International

On 14 April 2011, a Christen Eagle aircraft collided with terrain about 60 km north-east of Bangkok, Thailand. Both persons on board, one of whom was Australian and held a Recreational Aviation Australia pilot certificate, were fatally injured.

As the accident took place in Thailand, the Aircraft Accident Investigation Committee (AAIC) of Thailand is responsible for its investigation. As part of its investigation, the AAIC requested assistance from the Australian Transport Safety Bureau (ATSB) to gather details of the Australian pilot's qualifications and experience. In accordance with clause 5.23 of Annex 13 to the Convention on International Civil Aviation (Annex 13), the ATSB appointed an accredited representative to assist the AAIC and initiated an investigation under the Australian Transport Safety Investigation Act 2003. The ATSB provided details of the pilot's qualifications and experience to the AAIC.

In accordance with Annex 13, the AAIC of Thailand is responsible for releasing the final investigation report on this occurrence.

Contact details for the AAIC are:

Acting Chief, Aircraft Accident Investigation Group
(Member & Secretary, the Aircraft Accident Investigation Committee of Thailand)
Flight Standards Bureau
Department of Civil Aviation
71, Soi Ngarmduplee, Rama IV Road
Sathorn, Bangkok, 10120, Thailand
Tel: +66 2286 2933, Fax: +66 2286 2925

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

The United States National Transportation Safety Board (NTSB) requested assistance from the Australian Transport Safety Bureau (ATSB) in investigating the circumstances of an accident involving a Mooney M20R, with Australian registration, that collided with terrain shortly after takeoff from Hollister Municipal Airport, Hollister, California on 25 November 2010. The Australian pilot, the sole occupant, was fatally injured and the aircraft destroyed.

The NTSB request sought assistance in obtaining details of the pilot's experience and training. In accordance with clause 5.23 of Annex 13 to the Convention on International Civil Aviation, the ATSB appointed an accredited representative to the NTSB investigation and initiated its own investigation under the Australian Transport Safety Investigation Act 2003. Details of the pilot's experience and training were provided to the NTSB.

The NTSB is responsible for releasing the final investigation report (docket WPR11FA059) and has advised that the NTSB investigation is complete, and that the investigation report will be released to the public in due course. When released, that report will be available via the NTSB website at www.ntsb.gov

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

What happened

On 15 February 2011, during a scheduled passenger service from Singapore to London, United Kingdom, the flight crew of an Airbus A380-842 aircraft, registered VH-OQC, observed a decrease in oil quantity on the number-4 engine. The aircraft was about 3 hours into the cruise near Delhi International Airport.

What happened

On 31 January 2011, a Boeing Company Aircraft 777-3ZGER, registered VH-VPH, was en-route from Phuket, Thailand to Melbourne, Victoria. When the aircraft was 170 NM north of Jakarta, Indonesia it encountered a period of sudden and unexpected turbulence. Six cabin crew members and four passengers received minor injuries.

At the time of the incident, the aircraft was established in the cruise and flying in cloud. The weather radar showed no significant weather in the immediate vicinity of the aircraft.

The flight continued to Melbourne where two cabin crew members consulted with paramedics, however no medical treatment was required.

The operator is considering including details of this occurrence in flight crew and cabin crew training to improve general crew awareness on the practical aspects of turbulence management and the importance of cabin discipline particularly relating to the handling of cabin equipment.

The operator is also considering changing a number of internal procedures to improve or standardise processes related to reporting injuries, providing support to crew in remote ports and assessing when crew are fit to return to duty.

Safety summary

What happened

On 9 May 2011, a Qantas Airways Limited Boeing 747-400 aircraft, registered VH-OJH, was enroute from Sydney, NSW to Singapore, when during climb from 36,000 ft to 38,000 ft, the crew noted abnormal indications from the No.4 engine. The indications included an increase in both the exhaust gas temperature and vibration levels. The flight crew reduced the engine’s thrust, however the vibration continued near maximum levels and the engine was subsequently shut down.

The aircraft continued to Singapore for a safe landing and disembarkation of the passengers and crew.

