The flight crew action of not applying an additional factor to the calculated final approach speed (V_APP) was consistent with the meteorological data that was accessed by the crew for application during the approach to Alice Springs. The crew report that a 'definite under/overshoot wind shear' had affected the approach was at variance with the Bureau of Meteorology's assessment of the likelihood for that to have occurred. However, the investigation was unable to discount that a short-term, localised wind shear might have affected the aircraft's performance during the approach and/or landing.

The recorded data indicated that the aircraft's performance remained within the company criteria for a stabilised approach.

The crew achieved their planned landing flaps reference speed (V_REF) at the required height of 50 ft radio altitude (RADALT) above the touchdown zone, and the required touchdown speed immediately before the discontinuity in the recorded data. However, the aircraft ROD at that time was consistent with that published by the aircraft manufacturer as a contributing factor in the development of a landing tail strike in a British Aerospace 146-300 (146-300) aircraft. That, coupled with a landing nose-up pitch attitude that approached 7° with the oleos compressed appeared to have made a tail strike inevitable in this incident.

The reported lack of any information in the operator's publications regarding the risk of a tail strike in the 146-300 aircraft may have influenced the outcome of this occurrence. Had that information been available to the crew, the tail strike may not have occurred.

FACTUAL INFORMATION¹

History of the flight

On 20 August 2005, at about 1340 Central Standard Time, a British Aerospace 146-300 (146-300) aircraft, registered VH-NJN, with a crew of five and 60 passengers, was being operated on a scheduled passenger service from Cairns, Qld, to Alice Springs, NT. The first officer was the handling pilot for the visual approach and landing to runway 12 at Alice Springs Airport.

The flight crew reported that, at about 50 ft above the ground, the aircraft rate of descent (ROD) increased significantly from what had previously been a 'normal' approach. Despite the initial reaction by both flight crew members to arrest the increased ROD by increasing the nose-up pitch attitude of the aircraft, and subsequently the engine thrust, the aircraft landed heavily and bounced into the air. The captain commanded a go-around for a second landing on runway 12. During the go-around, the flight crew reported to air traffic services that there was 'a fair bit of shear just at the touchdown point.'

A subsequent engineering inspection of the aircraft identified damage to the tailscrape indicator (Figure 1), indicating that a tail strike had occurred. There were no reported injuries to the crew or passengers, and there was no significant damage to the runway surface or other facilities.

Figure 1: Damaged aircraft tailscrape indicator

Operational information

The flight crew were appropriately qualified for the flight. Both pilots reported being fit and well at the time of the occurrence.

No evidence was found of a defect in the aircraft or its systems that may have contributed to the circumstances of the occurrence. Examination of the aircraft load sheet indicated that the planned aircraft landing weight was 35,785 kg, and that the centre of gravity was within limits. The flight crew reported calculating the actual aircraft weight for the landing as 37,300 kg. As a result, the flight crew applied the 38-tonne Landing Card to their approach planning. That resulted in a final approach speed (V_APP) of 124 kts, and a landing flaps reference speed (V_REF) of 119 kts.

Weather information

The Alice Springs Terminal Aerodrome Forecast indicated a wind of 150 degrees true at 13 kts and CAVOK² conditions. The forecast ambient temperature was 17°C, and the forecast mean sea level (MSL) pressure was 1025 hectopascals (hPa). The area forecast indicated a forecast wind at 3,000 ft above mean sea level (about 1,200 ft above ground level (AGL)) of 150 degrees true at 20 kts, nil significant cloud, fine weather, and good visibility.

Automatic Terminal Information Service (ATIS) 'Echo' was current at the time of the occurrence. That information included that the surface wind was 090 degrees magnetic at 15 kts, CAVOK conditions were present, the ambient temperature was 17°C, and the MSL pressure was 1023 hPa. ATIS 'Echo' provided no indication of any wind gusts that might have affected operations at Alice Springs.

Observations of the meteorological conditions at Alice Springs were recorded by a Bureau of Meteorology (BoM) Automatic Weather Station (AWS). The AWS was located near the wind sock on the south side of, and near the middle of runway 12/30. Reports from the AWS were available to pilots from air traffic services by radio, or by telephone. The 1330 AWS observation indicated a surface wind of 110 degrees magnetic at 7 kts and gusting to 11 kts, CAVOK conditions, an ambient temperature of 17°C, a dewpoint³ of 2.1°C, and MSL pressure of 1022.6 hPa. In addition, data from a weather balloon flight conducted at Alice Springs at 1430 indicated a generally east-north-easterly wind at less than 10 kts up to a height of about 1,000 ft AGL.

