International

The Air Accident Investigation Department (AAID) of the Ministry of Transport and Communication of the Republic of Kazakhstan is investigating a loss of separation that occurred in Kazakhstan airspace on 26 May 2012. One of the aircraft involved in the occurrence was an Australian-operated Boeing Company 747, registered VH-OJI, which was en route from Singapore to Frankfurt, Germany.

The investigation is being carried out in accordance the Republic of Kazakhstan’s obligations as the State of Occurrence under Annex 13 to the Convention on International Civil Aviation (Annex 13). On 18 June 2012, the AAID requested Australian Transport Safety Bureau (ATSB) assistance with obtaining relevant technical and operational information from the aircraft operator. In accordance with paragraph 5.23 of Annex 13, the ATSB appointed an Accredited Representative to assist the AAID. To facilitate this support, the ATSB commenced an investigation under the Transport Safety Investigation Act 2003. The ATSB obtained aircraft and flight crew details from the aircraft operator and forwarded them to the AAID.

The AAID is responsible for releasing the final investigation report into this occurrence. Any enquiries in respect of the AAID investigation and report should, in the first instance, be directed to the:

Air Accident Investigation Department
Ministry of Transport and Communication
47, Kabanbai batyr Avenue
010000 Astana
Republic of Kazakhstan

Telephone: +7 7172-242605
Fax: +7 7172-243165

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

On 7 January 2012, while operating in the vicinity of Carterton, New Zealand, a Cameron Balloons A-210 hot-air balloon, registered ZK-XXF, contacted power lines and caught fire before colliding with terrain.  The 11 occupants were fatally injured.

The Transport Accident Investigation Commission (TAIC) of New Zealand is responsible for the investigation of this occurrence.  On 14 March 2012, the TAIC formally requested the assistance of the Australian Transport Safety Bureau (ATSB) in the recovery of data from a damaged GPS receiver found at the accident site.

The ATSB successfully recovered the accident data from the GPS receiver. This data and a technical report have been sent to the TAIC of New Zealand to assist its ongoing investigation. The TAIC is responsible for releasing a final investigation report regarding this occurrence.

• TAIC website: www.taic.org.nz

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

On 29 August 2011, the Papua New Guinea Accident Investigation Commission (AIC) requested technical assistance from the Australian Transport Safety Bureau (ATSB), in the recovery of information from the global positioning system (GPS) and several engine and flight instruments from a MBB BO-105 aircraft that impacted terrain 5 km south of Timini, Morobe Provence, Papua New Guinea, on 8 August 2011. The pilot and two passengers on-board the aircraft were fatally injured in the accident.
 
The AIC is responsible for investigating this occurrence. In accordance with clause 5.23 of Annex 13 to the Convention on International Civil Aviation, the ATSB appointed an accredited representative to assist the AIC and initiated an investigation under the Australian Transport Safety Investigation Act 2003.
 
Examination of the GPS was commenced with the intent of downloading the GPS data, however the data was unrecoverable due to the absence of the memory device (chip) containing the GPS data for the accident flight. The flight and engine instruments were examined for evidence of indicating pointer contact marks on the instrument face. Support and information was provided to the AIC during the course of the investigation and the ATSB's Technical Analysis Reports were provided to the AIC.
 
The AIC of Papua New Guinea is responsible for releasing the final investigation report on this occurrence.
 
Contact details for the PNG AIC are:

Mr David Inau
Chief Executive Officer
Papua New Guinea Accident Investigation Commission
Telephone: +675 311 2406

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

At about 0615 on 2 February 2012, the 42.7 m passenger ferry Rabaul Queen capsized and sank about 9 nautical miles off the Papua New Guinea (PNG) town of Finschhafen. Two hundred and forty six people were rescued during a search and rescue operation that was coordinated by the PNG Maritime Rescue Coordination Centre and the Australian Rescue Coordination Centre. However, at least 142 people are thought to have died as a result of the sinking.

On 16 February, following a request from the PNG Government, four officials from the Australian Transport Safety Bureau (ATSB) travelled to the PNG capital Port Moresby to offer initial advice to local authorities in safety aspects of the investigation into the sinking.

From that time until 28 June 2012, two ATSB transport safety investigators provided assistance to the PNG Government's Commission of Inquiry into the sinking of Rabaul Queen in accordance with Section 12AA (2)(a)(iii) of the Transport Safety Investigation Act 2003. This part of the ATSB’s governing legislation provides for cooperation with authorities in other countries in the interest of transport safety.