What the ATSB found

The increase in the exhaust gas temperature and vibration from the No.4 engine was a direct result of the failure and separation of a single intermediate-pressure turbine blade. The turbine blade had fractured following the initiation and growth of a fatigue crack from an origin area near the blade inner root platform. Detailed modelling and analysis was undertaken by the engine manufacturer following the occurrence, and while the root cause for the IP turbine blade failure was not fully identified at the time of this report, it was considered that the wear and loss of material from the turbine blade outer interlocking shrouds had reduced the rigidity and damping effects of the shroud and may have contributed to the high-cycle fatigue cracking and failure. The manufacturer has advised that they are continuing work to understand the underlying mechanism of the failure and will advise the ATSB if any further information is obtained.

What has been done as a result

The engine manufacturer issued non-modification service bulletin (NMSB) 72-G739 in October 2011, which instructed operators to perform a once-around-the-fleet inspection of IP turbine blades for missing shroud interlock material. Accomplishment of this task was recommended by June 2012, taking advantage of any earlier planned maintenance opportunities. The operator indicated that they had completed inspections across the fleet with no instances of excessive wear identified.

Safety message

Operators and maintainers of Rolls-Royce RB211-524 engines are alerted to the potential for wear and degradation of the intermediate-pressure turbine blade interlocking shrouds, with the possibility that this mechanism, if not detected and addressed, could lead to turbine blade cracking and loss. Service experience has shown, however, that the probability of an intermediate-pressure turbine blade failure (from any mechanism) is extremely low, with only three reported occurrences across the RB211-524 engine operating history. While blade separation will likely cause malfunctions necessitating an in-flight engine shut down, the associated risks to the safety of continued flight are minor, in the context that such failures are very likely to be contained (i.e. no liberated debris) and procedures for managing engine failures in transport-category aircraft are detailed and effective.

What happened

On 5 November 2010, a Boeing Company 747-438 aircraft, registered VH-OJD departed Changi Airport, Singapore on a scheduled flight to Sydney, New South Wales. When the aircraft was climbing through 2,000 ft, a loud bang was heard accompanied with aircraft yaw and vibration. The crew shut down the number one engine, declared a PAN and received approval from air traffic control for a return to Singapore. The crew then jettisoned fuel for about forty minutes. Emergency services were in attendance when the aircraft landed safely a short time later.

A subsequent examination confirmed that the engine had sustained serious damage as the result of a compressor blade release from the stage 1 high pressure compressor (HPC 1). The engine was replaced, and the aircraft returned to service.

The aircraft operator is continuing to bring their RB211-524G engines to the latest modification status at engine shop visits. However, should the rate of engine failures increase significantly a review of current modification policy will be undertaken.

The ATSB has completed its technical analysis of flight recorder data from several Indonesian aviation accident events that occurred between 2009 and 2011.

The National Transportation Safety Committee (NTSC) of Indonesia is responsible for investigating these occurrences. The NTSC requested technical assistance from the Australian Transport Safety Bureau (ATSB) in the determination of the appropriate data frame layouts for the flight data recorder (FDR) information recovered from the occurrence aircraft. 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 NTSC and initiated an investigation under the Australian Transport Safety Investigation Act 2003.

In cooperation with NTSC staff, suitable data frame layouts were determined for all recovered FDR data, and the information was provided in a report to the NTSC. The NTSC is responsible for releasing the final investigation reports on these occurrences.

National Transportation Safety Committee
Ministry Of Transportation Republic Of Indonesia
Transportation Building 3^rd Floor
Jalan Medan Merdeka Timur No. 5
Jakarta Pusat 10110
Indonesia

Phone  :  +62 21 384 7601
Email    :  knkt@dephub.go.id

Website: http://knkt.dephub.go.id/knkt/ntsc_home/ntsc.htm

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

On 11 May 2011, the Indonesian National Transport Safety Committee (NTSC) requested technical assistance from the Australian Transport Safety Bureau (ATSB), in the recovery of information from the flight data recorder (FDR) and cockpit voice recorder (CVR) of a XAC MA60 aircraft that impacted the sea on approach to Kaimana Airport, Papua Barat, Indonesia on 7 May 2011. The 21 passengers and 4 crew on-board the aircraft were fatally injured in the accident.