The flight crew subsequently reported that they experienced nothing during the approach that was contrary to the forecast conditions, or to the information provided on the ATIS until about 50 ft AGL. The captain reported the presence of 'a definite under/overshoot wind shear' during the final approach, but that it was not as strong as he had experienced previously at Alice Springs.

The pilot of a Cessna Aircraft Company 210 (C210) that landed on runway 12 shortly after the 146-300, subsequently reported that he experienced gusty wind conditions during the initial landing approach, but that they were not outside the operational limits for the C210. In addition, that pilot reported being surprised that it was 'not that windy', and that he did not experience any turbulence at touchdown on runway 12.

A BoM aftercast ⁴ concluded that:

The situation [at Alice Springs] did not appear conducive to windshear. A high pressure system west of Perth extended a strong ridge across central Australia. With fine stable conditions and moderate south to south-east winds.

Instrument Landing System (ILS) and 'T' visual approach slope indicator system (T-VASIS) approach aids were available for approaches to runway 12 at Alice Springs. The T-VASIS approach aid provided 3° visual approach guidance to the touchdown point on the runway. The flight crew reported that the approach was flown visually, using the ILS as back-up reference, and that the aircraft was stabilised on the approach until reaching 50 ft above the runway. No evidence was found to suggest that the aerodrome, its facilities, or the characteristics of the runway influenced the circumstances of the occurrence.

Recorded data

The aircraft was fitted with a Plessey PV1584M Data Acquisition and Recorder Unit. The recorded flight data was examined by the Australian Transport Safety Bureau to establish the factors that led to the tail strike. The recorded data for the final approach below 500 ft radio altitude⁵ (RADALT) is represented at Figure 2. The aircraft's recorder installation did not include the option to record the presence of any windshear.

Examination of the available recorded data for the final approach below 500 ft RADALT revealed that the aircraft's pitch attitude alternated between 0 to 2.6° nose-down. The variations in the aircraft's attitude were accompanied by periods of varying indicated airspeed, including from a maximum of 133 kts at 223 ft RADALT, reducing to 120 kts at 49 ft RADALT, and 113 kts at 10 ft RADALT. Those reduced speeds appeared to reflect the planned vREF of 119 kts and anticipated touchdown speed of 112 kts. The glideslope angle and localiser deviation were examined and found to be within the expected range for the final approach.

The aircraft's ROD was derived from the recorded data. That derived data revealed that the aircraft's ROD varied during the final approach as follows:

• the average ROD was 690 ft/min until passing 300 ft RADALT
• below 300 ft RADALT, the average ROD was 630 ft/min
• the instantaneous ROD in the 2 secs immediately prior to touchdown, or below 21 ft RADALT was 657 ft/min, or 11 ft/sec.

The recorded aircraft pitch attitude data indicated that the flare was commenced at 21 ft RADALT.

Figure 2: Recorded data selected parameters below 500 ft RADALT

There was a one-second discontinuity in the recorded data on touchdown, which was considered to be consistent with the tail strike occurring at that time. Immediately prior to that discontinuity, the aircraft's derived nose-up pitch rate was 5.8 deg/sec. At that rate of nose-up pitch, interpolation of the missing data indicated the potential for the aircraft's nose-up pitch attitude with the main landing gear compressed to have been greater than 7°.

On the recommencement of the recording, the aircraft's pitch attitude was 6.7° nose up and the main landing gear was compressed. The nose landing gear was not recorded as touching the runway.

Organisational information

The company's Operations Manual stipulated the following requirements affecting the calculation of an aircraft's V_APP:

• V_APP = V _REF + 5 kts + an additional factor (in kts) to take account of any reported wind gusts, turbulence and windshear. The maximum additional factor for application by flight crews was 9 kts.
• The recommended additional gust factor for application by flight crews equalled half the reported wind speed gust.

