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Whilst in cruise at FL310 the cabin altitude commenced to rise. A check of the Engine Indication and Crew Alerting System (EICAS) showed the cabin was rising at 500ft/min, and all air-conditioning packs were off. The check list was actioned, but no packs were able to be reset. The system fault light remained on. At about 8000 feet cabin altitude, which was still climbing at 500ft/min with no packs on, the aircraft was descended to the lowest safe altitude and a diversion to Karachi initiated. A PAN call was made, and Tehran and Karachi were informed.

The Pack Temperature Controllers (PTC) were removed and inspected by the manufacturer who subsequently reported that a capacitor failure on the printed circuit board of the PTC in position 'A' caused all three pack flow control valves to close. The 'B' position PTC took control of the packs, as designed, but could not override the flow control valve closure commands from PTC 'A'. The manufacturer has instituted a modification program to the PTC to eliminate the problem.

The aircraft was being ferried to the Philippines. An intermediate stop was made at Palau, where it remained idle for about a month. The pilot reported that prior to take-off from Palau he had refuelled the aircraft from drum stock and that subsequent water drain checks were clear. Pre-take-off checks were normal but during take-off, as the aircraft was rotated at about 90 kts, the right engine lost power. The pilot said he feathered the propeller, and retracted the flaps and landing gear, but the aircraft failed to achieve single engine climb speed. Because the left engine oil temperature was at the red line the pilot elected to carry out a wheels up forced landing onto a sandbar on an adjacent island.

Photographs of the damaged aircraft indicated the right propeller blades were not in the feathered position. The propeller did not appear to have been rotating at impact. The reason for the loss of power was not determined.

On 17 July 2014 a Malaysia Airlines Boeing 777-200, registered 9M-MRD and operating as flight MH17, en route from Amsterdam in the Netherlands to Kuala Lumpur, Malaysia, disappeared from air traffic services radar overhead the Ukraine. Aircraft wreckage was subsequently identified over a large area to the south and west of the village of Hrabove, eastern Ukraine. There were no survivors.

Responsibility for the conduct of the investigation into that accident was delegated to the Dutch Safety Board (DSB) by the Ukrainian Government on 23 July 2014.

Subsequently, in July 2014 the DSB commenced a separate investigation into the operation of flight MH17 through eastern Ukrainian airspace. This second investigation was titled Decision-making regarding safety of flight routes.

Together with the investigation agencies of a number of other countries, on 18 September 2014 the ATSB received a request from the DSB for assistance in the conduct of its safety of flight routes investigation. The DSB request sought to provide a global context to its own investigation findings. The ATSB agreed to the DSB request and, in order to protect the information gathered as part of this process, initiated an external investigation under the Transport Safety Investigation Act 2003 on 7 October 2014.

The report on the ATSB’s investigation of the safety of flight-route decision-making in the Australian context was provided to the DSB on 21 November 2014 for inclusion in their final safety of flight routes investigation report. It is understood that this report is to be published early in the final quarter of 2015.

The DSB is responsible for, and will administer the release of the final investigation report. Any enquiries regarding the DSB investigation should, in the first instance, be directed to:

Dutch Safety Board
PO Box 95404 25 09 CK
The Hague

Tel: +31 70 333 70 00

General enquiries email: info@onderzoeksraad.nl

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

On 20 September 2014, a de Havilland Canada DHC-6-300 aircraft, registered P2-KSF, collided with terrain 12 km north-east of Jacksons International Airport, Port Moresby, Papua New Guinea. Four of the 9 occupants were fatally injured.

An investigation into the circumstances of the accident was conducted by the PNG Accident Investigation Commission (AIC). The AIC requested assistance from the Australian Transport Safety Bureau (ATSB) with the download and analysis of information from various components including a cockpit voice recorder (CVR), forward-looking cockpit video camera and an enhanced ground proximity warning system (EGPWS) computer. To facilitate this support and to provide the appropriate protections for the CVR information, the ATSB appointed an accredited representative in accordance with paragraph 5.23 of ICAO Annex 13 and commenced an investigation under the Australian Transport Safety Investigation Act 2003.

The PNG AIC published its final investigation report (AIC 14-1005) on 3 August 2015.

The report is available from the AIC website: www.aic.gov.pg.

On 17 July 2014 a Malaysia Airlines Boeing 777-200, registered 9M-MRD, en route from Amsterdam in the Netherlands to Kuala Lumpur, Malaysia, disappeared from air traffic services radar overhead the Ukraine. Aircraft wreckage was subsequently identified over a large area to the south and west of the village of Hrabove, eastern Ukraine. There were no survivors.

