Summary

On the morning of 26 February 2003, the Liberian flag bulk carrier, Pactrader, arrived at Thevenard from Lumut in Malaysia and embarked a pilot for berthing at Thevenard wharf. The ship entered the port and made fast, without incident, port-side-to the northern side of the wharf to load a cargo of gypsum for Auckland, New Zealand. The cargo was loaded as planned and completed during the early hours of 28 February. Pactrader remained alongside the wharf after completion of cargo operations waiting to sail on the high tide predicted for early the next morning, 1 March.

The pilot boarded Pactrader again at midnight, 28 February for the departure. The pilot and master discussed the outward pilotage and, at 0006 on 1 March, the ship commenced singling up the mooring lines as per the departure plan. A single tug was pushing up on the ship's starboard side at about midships. The wind was from about the south-south-west at 20 knots.¹ The tide was setting to the north (the last of the flood) at up to 0.5 knots.

At 0012 the last mooring line was let go and the ship started moving from the berth. As the ship moved ahead it was set to starboard by the tide and wind and, a short timelater, it ran aground along its starboard side when its stern was just clear of the end of the wharf. It had only moved about one ship length ahead.

At 0224 on 4 March, the ship was refloated with the assistance of a salvage tug despatched from Adelaide and returned alongside the wharf. Divers and a classification society surveyor inspected the ship and, when they indicated that there was no significant damage and that the ship was seaworthy, Pactrader was released by AMSA² to continue its voyage to New Zealand.

The report's conclusions include:

• The pilot did not make sufficient allowance for the significant forces acting on the beam of the ship at sailing time.
• The tug was not used to best advantage given the prevailing circumstances.
• The planning of the sailing operation was inadequate in that neither the master nor the pilot reviewed alternative strategies for unberthing, such as tug utilisation, engine movements and rudder usage.
• The 'soft nose' at the end of the wharf discouraged the pilot from remaining close to the wharf during his outward movement.

The report makes a recommendation that:

Flinders Ports should undertake a risk assessment of the Port of Thevenard, taking into account the variable environmental factors, together with infrastructure and pilotage ongoing training experience issues.

¹ 1 knot = 1 nautical mile (1852 metres) per hour.
² AMSA is the Australian Maritime Safety Authority.

Summary

At 1612 on 21 March 2003, the Australian flag roll-on/roll-off cargo vessel Searoad Mersey departed from Melbourne on a scheduled service to Devonport in Tasmania. By 1924 the vessel had cleared Point Lonsdale, at the entrance to Port Phillip and was en route to Devonport.

At 2118:50 the engine room alarm sounded in the duty engineer's cabin, followed shortly after by the fire alarm. During his subsequent inspection of the engine room the duty engineer found a main engine connecting rod lying on the deck on the inboard side of the port main engine. The port main engine had stopped. There was oil lying all over the floor plates, on and around the engine, and on the deck head above the engine. It was apparent that there had been a catastrophic failure of the number one piston assembly, cylinder liner and cylinder cover.

A short time later the port main generator overheated and shut down which caused the ship to black out. The port generator had stopped as a result of the damage to the port main engine which had caused a large loss of cooling water from the common cooling system.

By about 2215 the various engine room systems had been stabilised and checked by the engineers. The decision was made to return the ship to Melbourne and by 2230 the starboard main engine had been started and the vessel was proceeding under its own power. Searoad Mersey arrived alongside Webb Dock in Melbourne at 0715 on 22 March 2003 where repairs to the damaged port main engine commenced.

The report makes the following conclusions relating to the failure of Searoad Mersey's port main engine:

• A casting flaw found in the piston skirt fitted to number one unit initiated a fatigue crack which eventually caused the piston to fail in service.
• The vessel's maintenance system did not include a system for tracking the total operating hours of the main engine piston assemblies.
• The vessel's maintenance system did not include a procedure for crack testing the piston skirts in the areas stipulated by the manufacturer in their service bulletin Piston overhaul of VASA 32 engines after 24 000 running hours and later overhauls.
• The critical manufacturer's Main Components maintenance intervals for VASA 32, 32LN and 32GD bulletin had not been provided to the vessel or its technical manager.
• The evidence strongly suggests that Wartsila Vasa 32 engines have had a history of piston skirt failures similar to that experienced by Searoad Mersey.

The report makes recommendations to the operators of Wartsila Vasa 32 engines and to Wartsila NSD in relation to the servicing of piston assemblies and the distribution of engine service bulletins.

