International

Abstract

On 2 February 2011, the boatswain (bosun) on board the Panamanian registered bulk carrier Hanjin Sydney died as a result of injuries he received after falling about 25 m from the hatch coaming of the ship's number eight cargo hold to the tank top below.

The bosun had climbed onto the top of the hatch coaming to free a cargo runner that had jammed in the head of a davit the crew were using to lift iron ore residue from the hold. He lost his balance while pulling on the wire to free it and fell into the empty cargo hold.

The ATSB investigation found that the crew had previous experience with the cargo runner jamming in the head of the davit. However, nothing had been done to prevent it from happening again.

As a result of the accident, Hanjin Ship Management have instigated the requirement for the ship's safety officer to be more proactive in toolbox meetings and safety 'walk arounds' to ensure that he is aware of issues which may not be automatically brought to his attention.

The ATSB is satisfied that this safety action adequately addresses the report's identified safety issue.

The pilot was familiar with the destination aerodrome, having landed there on several previous occasions. On arrival, rain showers were in the area and the pilot held until the showers had cleared. After an apparently normal approach, the aircraft floated beyond the target touchdown point. The short grass surface was firm but wet, and the pilot was unable to stop the aircraft in the remaining strip length.

Circumstances:

The aircraft was engaged on a scheduled international passenger flight. Between Narita and Guam, the aircraft weather radar was used to avoid unforecast, isolated cumulonimbus cloud formations. Approaching Guam, the flight conditions were smooth with the aircraft flying through cirrus cloud. The Captain and Second Officer, who were on duty on the flight deck, were monitoring the weather radar. A heading change to the right of track was required to avoid weather activity observed by radar over the island. Whilst regaining track, the aircraft encountered an area of severe turbulence lasting for approximately 30 seconds and resulting in vertical accelerations of +1.8G and -0.4G. Forty passengers and two cabin attendants were injured. At the time of the encounter the seat belt signs were off and most of the injured passengers were asleep with their seat belts undone. The Captain illuminated the seat belt sign immediately the turbulence was noticed. The injured were treated by the cabin crew and a passenger who was a qualified medical practitioner. The Captain was advised that none of the injured required immediate specialised treatment and, as the aircraft did not sustain any significant damage, he decided to continue the flight to Sydney. The airline company was notified, and the aircraft was met by medical staff on arrival. Twenty-eight passengers and cabin crew were conveyed to hospital for further treatment. It was determined the aircraft had encountered an area of turbulence associated with cumulonimbus cloud which was not detected by the aircraft weather radar. Although the seat belt signs were not illuminated, passengers were advised during an after-take-off announcement, to keep their seat belts fastened when seated. These announcements were made in English and Japanese languages.

Significant Factors:

The following factors were considered relevant to the development of the accident

1. The aircraft encountered an area of turbulence undetected by the aircraft weather radar.

2. The seat belt sign was not illuminated.

3. Many passengers who were sleeping, did not have their seat belts fastened.

4. The cumulonimbus cloud formations in the vicinity of Guam were not forecast.

After take off from Porgera the aircraft proceeded West towards a gap which required 9500 feet for passage. The pilot noticed that the aircraft was not able to outclimb the rising terrain. He turned left, however, for undetermined reasons the helicopter descended. A right pedal turn was made through 180 degrees and although then tracking down the mountainside, the pilot realised he would not clear the terrain ahead. He carried out a forced landing amongst trees in steep, rough terrain. The helicopter may not have had sufficient performance to complete the attempted operation. The ambient conditions, particularly temperature, could not be determined.

The pilot was conducting a pleasure flight from Australia to the Solomon Islands via various aerodromes in Papua New Guinea. He reported that shortly after take-off the engine lost power and he was forced to ditch the aircraft, which subsequently sank in 100 metres of water. Investigation of this accident is the responsibility of the PNG authorities. The investigation indicated that the take-off attempt had been made with the aircraft loaded in excess of the maximum recommended for the length of strip available.

Circumstances:

Whilst cruising at 2000 feet the propeller separated from the engine, damaging the upper starboard wing leading edge. During the ensuing forced landing further damage was sustained to the landing gear and elevator. Investigation revealed the crankshaft had suffered a fatigue failure, causing the propeller to separate from the engine. The pilot reported the crankshaft had been in service for 150 hours and that all recommended modifications had been incorporated.