As the occurrence took place in the Ukraine, the National Bureau of Air Accident Investigation of Ukraine (NBAAI) commenced an accident investigation under Annex 13 to the Convention on International Civil Aviation Aircraft Accident and Incident Investigation (Annex 13) on 17 July 2014. As part of its investigation, the NBAAI requested assistance from the Australian Transport Safety Bureau (ATSB) and under clause 5.23 of Annex 13, the ATSB appointed an accredited representative and an adviser to the NBAAI investigation on 20 July 2014. In addition, an external investigation was initiated under the provisions of the Australian Transport Safety Investigation Act 2003.

The ATSB investigators departed for Kiev, Ukraine on 21 July 2014 to participate in the NBAAI accident investigation. Subsequently, on 23 July 2014, the Ukrainian Government delegated the conduct of the investigation to the Dutch Safety Board (DSB) under clause 5.1 of Annex 13. The ATSB investigators remained in Kiev to assist the Dutch investigation before relocating with the investigation team to the DSB headquarters in the Netherlands on 1 August 2014. The ATSB investigators returned to Australia on 8 August 2014.

During the investigation the ATSB and other accredited representatives contributed to the development of the DSB’s preliminary investigation report, which was released to the public on 9 September 2014. In addition, the ATSB representative attended two investigation progress meetings in The Netherlands. The second of these meetings included an examination of the reconstruction of the aircraft from recovered wreckage, items and components.

Subsequently, and consistent with Annex 13 standards and recommended practices, the ATSB and other accredited representatives received a copy of the draft investigation report for comment. The DSB considered these and comments from other relevant parties to the investigation before finalising their report.

The DSB has completed its investigation and report and, in accordance with the provisions of Annex 13, a final investigation report was published 13 October 2015. This report, together with information on the investigation, is available from the DSB’s website at www.onderzoeksraad.nl/en.

Any enquiries with respect to the DSB investigation should, in the first instance, be directed to:

Dutch Safety Board

PO Box 95404
2509 CK The Hague
The Netherlands

Telephone: +31 70 333 70 00 

On 4 October 2011, the container ship Rena departed Napier, New Zealand, bound for Tauranga, New Zealand, with an estimated arrival time of 0300 on 5 October. At about 0214 on 5 October, Rena grounded on Astrolabe Reef.

The Transport Accident Commission (TAIC) of New Zealand is undertaking a formal investigation into this accident. As part of that work, TAIC requested the assistance of human factors specialists at the Australian Transport Safety Bureau (ATSB), to assess the likelihood and extent of any performance impairment to the master and second mate due to fatigue. To protect the information supplied by TAIC, the ATSB initiated an investigation under the provisions of the Transport Safety Investigation Act (2003).

Following the analysis of the sleep and work data supplied by the TAIC, the ATSB conducted analysis of the fatigue likelihood and produced a report which was provided to TAIC on 26 August 2014. For further information on this occurrence and investigation, please contact the Transport Accident Investigation Commission of New Zealand.

On 23 May 2014, a Qantas Airbus A380 aircraft, registered VH-OQK, was operating a scheduled passenger service from Los Angeles, USA to Melbourne, Australia.  While overflying Hawaii, USA, the battery within a passenger’s personal air purifier (worn around their neck on a lanyard) began to overheat and produce smoke. The crew followed documented emergency procedures and immersed the device in water; effectively dissipating the heat from the battery and suppressing any further smoke evolution. The passenger received minor superficial burns which did not require first aid treatment.

A preliminary investigation conducted by the ATSB identified that the device contained a small non-rechargeable lithium battery; the size of which conformed with the limitations specified for carry-on items. The Bureau also found that the crew acted in an appropriate manner to manage the overheating battery and control the associated risks.

Given that the ATSB’s records show that this type of battery failure is quite uncommon and both the crew’s actions and documented procedures were effective in managing the small risks involved, there would be limited safety benefit in investigating the matter further, and as such, the ATSB investigation has been discontinued.

The ATSB continues to monitor and record incidents involving lithium batteries and reminds passengers to consult the dangerous goods brochure published by the Civil Aviation Safety Authority when bringing devices containing lithium batteries aboard aircraft.

What happened

On 2 July 2014, a Qantas Airbus A380 aircraft, registered VH-OQD, departed Los Angeles, USA, for Melbourne, Victoria. During the climb, the captain switched off the seatbelt sign. A few minutes later, a cabin attendant entered the business class galley and, as she switched the hot water on, observed water leaking out from under the meal carts. A cabin supervisor then pulled the carts forward to access and switch off the water shut off valve, but that did not stem the flow of water.

A second officer went into the cabin to determine how much water had leaked and confirmed that the valve was switched off. The flight crew contacted maintenance watch ground staff. They advised the crew that there was a main switch to the potable water on the flight attendants’ panel and the cabin crew located the switch and selected it to ‘OFF’, which then stopped the water flow.