Accident sequence

On 11 November 2003, a Piper Seneca, registered VH-CTT, was seen to diverge right during a go around from runway 11 Right at Bankstown Airport, NSW. It maintained a constant height above the ground and; when about halfway along the runway, the aircraft's nose lifted and it banked steeply to the right before impacting the ground in a near vertical nose-down attitude. A student pilot in the left seat and an instructor pilot in the right seat were the only occupants.

A fire commenced when the aircraft impacted the ground or shortly after the impact. The fire intensified after the aircraft came to rest. The main cabin door, located over the right wing, separated from the aircraft during the accident. The instructor pilot vacated the aircraft through that opening about 30 seconds after the aircraft came to rest. The student pilot was fatally injured. The instructor pilot received severe burns and was treated in hospital for three and a half weeks before succumbing to those injuries.

Effectiveness of fire fighting services

On 1 December 2003, the Minister for Transport and Regional Services signed an Instrument of Direction to the Australian Transport Safety Bureau (ATSB). That instrument directed the ATSB to 'investigate the effectiveness of the fire fighting arrangements for Bankstown Airport, as they affected transport safety at Bankstown Airport on 11 November 2003'. Effectiveness is defined as 'serving to effect the purpose; producing the intended or expected result'.¹ The instrument was issued to the ATSB on 15 December 2003.

¹ Macquarie Dictionary (revised third edition), The Macquarie Library, NSW, 2003.

On 02 April 2003, a Bangladesh registered McDonnell Douglas DC-10-30, S2-ACR, was climbing through 2,700 ft following departure from Chittagong - Patenga Airport, Bangladesh when the No. 1 engine failed. The EGT exceeded 1,000ºC and the engine was shutdown. The aircraft returned for an uneventful landing.

The flight data recorder (FDR) was recovered from the aircraft in April 2003. The Civil Aviation Authority of Bangladesh (CAAB) was responsible for investigating this accident and appointed an investigation committee which included the aircraft operator. The CAAB requested ATSB assistance in the recovery of data from the FDR. The Executive Director of the ATSB approved the request. The CAAB also requested that some of the investigation committee be present during the download and recovery procedure. To protect the information supplied by the ATSB to the CAAB, the operator and investigation work undertaken to assist these agencies, the ATSB initiated an investigation under theTransport Safety Investigation Act 2003.

In 2007, due to the continuing uncertainty of attendance by the Bangladesh representatives, the ATSB downloaded the FDR to enable its return to the operator. A factual report describing the recorded data found on the FDR was prepared and provided to the CAAB.

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Released in accordance with section 25 of the Transport Safety Investigation Act 2003.

Summary

Tauranga Chief arrived at Sydney from Port Kembla on 17 January 2003 on its normal liner route. It had sailed from Port Kembla the previous evening and arrived at the Sydney pilot boarding ground on schedule at 0300 local time. The pilot boarded as planned and the ship continued inwards toward the booked berth at White Bay container terminal.

When the ship came to an intended course alteration position in the harbour, east of Bradleys Head, the pilot initiated the turn to starboard to round the headland. He firstly ordered 5 starboard rudder and, when the ship did not respond quickly enough, he increased the order to starboard 10. The rate of swing increased markedly and so the pilot ordered port 20 to slow the swing. The seaman on the wheel made an error executing this last wheel order and instead applied starboard 20 wheel. Before the consequences of this error could be corrected, the ship ran aground on a mud/sand patch just south of the light on the southern end of the headland.

Two harbour tugs, which were waiting to assist the berthing operations for the ship, were called to the location and the ship was refloated using the tugs, the ship's anchor and main engine after being aground for about half an hour. Tauranga Chief continued to its berth where divers checked the ships hull externally for any damage, while it was alongside the wharf for cargo operations.

Only slight, localised scratching of the underwater paintwork on the bottom of the hull under the bulbous bow and around the forward end of the hull was reported after the divers inspection and video report so the ship was released by AMSA to continue its voyage to New Zealand.

The report concludes that the grounding was caused by an error in the execution of wheel orders during a routine course alteration. Contributing factors identified included:

• The grounding was initiated by an error in the execution of wheel orders during a routine course alteration.
• The pilot did not order midships before ordering counter rudder. This may have contributed to the helmsmans failure to recognise and act upon the change in rudder direction.
• The seaman on the wheel was possibly affected by fatigue, predominantly caused by the circadian low at the time of the incident and compounded by the effects of circadian dysrhythmia (jet lag). The concentration and reaction time of the master and OOW may also have been affected by these effects.
• The handling characteristics of the ship, due to its load and trim at the time of the incident, made the handling of the ship more difficult than usual. The following flood tide and wind on the passage down the harbour would have accelerated the rate of turn which reduced the likelihood of success of the attempted corrective actions.