The flight crew reported that based on the content of ATIS 'Echo', an additional factor was not applied to the interpretation of vAPP in this instance.
The risk of an aircraft sustaining a landing tail strike is elevated if the aircraft is subjected to an unstabilised final approach for landing, which can include turning onto final approach with excessive airspeed, altitude, or both. The definition of a stabilised approach in the company's Operations Manual included that:

• the aircraft must be stabilised in the landing configuration by 400 ft above airport level
• for visual approaches, the aircraft was not greater than one dot high or low on the T-VASIS
• the aircraft was established on the runway centreline with only small changes in heading or pitch required to maintain the approach path
• the aircraft's speed was not above V_APP + 10 kts and not less than V_APP - 5 kts
• ROD was required to be not greater than 1,000 ft/min
• momentary excursions of slope and speed, caused by wind gusts or turbulence, were acceptable.

The operator's Training Manual included that:

• flight crews should aim to cross the runway threshold at 50 ft above the touchdown elevation at V_REF
• touchdown was anticipated at approximately V_REF - 7 kts
• the touchdown should usually be achieved at a pitch attitude of 4 to 5° nose-up, and that the aircraft's pitch attitude must not exceed 8° nose-up in the flare.

The operator reported that there was no specific mention in the Training Manual, or the Operations Manual of the risk of tail strike in the company's 146-300 aircraft.

The aircraft manufacturer had promulgated preliminary notes regarding tail strikes during take-off and landing in the 146-300 aircraft. Those notes included that the risk of a tail strike during landing was elevated if:

• A late flare was initiated by a flight crew while their aircraft was experiencing a high sink rate that would result in a heavy landing. That implied a nose-up attitude of about 8° at touchdown and a ROD of in excess of 10 ft/sec. The manufacturer indicated that a typical landing pitch attitude was about 2 to 3° nose-up.
• Maintenance of the required airspeed was inaccurate from the 'screen height' of 50 ft until touchdown. The manufacturer commented that if that airspeed was allowed to decay excessively, the pitch attitude could become critically close to tail strike angles. The manufacturer's notes concluded that:

On the 146-300 [and RJ100] pitch angles in excess of 5 degrees should be avoided and angles in excess of 7 degrees with the oleos compressed may result in a tail strike.

1. Only those investigation areas identified by the headings and subheadings were considered to be relevant to the circumstances of the occurrence.
2. Visibility, cloud and present weather better than prescribed values or conditions - ICAO Doc 8400, 24 November 2004.
3. Temperature at which, under ordinary conditions, condensation begins in a cooling mass of air.
4. A retrospective statement of anticipated meteorological conditions affecting a given place during a specified period, which can include the interpretation of recorded radar data, synoptic observations, recorded AWS data, and other available sources of recorded meteorological information.
5. An indication of the height of the aircraft above ground level (AGL). Approximates the theoretical concept of 'absolute altitude', which is the distance along a local vertical between an aircraft and a point on the ground where the local vertical cut's the earth's surface.

On 20 August 2005, at about 1340 Central Standard Time, a British Aerospace 146-300 (146-300) aircraft, registered VH-NJN, with a crew of five and 60 passengers, was being operated on a scheduled passenger service from Cairns, Qld, to Alice Springs, NT. The first officer was the handling pilot for the visual approach and landing to runway 12 at Alice Springs Airport.

The flight crew reported that, at about 50 ft above the ground, the aircraft rate of descent (ROD) increased significantly from what had previously been a 'normal' approach. Despite action by both flight crew members to arrest the increased ROD, the aircraft landed heavily and bounced into the air. The captain commanded a go-around for a second landing on runway 12.

A subsequent engineering inspection of the aircraft identified damage to the tailscrape indicator, indicating that a tail strike had occurred. There were no reported injuries to the crew or passengers, and there was no significant damage to the runway surface or other facilities.

The aircraft's rate of descent immediately prior to touchdown was consistent with that published by the aircraft manufacturer as a contributing factor in the development of a landing tail strike in a 146-300 aircraft. That, coupled with a landing nose-up pitch attitude that approached 7° with the oleos compressed appeared to have made a tail strike inevitable in this incident.

In response to this occurrence, the operator has amended its British Aerospace 146-300 Training Manual to reflect the information provided by the aircraft manufacturer with regard to aircraft pitch angles on landing.

On 21 August 2005, the Aircraft and Railway Accidents Investigation Commission (ARAIC) of Japan notified the Australian Transport Safety Bureau (ATSB) of an air safety occurrence involving an Australian-registered and operated aircraft, which occurred earlier that day at Kansai International Airport. The ATSB appointed an accredited representative to participate in the investigation into the occurrence, in accordance with Annex 13 to the Convention on International Civil Aviation.

