issues.

In the early hours of 22 June 2009, an Airbus Industrie A330 (A330), registered VH-QPI (QPI), encountered an area of severe turbulence associated with convective activity while en route from Hong Kong to Perth, Western Australia. As a result of the incident, a combined total of seven passengers and crew members received minor injuries. After consultation with medical and operational personnel, the pilot in command continued the flight to Perth. The aircraft suffered minor internal damage and, after a maintenance check, was returned to service.

The cloud associated with the convective activity consisted of ice crystals; a form of water that has minimal detectability by aircraft weather radar. Consequently, the convective activity itself was not detectable by QPI's radar. As the event occurred at night with no moon, there was little opportunity for the crew to see the weather.

The operator intends to upgrade the weather radar fitted to its A330 fleet, which will increase the fleet's capability to detect convective turbulence. Two other minor safety issues were identified during the investigation relating to the risks associated with the use of the pilot flight library when turbulent conditions are encountered, and the engagement of the manual latch to the cockpit door preventing timely access to the flight deck by other operational staff. The operator has taken, or is proposing, relevant safety action to address those issues.

The Airbus Industrie A330-303 aircraft was being operated on a scheduled passenger service between Hong Kong and Sydney. The pilot in command and second officer were seated at the aircraft control stations while the copilot was in the crew rest area.

In the course of discussions between the pilot in command and second officer, it became evident to the pilot in command that the second officer was no longer responding to conversation. Upon checking, the pilot in command found the second officer to be suffering from what he believed to be a seizure. He was removed from the operating station and replaced by the aircraft's copilot.

The second officer was removed to the crew rest area and immediately attended by a medical practitioner who was travelling on the flight. The flight continued to Sydney.

On 6 January 2007, a TL-2000 Sting Sport ultralight aircraft, registered 24-3770, was found to have impacted the ground approximately 30 km north-west of Goulburn. The aircraft was fitted with a Rotax 912 ULS Engine. The engine disassembly and inspection was conducted by a Rotax engine specialist at the request of the NSW police, during which, the crankshaft was found to have fractured. Recreational Aviation Australia subsequently requested the assistance of the Australian Transport Safety Bureau in conducting technical analysis of the crankshaft. That analysis found no indications that would have prematurely initiated failure or have been detrimental to the fatigue life of the crankshaft.

Preliminary report released 4 August 2009

On 10 June 2009 at 1205 Universal Coordinated Time (UTC), an Airbus Industrie A330-202 aircraft, registered VH-EBF, departed Kansai International Airport, Osaka, Japan on a scheduled passenger transport service to the Gold Coast Airport, Qld., Australia with 182 passengers, 13 cabin crew and four flight crew on board.

At 1523, at approximately 427 km south-west of Guam, the flight crew noticed a burning rubber smell on the flight deck. At about that time, two caution messages were displayed to the crew identifying a fault in the right windshield heating. This was followed by a loud bang along with a flash of light, followed by smoke and fire from the bottom right corner of the right windshield. All flight crew donned oxygen masks, and a crew member used a BCF extinguisher to extinguish the fire.

The flight crew diverted the aircraft to Agana Airport, Guam, and reported that no other systems were affected by the fire. At 1614, the aircraft landed at Guam and there were no reported injuries to any of the passengers or crew.

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Update: 24 March 2011

The Australian Transport Safety Bureau (ATSB) is finalising its investigation into the June 2009 in-flight fire event that occurred in the cockpit of an Airbus A330 aircraft (registered VH-EBF) during a scheduled passenger service between Osaka, Japan and Gold Coast Airport, Queensland, Australia.

As the preliminary report on this incident indicates, the ATSB has identified the source of the fire to have been an electrical fault within a terminal block located at the lower right corner of the cockpit right forward windshield. The terminal block served to direct electrical power into the windshield's heating circuitry; ensuring they remain clear and free of ice and fogging that may otherwise interfere with the pilots' outside visibility.

Terminal block failure

Under the oversight and support of the accredited representative from the French investigation agency (Bureau d'Enquetes et d'Analyses pour la securite de l'aviation civile, BEA), the damaged windshield terminal block was dismantled and examined in detail at the manufacturer's facilities in France. While the analysis of the technical findings will be presented in the final ATSB report, it has been ascertained that the terminal blocks of certain windshields produced between February 2007 and August 2008 were susceptible to overheating in a manner similar to that sustained during this occurrence.

Investigation status

The draft report on this investigation is nearing completion and distribution to directly involved parties for comment. A final report should be published during the second quarter of 2011. However, the following safety actions have already been initiated:

Aircraft operator

Following the occurrence affecting VH-EBF, the aircraft operator inspected all windshield terminal block fittings within the aircraft in its fleet. The inspection centred on identifying any evidence of thermal effects or localised heating that may be precursor indications of a similar overheating mechanism. No such evidence was observed during any of the inspections undertaken.

Aircraft manufacturer

In early 2010 the aircraft manufacturer initiated an ongoing retrofitting program to remove and replace all suspect aircraft windshields.

On 10 June 2009, at about 1545 Eastern Standard Time, the pilot of a Bell Jetranger 206B helicopter, registered VH-JTI, was conducting a 20-minute scenic flight, with four passengers, from a helipad at an entertainment facility at Coomera, Queensland.

