On 23 September 2005, a Fairchild Metro III, registered VH-SEF, with 2 crew and 16 passengers on board, was being operated on a scheduled passenger service from Thangool, Qld, to Brisbane. At about 1942 Eastern Standard Time, when the aircraft was just north of the Gayndah non-directional beacon, the L XFER PUMP (left fuel transfer pump) warning illuminated. In accordance with company procedures, the crew selected the alternative fuel boost pump. However, the warning remained illuminated. The crew diverted the flight to Bundaberg. When the aircraft was about 10 NM from Bundaberg, the left engine failed. The crew conducted a single-engine visual approach and landing to Bundaberg aerodrome.

A maintenance engineer subsequently drained the aircraft fuel tanks, obtaining 2 L of fuel from the left tank, and 28 L from the right tank.

The Metro III fuel system consisted of two integral fuel tanks, located in the left and right wings. Each wing tank contained a hopper tank and two fuel boost pumps to provide fuel to the aircrafts engines. According to the Metro III Airplane Flight Manual, when a fuel boost pump was operating, activation of the fuel transfer pump warning indicated that there was 65 to 75 pounds (36 to 43 L) of fuel remaining in the respective tank.

The aircrafts fuel quantity indicating system consisted of five capacitance sensors and a temperature compensator in each wing tank. The capacitance values, adjusted for temperature, were transmitted to a dial-type fuel quantity gauge located in the cockpit, which displayed the quantity of fuel, in pounds, in each fuel tank. After the aircraft landed at Bundaberg, the fuel gauge indicated that there was approximately 400 pounds (227 L) of fuel in the left tank, and 300 pounds (170 L) in the right tank.

Prior to the occurrence flight, the aircraft had completed a scheduled passenger service from Brisbane to Thangool. Before departure from Brisbane, the pilot in command had been told that there was 850 pounds (483 L) of fuel on board the aircraft. He subsequently arranged for the aircraft to be refuelled with 642 L. The aircraft was not refuelled in Thangool.

The aircraft was fitted with a mechanical fuel totaliser, which recorded the quantity of fuel that had been consumed by the aircrafts engines. It was the operators practice for pilots to reset the totaliser to zero before each flight. The recorded totaliser values indicated that the total fuel consumed during the Brisbane to Thangool and Thangool to Bundaberg flights was 1,283 pounds (729 L).

Immediately before the flight from Brisbane to Thangool, the aircraft had been at an independent maintenance facility undergoing various maintenance actions, including the replacement of the aircrafts fuel gauge¹. The maintenance organisation reported that the replacement fuel gauge was calibrated according to the aircraft manufacturers instructions before the aircraft was released for service.

Each fuel tank was also fitted with an optional direct-reading mechanical fuel level indicator called a magna-stick. A magna-stick was located on the underside of each wing, inboard of the engine nacelle, and consisted of a doughnut-shaped float inside the fuel tank, which was attached to a calibrated indicator stick. The magna-stick could be used to provide an indication of fuel quantity if the quantity in the tank was between approximately 30 and 160 US gallons (115 and 585 L).

Following the occurrence, the Civil Aviation Safety Authority (CASA) required the aircraft to be refuelled to full tanks before it was flown by day and without passengers to Brisbane for maintenance examination.

Safety Action

1. On 27 September 2005, CASA prescribed a temporary direction on the operator regarding the total fuel to be carried on all Metro aircraft flights. On 28 September 2005, CASA rescinded that direction and further directed the operator to amend the company Metro III operations manual with respect to the pre-flight procedure for the check of fuel on board. A copy of that procedure is at attachment A.

2. On 28 September 2005, CASA issued the following directions to the operator with regard to aircraft maintenance:

• A formal fuel indication system inspection and calibration check was to be conducted on the operator's fleet of three Metro aircraft in the presence of a CASA airworthiness inspector. Plans for those activities were to be completed within five working days
• Maintenance control manual procedures were to be developed for recording fuel related maintenance activities. Those procedures were to include provision for engineers to enter the maintenance fuel burn after engine runs and fuel system maintenance in the flight log or the maintenance log. Those procedures were to be communicated as a notice to pilots and to all relevant maintenance organisations. The procedures were to be included as a revision to the company's maintenance control manual.
• Within the next 10 working days, the company's Metro system of maintenance relating to ATA² Section 28 fuel indicating systems was to be reviewed in conjunction with CASA airworthiness inspectors.
• Within the next 10 working days, the company's Metro minimum equipment list relating to ATA Section 28 fuel indication system defects was to be reviewed in conjunction with CASA airworthiness inspectors.