On arrival at a sloping helipad, the pilot overflew the pad to ascertain that it was clear, and made a final approach to the pad. During the landing two of the main rotor blades struck the surface of the slope. The investigation was carried out by the Department of Civil Aviation Malaysia.

Safety summary

What happened

On 4 November 2010, while climbing through 7,000 ft after departing from Changi Airport, Singapore, the Airbus A380 registered VH-OQA, sustained an uncontained engine rotor failure (UERF) of the No. 2 engine, a Rolls-Royce Trent 900. Debris from the UERF impacted the aircraft, resulting in significant structural and systems damage.

The flight crew managed the situation and, after completing the required actions for the multitude of system failures, safely returned to and landed at Changi Airport.

What the ATSB found

The Australian Transport Safety Bureau (ATSB) found that a number of oil feed stub pipes within the High Pressure / Intermediate pressure (HP/IP) hub assembly were manufactured with thin wall sections that did not conform to the design specifications. These non-conforming pipes were fitted to Trent 900 engines, including the No. 2 engine on VH-OQA. The thin wall section significantly reduced the life of the oil feed stub pipe on the No. 2 engine so that a fatigue crack developed, ultimately releasing oil during the flight that resulted in an internal oil fire. That fire led to the separation of the intermediate pressure turbine disc from the drive shaft. The disc accelerated and burst with sufficient force that the engine structure could not contain it, releasing high-energy debris.

What has been done to fix it

Following the UERF, the ATSB, Rolls-Royce plc, regulatory authorities and operators of A380 aircraft with Trent 900 engines took a range of steps to ensure that HP/IP hub assemblies with non-conforming oil feed stub pipes were identified and either removed from service, or managed to ensure their safe continued operation. Rolls-Royce also released an engine control software update that included an IP turbine overspeed protection system (IPTOS) that is designed to shut the engine down before the turbine disc can overspeed, in the unlikely event that a similar failure occurs.

Rolls-Royce has also made a range of changes to their quality management system to improve the way in which they manage non-conforming parts, both during the manufacturing process and when it has been identified that parts had unknowingly been released into service with non-conformances.

Safety message

The ATSB identified a number of issues during the manufacture of Trent 900 HP/IP hub assemblies that resulted in their release into service with non-conforming oil feed stub pipes. Those issues highlighted the importance of providing clear procedures during the manufacturing process and of personnel complying with those procedures. Even though modern civil turbine engines are very reliable, and UERFs are very rare events, the resulting damage from such a failure can be significant and the potential effects catastrophic. This accident represents an opportunity for the regulatory authorities to incorporate any lessons learned into their certification advisory material to enhance the safety of future aircraft designs.

What happened

On 1 November 2010, an Airbus A330-302, registered VH-EBF (EBF), departed Phuket, Thailand on a scheduled passenger flight to Sydney, New South Wales.

When the aircraft was approaching overhead Kuala Lumpur International Airport, Malaysia, in icing conditions, the aircraft systems indicated a loss of total air temperature (TAT) data. This resulted in the loss of autopilot and autothrottle capabilities. The crew attempted to resolve the fault but were unable to restore the auto-flight capabilities.

The crew conferred with company operational and maintenance personnel and elected to divert to Singapore. The aircraft landed in Singapore without further incident.

Analysis of the data from the flight data recorder indicated that both TAT probes failed during the incident flight, triggering the loss of autoflight capabilities. The manufacturer suspected that the TAT probes failed due to icing.

A new TAT probe was certified for the A330 aircraft and issued through an optional Service Bulletin in 2008. As of November 2010, there had been no reported events of multiple failures involving the new TAT probes. At the time of the incident, EBF was not fitted with one of the new TAT probes.

The Australian Transport Safety Bureau (ATSB) has completed its download and replay of the cockpit voice recorder (CVR) from a Bombardier DHC-8-300 aircraft, registered ZK-NEB. The work was conducted on behalf of the Transport Accident Investigation Commission (TAIC) of New Zealand, in support of their investigation into the collapse of the aircraft's nose landing gear during landing at Blenheim Aerodrome, New Zealand, on 30 September 2010.

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 to the ATSB, 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 7 October 2010.

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.