After about 15 minutes flying, the fuel boost pump low pressure (FUEL PUMP) warning light illuminated briefly. The pilot believed he had sufficient fuel on board and continued the flight. While the helicopter was descending to land at the helipad, the FUEL PUMP warning light illuminated again and shortly afterwards the engine lost all power.

During the final stages of the autorotative landing, the pilot was unable to arrest the helicopter's descent rate and the helicopter struck the ground heavily, resulting in substantial damage. Two passengers sustained serious injuries; the other two passengers and the pilot were uninjured.

A subsequent check of the helicopter and its fuel system showed that the fuel gauge may have been over reading. The operator's practice when calculating the quantity of fuel to be added during refuelling relied on the fuel gauge reading, without using an independent method to crosscheck that reading against the actual fuel tank quantity.

The investigation found that the helicopter departed with insufficient fuel to complete the flight. The low fuel quantity and manoeuvring combined to uncover the fuel boost pumps and the engine was starved of fuel. The helicopter's low speed, height and rotor RPM at that time precluded a safe landing from the subsequent autorotation.

On 5 June 2009, during a scheduled passenger service from Melbourne, Victoria (Vic.) to Coolangatta, Queensland (Qld), the cabin crew of a Boeing Company 737-800 aircraft, registered VH-VBL, detected a strong intermittent smell in the rear of the cabin. An inspection by the cabin crew did not detect the source of the smell.

On descent prior to landing, cabin crew presented various symptoms. Two of the cabin crew used oxygen before recovering sufficiently to resume their duties. No passengers were affected.

The airport rescue and fire fighting service attended the aircraft at the arrival gate. Paramedics conducted medical checks on the cabin crew. Both the cabin crew and flight crew were taken to the local hospital for further examination and later released.

The cargo holds were opened prior to a precautionary inspection for the source of the fumes. The source and nature of the fumes was not identified.

As a result of the incident, the operator initiated and completed a number of safety actions to improve communications and processes in relation to air contamination events.

While it was not possible to determine the nature or source of the reported fumes, the incident highlights the potential for crew incapacitation from exposure to toxic smoke and fumes.

On 22 May 2009, a temporary modification was made to the runway 11/29 lighting at Darwin aerodrome, Northern Territory (NT), due to runway works being conducted on the runway 11 threshold. At 1840 Central Standard Time1, 10 minutes prior to last light, Darwin air traffic control (ATC) attempted to activate the runway lights; however, the runway 11/29 edge lights failed to turn on. Due to the lighting failure, ATC asked all aircraft intending to land at Darwin to hold. After requesting the reason for holding, the crew of a Boeing Company 717-200 aircraft, registered VH-NXM, on a scheduled passenger service with 117 people on board, advised that they had 30 minutes of holding fuel available (equivalent to 1920).

Just prior to 1910, ATC notified the crew of the 717 the lighting was still unavailable and reported asking the crew if they could divert. Initially the crew
advised ATC that they did not have diversion fuel. However, after further calculations, they determined that they had enough fuel for an immediate diversion to Tindal aerodrome, NT. The aircraft was diverted to Tindal and landed without further incident. The pilot in command (PIC) reported that it landed with 1,000 kg of fuel remaining, equating to the fixed fuel reserve.

The lighting at the aerodrome was subsequently restored and the other aircraft holding landed safely at Darwin.

The aerodrome operator advised the ATSB that, as a result of this incident, it has implemented a number of safety actions, including:

• they introduced standard operating procedures for placing night displaced thresholds
• on the recommendation of an independent consultant, they employed an electrical engineer as the engineering manager
• investigated alternative options for establishing a cross runway primary circuit
• purchased temporary portable lighting which can be pre deployed where similar works on the aeronautical ground lights are proposed.

In addition to having robust practices and procedures in place for conducting runway works, this incident highlights the importance of using clear and consistent radio phraseology to avoid confusion between ATC and crews.

On 18 May 2009, an Airbus Industrie A320-232 aircraft, registered VH-VNC was on a regular public transport flight from Mackay, Queensland (Qld) to Melbourne, Victoria when at about 1249 Eastern Standard Time, the aircraft started to vibrate. Cockpit indications showed that the left aileron was oscillating. The crew diverted the aircraft to the Gold Coast Aerodrome, Qld and landed.

The source of the aileron oscillation was an internal fault in one of the left aileron's hydraulic servos. The fault was introduced during manufacture by an incorrect adjustment of the servo, which caused internal wear in a number of the servo's hydraulic control components. The aileron servo manufacturer has incorporated a new method of adjusting the aileron servos during assembly to minimise the likelihood of a recurrence of the problem.

During the investigation, it was found that an identical fault had occurred to the same aircraft 8 months prior to this incident. The previous incident was not reported to the Australian Transport Safety Bureau by the operator as required by the Transport Safety Investigation Act 2003. The operator has improved the training of its staff and the reportable event requirements in its safety management system manual in an effort to address the non-reporting risk.

On 21 May 2009, the pilot of a Piper PA-31 Navajo, registered VH-WAL, was conducting a flight under the instrument flight rules from Albury, NSW to Canberra, ACT with one passenger on board. Approximately halfway through the flight, the pilot became concerned about the quantity of fuel remaining and subsequently conducted a precautionary landing 50 km south-west of Canberra. There was no reported damage to the aircraft or injuries to the occupants.

The aircraft operator has advised the ATSB that, as a result of this occurrence, it has implemented a requirement for all of its pilots to use a documented fuel plan in all circumstances when flying from one location to another.