Rejected take-off, Hervey Bay, Queensland, VH-KEX, Fairchild SA227-DC

Summary

On 25 August 2006 at 1610 Eastern Standard Time a Fairchild Industries Inc SA227-DC Metroliner (Metroliner) aircraft, registered VH-KEX, commenced its take-off roll on runway 29 at Hervey Bay Aerodrome, Qld. The aircraft was being operated under the instrument flight rules (IFR) on a scheduled passenger service to Brisbane, Qld. After reaching 60 kts, and while still on the runway, the pilot in command observed a Eurocopter EC 135 P2 (EC 135) helicopter, registered VH-ESZ, on final approach to land on runway 11 at Hervey Bay Aerodrome. The EC 135 was being operated under the visual flight rules (VFR) on a short flight from the Hervey Bay Hospital to Hervey Bay Aerodrome to refuel. The pilot in command of the Metroliner rejected the take-off.

Occurrence summary

Investigation number 200605091
Occurrence date 25/08/2006
Location Hervey Bay Aerodrome
State Queensland
Report release date 16/02/2007
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Air-ground-air
Occurrence class Incident
Highest injury level None

Aircraft details

Manufacturer Fairchild Industries Inc
Model SA227
Registration VH-KEX
Serial number DC-872B
Sector Turboprop
Operation type Air Transport Low Capacity
Departure point Hervey Bay, Qld
Destination Brisbane, Qld
Damage Nil

Aircraft details

Manufacturer Eurocopter
Model EC135
Registration VH-ESZ
Serial number 331
Sector Helicopter
Operation type Aerial Work
Departure point Hervey Bay Hospital, Qld
Destination Hervey Bay, Qld
Damage Nil

Smoke event, 80 km west-north-west of Ravensthorpe, Western Australia, on 29 August 2006, VH-NJE, BAE SYSTEMS BAe 146-100

Summary

At 1745 Western Standard Time on 29 August 2006, a BAE SYSTEMS BAe 146-100 (BAe146) aircraft, registered VH-NJE, departed Ravensthorpe Aerodrome, WA for Perth.

The flight crew recalled noticing a smell on the flight deck as the aircraft climbed through about FL130 but commented that it was different from the oil-like smell historically associated with the operation of the BAe 146, and to the normal smells associated with the operation of the aircraft's galley. The pilot in command recalled that, shortly after, there were a number of 'popping noises' accompanied by a series of bright yellow flashes and some glowing behind the escape rope panel on the copilot's side of the flight deck.

Shortly after, the smoke and related symptoms dissipated, and the flight crew donned their emergency oxygen equipment and returned to the departure aerodrome. The crew stated that the aircraft's emergency oxygen equipment adversely affected their communication during the remainder of the flight.

The investigation determined that the aircraft's 'A' windscreen electrostatic filter had failed. That failure was consistent with an electrical arcing event.

In response to this and a number of other similar failures in the UK and in Europe, the aircraft manufacturer undertook a number of safety actions, including issuing a Service Information Letter advising operators to check the correct positioning of the insulation blankets in the vicinity of their aircraft electrostatic filters at the next available opportunity. The Australian Transport Safety Bureau has issued two safety recommendations that seek to reduce the likelihood of electrical arcing events in 'A' windscreen filters in BAe 146 aircraft.

Occurrence summary

Investigation number 200605039
Occurrence date 29/08/2006
Location 43 NM NW Ravensthorpe
State Western Australia
Report release date 06/02/2008
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Windows
Occurrence class Incident
Highest injury level None

Aircraft details

Manufacturer British Aerospace
Model 146-100
Registration VH-NJE
Serial number E1104
Sector Jet
Operation type Air Transport High Capacity
Departure point Ravensthorpe, WA
Destination Perth, WA
Damage Nil

Flight control system event, 120 km north of Brisbane Airport, Queensland

Summary

The flight crew of the Boeing Company 737-76N aircraft reported that during descent and taxi operations, they felt several rudder 'kicks' in the pilot in command's rudder pedals, accompanied by an audible noise.

Subsequent examination of the pilot in command's rudder pedal jackshaft assembly revealed two bearings and a universal joint were worn excessively.

The wear of the components of the jackshaft assembly, although not desirable, was not an immediate safety of flight concern for the operation of the aircraft.

The operator issued a flight crew operations notice and an engineering notice to highlight the occurrence to personnel.