3. On 24 September 2005, the operator advised all Metro III flight crew of the contents of Standing Order #155 via emailed memo and individual telephone calls. On 28 September 2005, the operator issued company Standing Order #155, effective immediately, which amended its Metro III operations manual as follows:

The following fuel checks must be carried out before every departure and or after every refuelling:

1. A Magna-Stick Check must be carried out, and its reading noted (take at least 3 readings and use the lowest reading).
2. This reading must then be compared to the gauge reading.
3. If there is any discrepancy between the two, the Lower reading must be used for all fuel calculations and the Higher reading must be used for all weight and balance calculations.

Remember Magna-Sticks are only useful when fuel tanks are less than half full (2171 lbs) but have at least 201 lbs in them. Whenever possible, limited fuel loads to no more than 2170 lbs to allow an accurate Magna- Stick reading.

Accurate readings are obtainable only when the airplane is on a reasonably level ramp because the Magna-Stick indications depend upon the level of the fuel in the tank. Avoid inaccurate readings caused by binding of the indicator stick in its bushing by tapping the bottom surface of the wing around the Magna-stick as and before taking readings. Due to the slope of some of our parking bays (i.e. Armidale) accurate reading will not be obtained. Therefore, so long as there is no unexplained discrepancy between planned fuel remaining upon arrival and the actual fuel remaining upon arrival, the aircraft may depart without completing a Magna-Stick Check, provided a Magna-Stick Check is completed before departure from the next port that contains a level parking bay.

On Wednesday 28 September, the operator issued company Standing Order #156 as follows:

Effective immediately, before every departure the Pilot in Command MUST complete the attached form [see Attachment A]. The completed form MUST be returned with the FDL [flight deck log] at the completion of the days flying.

I would also like to remind all pilots of the obligation to carry out a 3% check before each flight as per CAO [Civil Aviation Order] 20.2.6.1.

If the difference is calculated exceed 3%, maintenance control must be notified before further flight.

With regard to the Metro, the procedures stated in Standing Order 155 must also be completed.

With regard to the CASA directions of 28 September on Metro aircraft maintenance, the operator reported that the following action had been taken:

1. A notice to pilots and engineers was issued to direct engineering organisations that maintain the company's Metro aircraft to record fuel burns and uplifts in the captain's report area of the current FDL, in advance of a new style FDL being released.
2. An internal task force was convened on 6 October 2005 to review, in conjunction with CASA, the company's system of maintenance and minimum equipment list for the Metro aircraft with regard to ATA Section 28 items.
3. A notice was issued to pilots and engineers stating that the preferred method of calibration (complete system calibration) and not the alternative method (abbreviated method) was to be used whenever maintenance action that required fuel system calibration was conducted.
4. A complete fuel indication system check and fuel system calibration was scheduled for completion on two of the company's Metro aircraft by 11 October 2005. Fuel system calibration of the occurrence aircraft would be undertaken once repairs had been completed. All calibration checks would be conducted in the presence of a CASA airworthiness inspector.

Attachment A: Procedure for pre-flight checks for fuel on board
 

¹ The fuel gauge was a single display incorporating an indicator for each of the two fuel tanks.
² A specification issued by the Air Transport Association of America that establishes a standard for the presentation of certain data produced by aircraft, engine, and component manufacturers, required for the support of their respective products.

On 1 September 2005, the crew of an Embraer EMB110-P2 (Bandeirante) aircraft, registered VH-OZF, was conducting a private flight under the visual flight rules from Bankstown Airport to Camden, NSW. At 1343 Eastern Standard Time, on the initial climb from runway 11 Left (11L), the pilot in command (PIC) experienced excessive nose down pitch control forces.