As a precaution, the cabin crew switched off the in-flight entertainment system and the power to all controls in the seats. With the potable water supply switched off, there was no water available for the toilets or basins for the duration of the flight. The crew elected to return to Los Angeles.

Initial engineering inspection found that the coupling that joins the water pipe at the floor level where the water supply enters the galley was unlatched. There was evidence that the rope-style mops used by cleaners may have contributed to the coupling coming undone. A fleet wide inspection of the aircraft was carried out and temporary preventative action taken on all similar galley installations.

This incident provides an excellent example of effective crew resource management techniques.

Aviation Short Investigation Bulletin - Issue 35

On 9 June 2013, an Australian-registered Cessna 206 aircraft, registration VH-JIA, was extensively damaged in an accident while attempting to land on a beach strip near Bukaua River, Papua New Guinea. The pilot reported that during the landing roll, the nose landing gear fork had failed, allowing the aircraft to dig into the soft sand and flip over.

The Accident Investigation Commission (AIC) of Papua New Guinea was responsible for investigating this accident. As part of its investigation, the AIC requested technical assistance from the Australian Transport Safety Bureau (ATSB), in the metallurgical examination of the failed landing nose fork and the download and analysis of the pilot's navigational GPS unit that was recovered from the accident site. To provide the necessary protections for the GPS information and the findings of the landing gear analysis, the ATSB appointed an Accredited Representative to the investigation in accordance with clause 5.23 of Annex 13 to the Convention on International Civil Aviation (ICAO Annex 13), and initiated an investigation under the Australian Transport Safety Investigation Act 2003.

Landing gear analysis

The characteristics of the nose landing gear fork failure revealed during the ATSB laboratory examination were consistent with fracture occurring from a pre-existing manufacturing condition that predisposed the fork to brittle fracture along the forging seam (parting) lines during conditions of elevated lateral stress (such as sustained during beach or other soft-surface landings). The fracture surfaces showed no evidence of fatigue cracking, stress-corrosion cracking or other progressive failure mechanisms.
Cracking and failure of Cessna nose forks has been an isolated but recurrent problem for Cessna 100- and 200-series aircraft, and a supplemental inspection ('32-20-01 Nose Landing Gear Inspection') has been promulgated by the manufacturer to address the issue. In light of the history of related failures contained on the Australian record, the Australian Civil Aviation Safety Authority (CASA) is considering a review of their existing Airworthiness Bulletin, AWB 32-016 Cessna Single Engine Nose Landing Gear Forks, with respect to this issue.

GPS download

Following recovery and preliminary examination of the GPS track data, it was evident that the most recent information stored on the device was recorded approximately twelve months prior to the accident. As such, the ATSB concluded that the unit had not been in use during or immediately prior to the accident flight, or the track recording functionality had been switched off.

Provision of information to the AIC:

The findings of the ATSB's examination of the nose landing gear and GPS examination were provided to the PNG-AIC on 7 January 2014, and the components were subsequently returned to the AIC investigator in-charge. The AIC is responsible for releasing a final investigation report into this occurrence.

• Contact details for Accident Investigation Commission (AIC) of Papua New Guinea

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

On 13 December 2013, a Hughes 500D helicopter, registration ZK-HNA, was flying from Rat Point on Lake Wakatipu, 16 km South West of Queenstown, New Zealand, to Dumpling Hut on the Milford Sound walking track. When the helicopter did not arrive at its
destination, the alarm was raised, and after a short search, the wreckage of the helicopter was found near the top of the Glade Burn Valley. The pilot, who was the sole occupant of the helicopter, had been fatally injured.

The Civil Aviation Authority of New Zealand (CAANZ) is undertaking a formal investigation into this accident. As part of that work, the CAANZ requested technical assistance from the Australian Transport Safety Bureau (ATSB), in the recovery of data from a damaged
navigational GPS unit recovered from the accident site. To protect the information supplied by the CAANZ, and any data recovered from the GPS unit, the ATSB initiated an investigation under the provisions of the Transport Safety Investigation Act 2003.

Following examination and disassembly, it was evident that the GPS unit had sustained circuitry damage sufficient to prevent its download by conventional means. Subsequently, the discrete device (chip) containing the track memory was identified, removed, and a raw data file downloaded using specialised techniques. Decoding of the raw information showed that the entire track memory had been recovered, including the accident flight and several previous flights. The data and a report detailing the download procedure was provided to the CAANZ on 26 June 2014 for use in their investigation.

For further information on this occurrence and investigation, please contact the Civil Aviation Authority of New Zealand.

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