The NTSC 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 NTSC and initiated an investigation under the Australian Transport Safety Investigation Act 2003.

Download and analysis of the FDR and CVR was successful and both were found to contain good quality data including the entire accident flight. Support and information was provided to the NTSC during the course of the investigation and the ATSB's Technical Analysis Report was provided to the NTSC.

A final investigation report regarding this occurrence will be released by the NTSC.

The National Transport Safety Committee of Indonesia is responsible for releasing the investigation report.

National Transportation Safety Committee
Ministry Of Transportation Republic Of Indonesia
Transportation Building 3^rd Floor
Jalan Medan Merdeka Timur No. 5
Jakarta Pusat 10110
Indonesia

Phone  :  +62 21 384 7601
Email    :  knkt@dephub.go.id

Website: http://knkt.dephub.go.id/knkt/ntsc_home/ntsc.htm

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

The Australian Transport Safety Bureau (ATSB) has completed its download and replay of the cockpit voice recorder (CVR) from a Bombardier DHC-8-311 aircraft, registered ZK-NEQ. The work was conducted on behalf of the Transport Accident Investigation Commission (TAIC) of New Zealand, in support of their investigation into the failure of the aircraft's nose landing gear, and subsequent diversion to Woodbourne Aerodrome, New Zealand, on 09 February 2011.

The TAIC is responsible for investigating this occurrence and requested assistance from the ATSB to download and replay the CVR. To facilitate the ATSB's involvement, an accredited representative was appointed to the investigation, in accordance with clause 5.23 of Annex 13 to the Convention on International Civil Aviation.

To protect the CVR audio and other information supplied by the TAIC, the ATSB initiated an investigation under the Transport Safety Investigation Act 2003. The CVR was downloaded at the ATSB's technical facilities in Canberra and a copy of the recovered audio was provided to the TAIC on 16 February 2011. A download and replay of a CVR fitted to ZK-NEZ was also carried out at the ATSB on 16 Mar 2011 to assist the investigation.

The TAIC is responsible for releasing a final investigation report regarding this occurrence.

Contact details for the TAIC are available at www.taic.org.nz

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

Abstract

On 24 February 2011 and 3 November 2011 respectively, two different Airbus A380-842 (A380) aircraft were being operated by Qantas Airlines on scheduled passenger services from Singapore to London, United Kingdom.

About 8 hours into the flight on 24 February 2011, the flight crew detected a reduction in the indicated oil tank quantity for the No 3 engine. The crew reduced the thrust on the affected engine to idle and continued to the planned destination. Maintenance personnel found that one of the engine's external oil feed pipes was finger tight and had leaked. This was the fourth event involving similar in-flight oil loss from engines installed on the operator's fleet of A380 aircraft.

Examination and testing by the engine manufacturer found that the oil leaks were the result of a loss of clamping force on the oil feed pipe connection at the engine casing. Potential factors in the loss of clamping force were identified and were subject to ongoing engineering analysis. In the interim, the aircraft operator checked the engine oil feed pipes every five flight cycles, then every 20 cycles for evidence of oil leakage.

On 3 November 2011, a different aircraft was about 3 hours into the flight when the flight crew received a low oil quantity advisory for the No 4 engine. Forty minutes later, the crew received a low oil pressure warning from that engine. The crew shut down the engine and diverted the aircraft to Dubai, United Arab Emirates. Maintenance personnel found that one of the engine's oil feed pipes had leaked in the same location as the earlier A380 engine oil loss events.

By the time the November event occurred, there had been 15 engine oil leaks across the A380 fleet worldwide. The engine manufacturer conducted an ongoing investigation into the oil leaks and at the time of writing this report had identified high pipe deflection loads as a significant factor. Subsequent action by the engine manufacturer included modification of the oil pipe clipping arrangement and revised securing methods for the pipe connection and deflector assembly. In addition, trend monitoring of engine oil consumption was enhanced and work continued to develop a new oil pipe design.