The report makes recommendations relating to pilotage and crew change practices.

On 3 October 2003, Convair 580, registered ZK-KFU, was operating on a scheduled night freight flight from Christchurch to Palmerston North, New Zealand. After passing Paraparaumu Non-Direction Beacon (NDB), the crew were cleared by air traffic control for descent and approach to Palmerston North. Shortly after, the aircraft was observed on radar to enter a tightening left turn and disappear from the controller’s display. Attempts to contact the crew were unsuccessful and a search for the aircraft was commenced.

In accordance with its obligations under Annex 13 to the Convention on International Civil Aviation (Annex 13), the Transportation Safety Board of Canada (TSB) investigated the circumstances surrounding the accident involving Bell Helicopter Co 204B helicopter, registered C-GEAP, at Bonaparte Lake, British Columbia on 17 August 2003.

The pilot, the sole occupant of the helicopter, was carrying out fire suppression work and had just departed a staging site with an empty underslung water bucket. Shortly after takeoff, the engine ceased operating and, during the attempted autorotation emergency landing, the attached long line entangled a tree. The helicopter impacted the ground within a forest and was destroyed by a post-impact fire. The pilot was fatally injured.

The TSB requested that the Australian Transport Safety Bureau (ATSB) assist their investigation by sourcing specific information. In accordance Annex 13 Paragraph 5.23, the ATSB appointed an Accredited Representative to the TSB investigation to provide information related to the pilot's qualifications and recent operational history.

On completion of the TSB investigation, the final investigation report will be made available on the TSB web site.

On 10 June 2003, during a routine maintenance inspection between flights, the number 3 main landing gear wheel of a Boeing Commercial Aircraft Co. 727 freight aircraft, registered VH-VLH, was found cracked through the central hub body around the inboard bearing position. Some associated damage had been sustained by the brake unit as a result of the hub failure, however the tyre had not deflated. The adjacent number 4 wheel was undamaged. Following removal from the aircraft, the aircraft operator forwarded the wheel assembly to the Australian Transport Safety Bureau on 01 July 2003, for evaluation and analysis of the failure and consideration of the likely contributory factors.

Summary

On 24 December 2003, a Boeing 737-7BK (737) operating under the instrument flight rules (IFR) was en route from Sydney and descending for a landing at Launceston, Tasmania. A Socata TB10 (Tobago) operating under the visual flight rules (VFR) was en route from Hobart, Tasmania, to Sydney at about 7,500 ft. As the 737 was descending through about 8,300 ft, at around 1333:53 ESuT¹, the crew received a traffic advisory (TA) from their traffic alert and collision avoidance system (TCAS) about the Tobago. This was followed approximately 15 seconds later by receipt of a TCAS resolution advisory (RA) to climb. The crew responded to the RA and after arresting the aircraft's rate of descent, climbed the aircraft to approximately 9,200 ft. The pilot in command of the 737 reported that the TCAS indicated that the Tobago passed the 737 within about 200 ft vertically, slightly to the left, and certainly less than 1 NM horizontally.

Both aircraft were operating in Class E airspace that was introduced as part of the National Airspace System (NAS) phase 2b on 27 November 2003. As no prescribed separation standards are applicable in these circumstances, there was no infringement of separation standards. However, TCAS data and information obtained from the pilots of both aircraft indicate that the aircraft came into such close proximity that a threat to the safety of the aircraft may have existed. Therefore, the occurrence has been classified by the ATSB as an airprox² event, which is a type of serious incident.

¹ Eastern Summer Time.
² Under the Transport Safety Investigation Regulations 2003, an 'airprox is defined as an occurrence in which two or more aircraft come into such close proximity that a threat to the safety of the aircraft exists, or may exist, in airspace where the aircraft are not subject to an air traffic separation standard, or where separation is a pilot responsibility.

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History of the event

While taxiing for a scheduled passenger service from Sydney, NSW, to Lord Howe Island, the crew of the DeHavilland DHC-8 (Dash-8) reported that the aircraft had sustained a deflated left outboard main tyre and was returning to the departure bay. Shortly after, the cabin crewmember advised the flight crew that the tyre appeared to be 'wet' and that some passengers had seen smoke coming from the wheel area. The flight crew stopped the aircraft on the taxiway and asked the airport rescue and fire-fighting services (RFFS) to check for signs of fire. After receiving the all-clear, the passengers were disembarked and the aircraft was towed to the operator's maintenance facility.