The Commission of Inquiry’s final report was presented to the Prime Minister of PNG on 28 June 2012 and it was subsequently tabled in parliament on 5 September 2012. Information, including the Commission of Inquiry's terms of reference, hearing transcripts and final report can be found at: http://www.coi.gov.pg/rabaulqueen.html

Safety summary

What happened

On 8 October 2011, the flight crew of an Airbus A380-800, registered VH-OQE, was preparing for departure from Los Angeles International Airport, United States of America.

Prior to take-off, the captain changed the departure runway that was entered in the aircraft's flight management system. The procedure for completing that task was not followed exactly, resulting in the take-off speeds not being displayed on the flight instruments.

During the take-off roll, the flight crew, becoming aware that the take-off speeds were not displayed, called out the speeds from their notes instead and proceeded with the take-off.

What the ATSB found

The ATSB found that the captain was distracted from initially updating the runway change in the aircraft's navigation systems prior to the aircraft taxiing for the runway. Twice prior to take-off the aircraft's systems displayed a message to check take-off data. The first officer cleared the first message on the understanding that the take-off data would be checked and in the second instance, believing that it had been checked. There were no other warnings in place to alert the crew that they were commencing the take-off without the take-off speeds in the aircraft's navigation systems.

What has been done as a result

Qantas has advised that the aircraft manufacturer has updated the aircraft's warning systems as part of a planned upgrade program. This upgrade will issue a warning if take-off is commenced without the take-off speeds having been entered into the aircraft's systems. They also advised that their standard operating procedures have been updated to avoid any misinterpretation regarding the required actions in the case of a runway change.

Safety message

This incident highlights the problem of distraction during critical stages of flight preparation. It also highlights the importance of good flight crew communication to ensure a shared understanding of the aircraft's systems status.

This investigation report was originally released in August 2012. This revision contains an update based on additional information from the outcomes of the engine manufacturer’s internal investigation into the occurrence.

What happened

On 16 October 2011, at about 1033 Coordinated Universal Time (UTC), a Boeing 747-438 aircraft, registered VH-OJS, operated by Qantas Airways, departed Suvarnabhumi Airport, Bangkok, Thailand on a scheduled passenger flight to Sydney, Australia.
About 8 minutes into the flight, as the aircraft was climbing through 13,000 ft, the crew reported hearing a loud bang and experiencing vibrations and abnormal indications from the No. 3 engine. Fumes were also reported in the cabin for several minutes after the event.

The flight crew shutdown the engine and broadcast a ‘PAN’ before jettisoning approximately 55 tonnes of fuel and returning to Bangkok where the aircraft landed safely at 1147 UTC. The engine failure was fully contained and there were no reported injuries to passengers or crew.

Aviation Short Investigation Bulletin - Issue 23

The Papua New Guinea Accident Investigation Commission (PNG AIC) is investigating a double propeller overspeed and impact with terrain, followed by a fire that occurred 33 km south-east of Madang, Madang Province, Papua New Guinea on 13 October 2011. The accident involved a Bombardier DHC-8-108 aircraft, registration P2-MCJ, with two pilots, a flight attendant, and 29 passengers on board. Twenty-eight passengers sustained fatal injuries during the accident sequence, one passenger survived with serious burns and all three crew survived.

The investigation is being carried out in accordance with Papua New Guinea's obligations as the State of Occurrence under Annex 13 to the Convention on International Civil Aviation Aircraft Accident and Incident Investigation (Annex 13). Shortly after the accident, the PNG AIC requested Australian Transport Safety Bureau (ATSB) assistance in the conduct of the investigation by providing investigator support, technical advice and facilities support.

In accordance with paragraph 5.23 of Annex 13, the ATSB appointed an accredited representative and a number of advisers to assist the PNG AIC. To facilitate this support, the ATSB commenced an external investigation under the Transport Safety Investigation Act 2003 and assisted the AIC during the on‑site phase of the investigation, in the technical examination of a number of recovered aircraft items and components, with the download and analysis of the aircraft’s flight data and cockpit voice recorders and as requested by the AIC during the remainder of its investigation.