Occurrence summary

Investigation number 200604949
Occurrence date 25/08/2006
Location 120km N Brisbane Airport
State Queensland
Report release date 10/05/2007
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Flight control systems
Occurrence class Incident
Highest injury level None

Aircraft details

Manufacturer The Boeing Company
Model 737
Registration VH-VBN
Serial number 33005
Sector Jet
Operation type Air Transport High Capacity
Departure point Cairns, Qld
Destination Brisbane, Qld
Damage Nil

SAAB Aircraft Co. 340B; Sydney Airport, NSW

Summary

Discontinued Investigation

Statement of Reasons

Occurrence investigations commenced from 1 July 2003 are initially categorised as category 4 unless agreed by the ATSB Executive to be above this level at the outset. As detailed in Section 21 (2) of the TSI Act 2003, the Executive Director in empowered to discontinue an investigation at any time. Section 21 (3) of the TSI Act 2003 requires the Executive Director to publish a statement setting out the reasons for discontinuing an investigation (commenced from 1 July 2003) within 28 days of discontinuing the investigation.

Preliminary investigation was undertaken into a level 4 occurrence involving a SAAB 340 aircraft that had been cleared for takeoff and an aircraft tug that entered the runway strip at Sydney Airport on 27 August 2006. Safety action relevant to this occurrence has been taken in response to an earlier incident of a similar nature. Details of that safety action are contained in ATSB safety investigation report 200505170, published on 6 December 2006 and available on the ATSB website. Given the safety action already taken, there was limited safety benefit in continuing the 27 August 2006 investigation compared with other priorities.

Status: Downgraded the occurrence to level 5 and investigation discontinued.

Occurrence summary

Investigation number AO-2006-152
Occurrence date 27/08/2006
Location Sydney Airport
State New South Wales
Report release date 30/08/2006
Report status Discontinued
Investigation level Systemic
Investigation type Occurrence Investigation
Investigation status Discontinued
Mode of transport Aviation
Aviation occurrence category Runway incursion
Occurrence class Incident
Highest injury level None

Aircraft details

Model 340
Registration VH-PRX
Serial number 340B-303
Operation type Air Transport Low Capacity
Departure point Sydney, NSW
Destination Moruya, NSW
Damage Nil

Cessna Aircraft Corporation 404, VH-ENT

Summary

Discontinued Investigation

Statement of Reasons

Occurrence investigations commenced from 1 July 2003 are initially categorised as category 4 unless agreed by the ATSB Executive to be above this level at the outset. As detailed in Section 21 (2) of the TSI Act 2003, the Executive Director in empowered to discontinue an investigation at any time. Section 21 (3) of the TSI Act 2003 requires the Executive Director to publish a statement setting out the reasons for discontinuing an investigation (commenced from 1 July 2003) within 28 days of discontinuing the investigation.

Summary

Notification reports received from air traffic control and the pilot of a Cessna 404 revealed that the pilot was instructed by air traffic control to maintain 5,000 ft due to crossing traffic at 6,000 ft. He reported that he trimmed the aircraft to maintain 5,000 ft, but it climbed to 5,140 ft. The pilot noticed the aircraft climbing and immediately initiated a descent. Air traffic control reported that as the crossing aircraft passed, the Cessna 404 was observed on radar at 5,400 ft. The crew of the crossing aircraft did not sight the Cessna 404 or receive a TCAS advisory or alert.

The pilots report also advised that, following the occurrence, the Cessna 404s altitude encoder was checked and was found to have an error. The encoder was subsequently repaired.

The ATSB commenced a category 4 investigation to determine if safety was compromised. An assessment of available information indicates that although there was a breakdown of separation standards there was limited safety benefit in continuing the investigation.

Status: Downgraded the occurrence to category 5 and investigation discontinued.

Occurrence summary

Investigation number 200604922
Occurrence date 24/08/2006
Location 16 NM north of Adelaide
State South Australia
Report release date 30/08/2006
Report status Discontinued
Investigation type Occurrence Investigation
Investigation status Discontinued
Mode of transport Aviation
Aviation occurrence category Loss of separation
Occurrence class Incident
Highest injury level None

Aircraft details

Manufacturer Cessna Aircraft Company
Model 404
Registration VH-ENT
Serial number 404-0818
Operation type Charter
Departure point Adelaide, SA
Destination Balcanoona, SA
Damage Nil

Violation of controlled airspace, Tecnam P2002 and a Fairchild aircraft, near Sydney Airport, New South Wales, on 19 August 2006