On 20 August 2005, an A330 aircraft, registered VH-QPE, was being operated on a scheduled passenger service from Narita International Airport, Japan, to Perth International Airport, Western Australia. The aircraft departed Narita at about 1238 Coordinated Universal Time, with 13 crew and 181 passengers on board. At 1405, while the aircraft was in cruise, the crew received an Electronic Centralized Aircraft Monitoring (ECAM) warning indicating that there was smoke in the forward cargo hold. The crew activated the fire extinguishing system, and diverted the aircraft to Kansai International Airport, Japan. At 1551, immediately after the aircraft had landed, emergency services personnel reported that there appeared to be smoke in the vicinity of the nose landing gear. The flight crew initiated an emergency evacuation of the aircraft. During the evacuation, one passenger sustained serious injuries, and eight passengers sustained minor injuries.

The ARAIC is the independent Japanese government authority responsible for the safety investigation of aviation accidents and incidents in Japan. The ARAIC will publish the final report related to the investigation of this occurrence.

The right main landing gear down-light did not illuminate because the down-lock hook had not completely engaged and actuated the microswitch. Post-accident extension of the landing gear indicated that stiffness of the down-lock assembly prevented complete engagement. The initial inspection indicated that failure of the right landing gear down-lock to properly engage was the result of inadequate lubrication. This was consistent with the circumstances involved in four Chieftain occurrences in the preceding 12 months that each involved failure of a main landing gear down-lock assembly to properly engage.

Had the main landing gear down-lock assemblies been lubricated in accordance with Part I of Service Letter 755C, it is likely that the right main gear down-lock assembly would have fully engaged. Although the service letter referenced in the operator's 50-hour maintenance schedule indicated that the down-lock assembly should have been lubricated, that task was not specifically stated in the schedule. Incorporation of a specific requirement for down-lock assembly lubrication at 50-hour intervals in Chieftain maintenance schedules will reduce the risk of incomplete down-lock engagement and gear-up landings.

On 1 August 2005, at about 1000 Eastern Standard Time, a Piper Aircraft Corporation PA-31-350 (Chieftain), registered VH-LMB, departed Adelaide on a scheduled passenger flight to Port Augusta. The aircraft was being operated under the instrument flight rules with a pilot and seven passengers, including an aircraft maintenance engineer. On arrival in the circuit area at Port Augusta the pilot selected the landing gear down. The landing gear appeared to operate normally, but the right main landing gear down-light did not illuminate, the gear selector did not return to the neutral position and the transit light remained on.

A number of landing gear retractions and extensions produced the same result. With the assistance of the engineer in the copilot seat, the right gear-down indicator light was changed and the manual extension procedure carried out. However, the landing gear unsafe condition remained and the pilot conducted a low pass to allow an aircraft maintenance engineer on the ground to observe the gear. The landing gear appeared to be down and locked, but the inboard gear doors (flipper doors) remained extended, indicating that the extension cycle was not complete. The pilot attempted to engage the right main landing gear down-lock by manoeuvring the aircraft and repeating the normal and manual gear extensions, but was unsuccessful.

The pilot reported that, consistent with the operator's procedures, he elected to land with the landing gear retracted. The passengers were briefed and the engineer moved to the seat adjacent to the emergency exit. After a total of about 1 hour 40 minutes in the Port Augusta area, the pilot landed on runway 33. The propellers, underbelly skin and flaps were damaged. The occupants were not injured.

Aircraft maintenance engineers who inspected the aircraft after it was lifted, found that when the landing gear was manually extended, the right down-lock assembly was stiff and did not completely engage. A force applied to the down-lock assembly completed its engagement and actuated the right down-light. The operator advised that an engineering report would be completed once the aircraft was recovered and full retraction tests carried out.

The aircraft manufacturer issued Service Letter 755C in November 1985. Part I of the service letter addressed inspection and lubrication of the landing gear lock actuator rod and rod end bearing assemblies. This was recommended at each 50 hours of operation and whenever landing gear and wheel areas were washed. Part I included the following statement:

It has been determined that the location of the exhaust outlets on the … PA-31-350 … aircraft are such that an increased frequency of inspection and lubrication is recommended. It is also recommended that the inspection and lubrication includes downlock latch and pivot bolts.

Although operators were not required to comply with service letters, the operator's Chieftain System of Maintenance included a 50-hour maintenance schedule that specified inspection of the main landing gear down-lock rod and cable assemblies and referred to Piper Service Letter 755C. The 50-hour maintenance schedule did not specifically require lubrication of the landing gear, and the aircraft's main landing gear down-lock had not been lubricated at the recent 50-hour inspection.