The PIC attempted to correct the pitch force with the manual elevator trim wheel and electric trim, but the trim did not move. The copilot assisted by applying back pressure to his control column and observed that the elevator trim wheel was in the full nose down position. The pilots were unable to maintain altitude and the aircraft descended from approximately 470 to 150 ft.

The PIC reduced engine power and the airspeed reduced. The copilot applied significant force to the elevator trim wheel and the wheel released from the full nose down position. The pilots regained control and landed.

The investigation found that the left yoke-mounted trim switch did not to return to the neutral position, when operated and released, due to a sticky substance binding the levers. It also found that the elevator electric trim servo mechanical clutch did not release at the specified setting due to a lack of maintenance.

The circumstances of this event were consistent with an electric trim runaway occurring during or shortly after take-off. The investigation established that the trim runaway was probably due to the non return of the switch from the nose down position or an unidentified electrical fault.

The pilots reported that they were unable to pull the electric trim circuit breaker, in accordance with the manufacturer’s procedure, because they were unable to release the control column.

As a result of the investigation the operator and manufacturer initiated a number of safety actions.

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 is 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. To obtain a copy of the Brief Print Public for Discontinued Investigations prior to 1 July 2003 send a request via email to the ATSB information line.

On 31 August 2005, the crew of a Fairchild Industries Inc SA227–DC (Metro) aircraft had been issued a clearance for a visual approach to runway 14 at Brisbane Airport. At about the same time, the crew of a Boeing Company 717–200 (717) aircraft had been issued a take-off clearance from runway 01. The crew of the Metro commenced a go-around from runway 14 at about the same time the 717 became airborne from runway 01. The 717 crossed about 625 m in front of, and 580 ft above, the Metro. There was a breakdown of separation.

The Metro’s descent to Brisbane had been restricted by another aircraft, which placed it above the normal descent profile. The crew of the Metro subsequently continued an approach that was unlikely to be conducted successfully. The aerodrome controller misjudged the position of the Metro, which resulted in the incorrect application of separation standards. This also meant that the controller did not give adequate consideration to the likelihood of a go-around by the crew of the Metro.

After the Metro crew commenced the go-around, the controller was unable to visually separate the aircraft. The controller had not provided traffic information to the crew of either aircraft, nor was he required to do so. The controller attempted to make the Metro crew aware of the 717, but did not provide the information in the form of a safety alert as required by the Manual of Air Traffic Services.

Without prior knowledge of the 717, the crew of the Metro found it difficult to identify the correct aircraft, as the 717 was initially below their level and masked by background lighting.

As a result of previous occurrences, the ATSB had previously issued a safety recommendation to Airservices Australia in October 2006 in relation to the provision of relevant traffic information, to enhance pilot situational awareness.

On 25 August 2005, while on a scheduled flight from Brisbane, Qld, to Sydney, NSW, a Boeing 737-476 aircraft, registration VH-TJX, experienced an in-flight engine malfunction approximately 6 km SSE of Sydney Airport.

An inspection of the left engine by the operator's engineering personnel revealed damage within the high-pressure compressor (HPC). The left engine, a General Electric CFM56-3C1, was subsequently removed and disassembled at the operator's maintenance facility. The teardown revealed that a single dowel pin had come loose from its installed position within stage-three of the HPC and was ingested by the downstream rotating hardware, resulting in damage to the HPC rotor and stator components.

Further examination of the HPC stator components revealed that the dowel pin had come loose due to excessive clearance and recession of the stage-three stator shroud anti-rotation pins.

As a result of this occurrence, the engine manufacturer, General Electric, initiated a number of safety actions that included a redesign of the HPC anti-rotation pin. The manufacturer also released an alert Service Bulletin CFM56-3 S/B 72-1091 to all operators and maintainers of CFM56-3 engines that recommended the introduction of the new pin design into existing engines. Other safety actions taken included amendments to the CFM56-3 maintenance manual for HPC stator shroud component inspections.