Summary

On 19 August 2006, the pilot of a Tecnam Costruzioni Aeronautiche P2002 aircraft, registered VH-JFV, was tracking from Bankstown Airport to a flying training area, west of the airport. The flight was being conducted under the visual flight rules (VFR) and the pilot intended to remain in non-controlled airspace (OCTA) for the duration of the flight. The upper limit of OCTA on the intended track was 2,500 ft until 37 km west of Sydney Airport. At 1137, the aircraft was observed on air traffic control radar to be above 3,000 ft and climbing, inside controlled airspace (CTA). That placed the Tecnam in potential conflict with a Fairchild Industries Inc SA226-T Merlin aircraft, registered VH-SSM, which had departed from Bankstown for Wollongong. The Merlin was being operated on an instrument flight rules (IFR) flight.

At 1138, the Sydney Departures South controller received a short-term conflict alert on the air situation display (ASD). At the time of the alert the aircraft were separated by 900 ft vertically and 3,150 m (1.7 NM) laterally. The controller issued heading instructions to the pilot of the Merlin to avoid the Tecnam. A radar controller established radio communications with the pilot of the Tecnam and instructed the pilot to leave CTA. The pilot complied with the instruction by descending the aircraft and it left CTA at a position about 35 km west of Sydney Airport.

The pilot of the Tecnam had misidentified the aircraft's position in relation to the CTA boundary and consequently inadvertently entered CTA without a clearance. The pilot subsequently undertook additional training to ensure that he could visually identify the CTA boundaries in and around the Bankstown area

Occurrence summary

Investigation number 200604810
Occurrence date 19/08/2006
Location 28km west Sydney Airport
State New South Wales
Report release date 16/02/2007
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Loss of separation
Occurrence class Incident
Highest injury level None

Aircraft details

Manufacturer Tecnam - C. Aeronautiche SRL
Model P2002
Registration VH-JFV
Serial number 24
Sector Piston
Operation type Private
Departure point Bankstown, NSW
Destination Bankstown, NSW
Damage Nil

Aircraft details

Manufacturer Fairchild Industries Inc
Model SA226
Registration VH-SSM
Serial number T204
Sector Turboprop
Operation type Charter
Departure point Bankstown NSW
Destination Wollongong NSW
Damage Nil

Airprox, 22 km south of Williamtown, New South Wales

Summary

The crew of a Fairchild Industries Ltd. SA227 Metroliner were inbound to Williamtown, NSW, when the control zone and restricted airspace were not active. The copilot made an inbound broadcast on the common traffic advisory frequency (CTAF) at 20 NM south, to which no response was heard. The crew reported that at 10 NM south of Williamtown, as they were descending through 3,000 ft, they passed within an estimated 30 m of a low-wing, retractable landing gear, single-engine aircraft travelling in the opposite direction. The pilot in command, who was the pilot flying, reported that his attempt to avoid the other aircraft would not have been timely enough to affect separation and there was an Airprox.

The investigation was unable to identify the other aircraft and determine why its pilot had not used the radio to provide positional information when operating in the vicinity of an airport for which the use of a radio was required and to determine if the aircraft transponder equipment (if equipped) was serviceable.

The investigation found that since November 2005, the provision of radar services in the Williamtown area had been reduced when the military airspace was not active. That was due to an unresolved technical problem with the military secondary surveillance radar at Williamtown, which impacted the civilian air traffic control system. A replay of the military radar data showed that the Metroliner's radar return merged with the primary return (no identification or altitude information) of another aircraft travelling in the opposite direction, overhead Newcastle.

The occurrence demonstrated the limitations of the see-and-avoid concept as an adequate means of achieving safe separation from other traffic in an unalerted traffic environment. It also demonstrated the arbitrary hand played by good fortune in avoiding a mid-air collision over a populous area, when just one pilot in an airspace system that relies on the cooperation of all pilots, either cannot or does not choose to participate.

Occurrence summary

Investigation number 200604809
Occurrence date 19/08/2006
Location 22 km south Williamtown Aero
State New South Wales
Report release date 30/11/2006
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Near collision
Occurrence class Serious Incident
Highest injury level None

Aircraft details

Manufacturer Fairchild Industries Inc
Model SA227
Registration VH-HPB
Serial number DC-808B
Sector Turboprop
Operation type Air Transport Low Capacity
Departure point Sydney NSW
Destination Williamtown NSW
Damage Nil

Aircraft details

Manufacturer Unknown
Model Aeroplane
Operation type Unknown
Damage Nil

In-flight engine fuel leak, 482 km north-west of Darwin, Northern Territory, Boeing 747-438, VH-OJP

Summary

On 18 August 2006, a Boeing 747-438 aircraft, registered VH-OJP, with a crew of 18 and 243 passengers departed Hong Kong, China, on a scheduled passenger service to Melbourne, Australia.