A search of the Australian Transport Safety Bureau occurrence database showed that in each year from 1997 to mid 2004, there were up to two occurrences that involved Chieftain main landing gear down-locks. In the 12 months prior to the occurrence, there were four Chieftain main landing gear problems involving stiff or sticky down-lock assemblies. The operators or maintainers of those Chieftains indicated that inadequate lubrication was the main reason for the down-lock stiffness or stickiness.

On 1 August 2005, at about 1000 Eastern Standard Time, a Piper Aircraft Corporation PA-31-350 (Chieftain), registered VH-LMB, departed Adelaide on a scheduled passenger flight to Port Augusta. The aircraft was being operated under the instrument flight rules with a pilot and seven passengers, including an aircraft maintenance engineer. On arrival in the circuit area at Port Augusta the pilot selected the landing gear down. The landing gear appeared to operate normally, but the right main landing gear down-light did not illuminate, the gear selector did not return to the neutral position and the transit light remained on.

Sequence of events

On 25 July 2005, at about 1835 Eastern Standard Time, a Piper Aircraft Corporation PA-31-350 (Chieftain) aircraft, registered VH-PRJ, overran runway 27 at Nhill aerodrome following a rejected night take-off. The aircraft was being operated on an instrument flight rules charter flight to Charlton, Vic, with the pilot and three passengers on board. The pilot and passengers sustained injuries during the overrun and the aircraft was substantially damaged (Figure 1).

Figure 1: Wreckage of aircraft with runway in the background

Earlier that day, the pilot had flown the aircraft from Essendon to Ouyen and then to Nhill, arriving at about 1500. During the stopover at Nhill, the pilot secured the flight controls by inserting a lock pin in the control column.
The pilot stated that, when he started and warmed the engines at about 1700, he removed the lock from the control column and that it was reinserted after the engines were shut down. The passengers arrived at the aerodrome at about 1820 and boarded soon afterwards.

The pilot reported that, during the pre-flight preparation at Nhill, he set the elevator trim to the take-off position by winding the trim wheel to about three rotations back from the full nose-down position. The pilot recalled removing the lock from the control column prior to starting the engines for departure.

The pilot stated that he usually checked the flight controls for full and free movement while backtracking on a runway but he could not recall whether he performed that check when backtracking on runway 27 at Nhill. Part B of the operator's Operations Manual included a series of checklists to be used during operation of the aircraft. The 'Start Up' and 'Pre takeoff' checklists included checking full and free movement of the flight controls.

A witness, located in a house adjacent to the western perimeter of the aerodrome, reported that he observed the aircraft taxi to the eastern end of the runway and commence the take-off roll but lost sight of the aircraft as it moved along the runway.

The pilot stated that the take-off roll was from a rolling start with power being slowly applied until engine turbo-charger output stabilised. At about 90 kts indicated air speed, the pilot attempted to rotate the aircraft but encountered resistance to rearward movement of the control column. He decided to reject the takeoff because the aircraft speed at the time was below his nominated decision speed of 100 kts. The pilot reported that he then reduced the engine power to idle and applied maximum braking.

The aircraft overran the runway, passed through the airport boundary fence, continued across a public road, and passed through another fence before coming to a stop in a paddock about 162 m beyond the end of the runway. An inspection of the runway revealed a skid mark from the aircraft's right tyre, which commenced 65 m before the end of the runway.

After the aircraft came to a stop, the pilot exited the aircraft via the crew door, assisted the passengers to evacuate the aircraft through the rear cabin door and marshalled them to an area away from the aircraft. A passenger then used a mobile phone to contact emergency services, who attended the scene soon after.

The aircraft

A subsequent inspection of the aircraft revealed that there were no pre-existing defects in the elevator control system and elevator trim system or evidence of interference with the elevator surfaces. The elevator trim setting was found to be three and a half rotations of the trim wheel from the full nose-down position.

Between flights, the aircraft elevators and ailerons were locked with a removable control lock (Figure 2). The lock was a 10 cm long pin with a red plastic warning tag which was inserted through the control column and a locking collar that was attached to the instrument panel. There were no external control locks fitted.

The Australian Transport Safety Bureau was advised that the control lock was found in a cockpit stowage pocket after the accident. An inspection of the lock shaft did not reveal any witness marks or deformation caused by the lock being left in the locking collar during the impact sequence.