The PNG AIC is responsible for and will administer the release of the final investigation report into this accident. Any enquiries in respect of the ongoing AIC investigation should, in the first instance, be directed to:

Mr David Inau
CEO, PNG Accident Investigation Commission

Telephone: +675 323 2911 and 323 2151
Facsimile: +675 323 2139

Email: dinau@aic.gov.pg

Address:
Accident Investigation Commission
C/- PO Box 1489
Port Moresby
National Capital District
Papua New Guinea

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

Safety summary

What happened

On 26 August 2011, the pilot of an MD Helicopter Inc. 369D helicopter, registered YJ‑HEL, was conducting sling load operations near a small village 183 km north‑north‑west of Port Vila, Vanuatu. As the helicopter approached the village, with two passengers onboard, witnesses heard a single, loud bang and watched the helicopter fall 10 to 15 m to the ground before coming to rest on its right side. One of the passengers received minor injuries and was able to exit the helicopter unaided. The other passenger received serious injuries, and the pilot was fatally injured.

What the ATSB found

The ATSB found that as the helicopter approached the village to land, the wire rope attached to the helicopter’s cargo hook contacted a tree. That contact resulted in the rope fouling on the main rotor blades, which in turn led to the detachment of segments of the rotor blades and the tail boom. This rendered the helicopter uncontrollable. It was also found that the occupants of the helicopter were not wearing the installed shoulder harness restraints or using flight helmets during the flight.

What has been done as a result

This investigation was conducted by the ATSB at the request of the Civil Aviation Authority of Vanuatu and no organisational or systemic issues that might adversely affect the future of aviation operations in Vanuatu were identified.

Safety message

The circumstances of this accident serve as a reminder that the severity of contact injuries in survivable helicopter accidents can be significantly reduced by the use of shoulder harnesses and protective flight helmets. As such, pilots and operators should consider the use of such equipment in the interest of enhancing survivability should an accident occur.

The ATSB has completed its examination and analysis of the damaged tailrotor blade from the helicopter that went missing near Manus Island, Papua New Guinea on 13 February 2011.

On 13 February 2011, a Eurocopter AS350 helicopter, registered P2-PHL, was reported missing during operations over the Bismarck Sea, near Manus Island, Papua New Guinea. The pilot, who was the sole occupant of the helicopter, is also missing. A small amount of wreckage from the helicopter, including the damaged tailrotor blade, was recovered from the sea during search operations.

The Accident Investigation Commission (AIC) of Papua New Guinea is responsible for investigating this occurrence. As part of its investigation, the AIC requested assistance from the Australian Transport Safety Bureau (ATSB) in the examination and analysis of the damaged tailrotor blade. In accordance with clause 5.23 of Annex 13 to the Convention on International Civil Aviation, the ATSB appointed an accredited representative to assist the AIC and initiated an investigation under the Australian Transport Safety Investigation Act 2003. The ATSB provided a technical report to the AIC on the results of its examination of the tailrotor blade.

The AIC of Papua New Guinea is responsible for releasing the final investigation report on this occurrence.

Contact details for the PNG AIC are:

Mr David Inau
Chief Executive Officer
Papua New Guinea Accident Investigation Commission
Telephone: +675 311 2406 

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

On 14 January 2010, a Royal New Zealand Air Force (RNZAF) Red Checkers aerobatics team CT-4 Airtrainer aircraft collided with terrain while practicing for an upcoming aerobatics display. The pilot was fatally injured in the accident and the aircraft was destroyed by a post-impact fire.

An Appareo Systems GAU1000 data recorder was fitted to the aircraft to gather performance data as part of a fatigue monitoring programme. Although the recorder was severely fire damaged, it was recovered from the aircraft wreckage by RNZAF investigators, who subsequently requested assistance from the Australian Transport Safety Bureau (ATSB) in the recovery of any stored data on the recorder that may have survived the accident and fire.

Following preparatory research into the nature of the recorder's design and operation and the subsequent non-destructive examination to evaluate the physical condition of the damaged unit, a number of attempts were made to recover data from the removable secure digital/multimedia memory card (SD/MMC) - all of which were unsuccessful. Further examination of the recorder, however, located an on-board NAND flash memory device, which subsequently yielded a large quantity of valid recorded data after its removal from the primary circuitry and interrogation in a universal reader/programmer unit. The data was provided to the RNZAF on 12 August 2010.

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