While in cruise, at a position 482 km north-west of Darwin, one of the cabin crew notified the flight crew that there was a smell of fuel in the first-class cabin. One of the pilots verified the fuel smell and then proceeded to inspect the engines from the cabin windows.

A fluid trail was evident from the rear of the number 3 engine. During this time, it was noted by the other pilots that the number 3 engine had a higher-than-normal fuel flow. The flight crew conducted an in-flight shut down of the number 3 engine and diverted the aircraft to Darwin.

A subsequent inspection of the number 3 engine revealed the fuel manifold return line had fractured, causing a fuel leak. The fuel line was replaced, and the aircraft was returned to service.

In 2005, the ATSB investigated two other fuel manifold return line fractures, from the same engine type, under similar circumstances.

Occurrence summary

Investigation number 200604807
Occurrence date 18/08/2006
Location 482km NW Darwin
State Northern Territory
Report release date 09/11/2006
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Fuel systems
Occurrence class Incident
Highest injury level None

Aircraft details

Manufacturer The Boeing Company
Model 747
Registration VH-OJP
Serial number 25545
Sector Jet
Operation type Air Transport High Capacity
Departure point Hong Kong
Destination Melbourne, Vic.
Damage Minor

Boeing Aircraft Co B747-412 DQ-FJK, Sydney Airport NSW

Summary

Discontinued Investigation

Statement of Reasons

Occurrence investigations commenced from 1 July 2003 are initially categorised as category 4 unless agreed by the ATSB Executive to be above this level at the outset. As detailed in Section 21 (2) of the TSI Act 2003, the Executive Director in empowered to discontinue an investigation at any time. Section 21 (3) of the TSI Act 2003 requires the Executive Director to publish a statement setting out the reasons for discontinuing an investigation (commenced from 1 July 2003) within 28 days of discontinuing the investigation.

Preliminary investigation was undertaken into a level 4 occurrence involving a landing B747 aircraft and an aircraft tug that crossed the runway at Sydney Airport on 11 August 2006. Safety action relevant to this occurrence has been taken in response to an earlier incident of a similar nature. Details of that safety action are contained in ATSB safety investigation report 200505170, published on 6 December 2006 and available on the ATSB website. Given the safety action already taken,there was limited safety benefit in continuing the 11 August 2006 investigation compared with other priorities.

Status: Downgraded the occurrence to level 5 and investigation discontinued.

Occurrence summary

Investigation number AO-2006-151
Occurrence date 11/08/2006
Location Sydney Airport
State New South Wales
Report release date 30/08/2006
Report status Discontinued
Investigation level Systemic
Investigation type Occurrence Investigation
Investigation status Discontinued
Mode of transport Aviation
Aviation occurrence category Runway incursion
Occurrence class Incident
Highest injury level None

Aircraft details

Manufacturer The Boeing Company
Model 747
Registration DQ-FJK
Operation type Air Transport High Capacity
Departure point Nadi, Fiji
Destination Sydney, NSW
Damage Nil

In-flight engine shutdown, Boeing 737-400, VH-TJI

Summary

At 0812 eastern standard time on 18 August 2006, a Boeing Company 737-400 aircraft, registered VH-TJI, with a crew of 6 and 117 passengers departed Brisbane, Qld, on a scheduled passenger service to Sydney, NSW.

Climbing through flight level 150, the pilot in command noticed the number-1 engine oil pressure gauge was indicating low oil pressure.

Following the non-normal procedures checklist, the pilot in command shut-down the number-1 engine and returned the aircraft to Brisbane. There were no reported injuries.

A subsequent examination of the aircraft revealed the number-1 engine oil pressure indicator was unserviceable. The faulty oil pressure indicator was replaced and the aircraft was returned to service.

Occurrence summary

Investigation number 200604781
Occurrence date 18/08/2006
Location near Brisbane, Aerodrome
State Queensland
Report release date 19/09/2006
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Abnormal engine indications
Occurrence class Incident
Highest injury level None

Aircraft details

Manufacturer The Boeing Company
Model 737
Registration VH-TJI
Serial number 24434
Sector Jet
Operation type Air Transport High Capacity
Departure point Brisbane, Qld
Destination Sydney, NSW
Damage Nil