Figure 2: View of control lock partially removed from control column

The aircraft was fitted with a Bendix Altimatic V FD-1 autopilot system. The autopilot controller panel was located on the centre cockpit pedestal behind the engine controls. Engagement of the autopilot system was accomplished by pressing the AP ENGAGE BUTTON, located on the left side of the controller panel. The button would illuminate when the autopilot was engaged.

The pilot could not recall whether any buttons were illuminated on the autopilot controller prior to, or during, the take-off roll. The system was designed to allow a pilot to momentarily override an autopilot input to the flight controls.

The main landing gear wheel brakes were serviceable and did not exhibit any indications of overheating.

Aircraft performance

The take-off weight and centre of gravity of the aircraft were within limits for the flight.

The approved Aircraft Flight Manual (AFM) contained take-off distance and accelerate-stop distance performance charts for both normal and short field takeoffs. The investigation calculated the take-off performance of the aircraft using the following aerodrome and meteorological information:

• runway length 1,000 m with a bitumen surface
• runway slope 0.8 per cent down to the west
• wind 300 degrees true, 10 kts gusting to 13 kts
• no rainfall recorded during the previous three hours.

The normal take-off distance chart indicated that with take-off power being set before brakes release, the prevailing weather conditions and a take-off weight estimated by the investigation to be 2,941 kg, the aircraft would have a take-off distance of about 644 m from brakes release to 50 ft. With application of the 1.24 factor specified in Civil Aviation Order 20.7.4 for charter operations, the take-off distance required was 799 m, which was within the length of runway 27.

The normal accelerate-stop distance charts were based on take-off power being set before brakes release, wing flaps retracted, a paved, level and dry runway surface, and an 'abort' (reject) speed of 88 kts indicated air speed. The chart allowed for a failure recognition time of 3 seconds. If the pilot technique in applying take-off power differed from that stated on the accelerate-stop chart, the distance to perform the accelerate-stop manoeuvre would be more than the chart derived figure. Provided the takeoff was rejected at 88 kts, the chart indicated that, under the conditions prevailing at the time of the accident, the accelerate-stop distance was about 845 m, which was within the length of runway 27.

The aircraft manufacturer's procedure for a rejected takeoff was included in the emergency procedure for an engine failure during a normal takeoff at or below 85 kts. That procedure specified that the engine throttles were to be immediately closed and brakes applied as required to stop straight ahead.

On 25 July 2005, at about 1835 Eastern Standard Time, a Piper Aircraft Corporation PA-31-350 (Chieftain) aircraft, registered VH-PRJ, overran runway 27 at Nhill aerodrome following a rejected night take-off. The aircraft was being operated on an instrument flight rules charter flight to Charlton, Vic, with the pilot and three passengers on board. The pilot and passengers sustained injuries during the overrun and the aircraft was substantially damaged.

The pilot stated that the take-off roll was from a rolling start with power being slowly applied until engine turbo-charger output stabilised. At about 90 kts indicated air speed, the pilot attempted to rotate the aircraft but encountered resistance to rearward movement of the control column. He decided to reject the takeoff because the aircraft speed at the time was below his nominated decision speed of 100 kts. The pilot reported that he then reduced the engine power to idle and applied maximum braking.

A subsequent inspection of the aircraft revealed that there were no pre-existing defects in the elevator control system and elevator trim system or evidence of interference with the elevator surfaces.

The investigation considered a number of possible factors that could have resulted in the elevator control system difficulties reported by the pilot. Those factors included: mechanical interference in the system, control lock insertion, an excessive nose-down trim setting or nose-down autopilot inputs.

On 5 August 2005, the Federal Bureau of Aircraft Accidents Investigation of Germany (BFU) notified the Australian Transport Safety Bureau (ATSB) that it was investigating an air safety occurrence involving an Australian-registered and operated Boeing 747-438 (747) aircraft, registered VH-OJE, which occurred at Frankfurt, Germany on 28 July, 2005. The ATSB appointed an accredited representative to participate in the investigation into the occurrence, in accordance with clause 5.18 and clause 5.231 of Annex 13 to the Convention on International Civil Aviation. To protect the information supplied to the BFU, the ATSB initiated an investigation under the Transport Safety Investigation Act 2003. The report presented below was prepared principally from information supplied to the ATSB. Reported times are referenced to Coordinated Universal Time.