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 clause 5.18 ¹ and 5.23 ² of Annex 13 to the Convention on International Civil Aviation. To protect the information supplied by ARAIC to the ATSB and investigative work undertake to assist the ARAIC, 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.

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. In accordance with its obligations under Annex 13 to the Convention on International Civil Aviation, the ARAIC initiated an investigation of the factors that contributed to the development of the accident.

The ARAIC is the independent Japanese government authority responsible for the safety investigation of aviation accidents and incidents in Japan. The Australian accredited representative's role in the investigation has been to provide the ARAIC with information about the aircraft and its operation, and analyse recorded information.

The ARAIC will publish the final report related to the investigation of this occurrence.

1. The State of Registry, the State of the Operator, the State of Design and the State of Manufacture shall be entitled to appoint an accredited representative to participate in the investigation.
2. Any States which on request provides information, facilities or experts to the State conducting the investigation shall be entitled to appoint an accredited representative to participate in the investigation.

At 2108 Eastern Standard Time on 09 August 2005, a Boeing Company 737-700 aircraft, registered VH-VBD, completed a scheduled flight from Melbourne, Victoria to Sydney, NSW. The pilot then reported that the aircraft had 'heavy' flight controls. An inspection by maintenance engineers revealed that the left lower rear elevator cable was incorrectly routed around a stiffener and that the stiffener and cable section had been damaged as a result of contact between them. The aircraft was withdrawn from service for repairs.

In the last week of July 2005, a contract maintenance organisation had replaced eight elevator control cable sections during a scheduled heavy aircraft maintenance check. The cables were replaced to comply with Boeing Company service bulletin 737-27-1254 revision 1.

While preparing the rear elevator control cables for removal, a cable end was not secured at the lower left rear elevator input quadrant, before removing the cable keeper. When the cable keeper was removed, the unsecured cable section slipped from sight. While recovering the cable, it was inadvertently misrouted around a fuselage stiffener. When the new cable was pulled into place it followed the same incorrect route around the stiffener.  This resulted in contact between the cable and the stiffener.

As a result of the occurrence, the contract maintenance organisation implemented a number of changes to improve maintenance planning and documentation.

On 14 April 2005 a crew member of a SAAB Aircraft AB SF-340B suffered a minor injury as a result of coming into contact with the sharp edges of the aircraft's hardened cockpit security door. A similar injury was reported to have occurred previously in like circumstances. More significantly, reports were received from a number of aircraft operators regarding flight safety and operational hazards associated with the installation of hardened cockpit security doors in four different aircraft types.

The investigation determined that, to enhance security, regulation 4.68 of the Transport Security Regulations 2005 was drafted to combine a unique hardened cockpit security door requirement in aircraft having a passenger seating capacity of 30 to 59 seats, with the hardened cockpit door security requirements of Section 13.2.2 of Annex 6 to the Chicago Convention for application in aircraft with a seating capacity of 60 or more seats.

However, the development of regulation 4.68 did not take full account of the operational and flight safety requirements of the US Federal Aviation Regulations, or of other available international policy guidance. The result was a number of unintentional operational and flight safety hazards in affected aircraft, as evidenced by this investigation report.

The apparent scope of the potential hazards associated with the installation of hardened cockpit security doors, and their potential effect, formed the basis for the conduct of this investigation, which was formally commenced on 29 July 2005.

Post publication safety action update

As a result of this investigation, the Office of Transport Security (OTS) indicated that it would explore the establishment of a formal consultation mechanism with the Civil Aviation Safety Authority (CASA), and consult with CASA on relevant aviation security measures that had the potential to impact on aviation safety. The OTS also advised that it would, over time, consider the amendment of the Aviation Transport Security Regulations 2005, including in response to the potential safety concerns of the flight deck door requirements.

CASA indicated that it would seek a Memorandum of Understanding with the OTS to ensure the consideration of any potential operational and flight safety hazards that might result from the development of national aviation security requirements. Subsequently, in November 2009, CASA advised that it had established quarterly meetings with the Department of Infrastructure, Transport, Regional Development and Local Government to discuss the interaction of security and aviation safety regulatory requirements. On that basis, both organisations agreed that a formal Memorandum of Understanding was not required.