International

Abstract

At about 0935 Papua New Guinea local time on 26 September 2010, a Cessna Company T210L aircraft, registered VH-LMT, was being operated on a private, visual flight rules, flight from Tufi to Gurney, Papua New Guinea with the pilot and four passengers on board. When the aircraft was about 46 km north-east of Gurney, the engine lost power and the pilot conducted a ditching into shallow water adjacent to a beach. The aircraft was reported to have sustained minor damage and none of the occupants were injured.

The Papua New Guinea Accident Investigation Commission delegated the conduct of the investigation to the Australian Transport Safety Bureau (ATSB) in accordance with International Civil Aviation Organization Annex 13 paragraph 5.1.

The ATSB did not conduct an on-site investigation into the occurrence and the aircraft was not salvaged due to the remote location and limited access to salvage resources. As a result, the evidence available was limited and precluded determination of the factor(s) related to the power loss.

The Papua New Guinea Accident investigation Commission (PNG AIC) is investigating a runway excursion that occurred at Bwagaoia Aerodrome, Misima Island, Milne Bay Province, Papua New Guinea on 31 August 2010. The accident involved a Cessna Aircraft Company Citation 550, registration P2-TAA, with two pilots and three passengers on board. The aircraft landed at Misima Island and, when it became evident that the aircraft would not stop on the remaining runway, the pilot attempted a takeoff. The aircraft did not obtain flying speed before the end of the runway and was substantially damaged when it collided with trees shortly after. Four occupants sustained fatal injuries during the accident sequence and one occupant sustained serious injuries.

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. Shortly after the accident, the 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 AIC. To facilitate this support, the ATSB commenced an 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, 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, Accident Investigation Commission
Telephone: +675 311 2406
Facsimile: +675 342 7727
E-mail: 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.

Abstract

On 30 August 2010 at approximately 2330 Pacific Daylight Time, a Qantas Boeing 747-438 aircraft, registered VH-OJP, departed San Francisco International Airport on a scheduled passenger service to Sydney, Australia. As the aircraft passed through 25,000 ft, the aircraft's number 4 engine failed, resulting in the puncturing of the engine casing and nacelle and the release of debris. The engine was shut down and the flight crew returned the aircraft to San Francisco International Airport. There were no injuries.

An investigation conducted by the engine manufacturer found that the engine failure was initiated by the fatigue fracture of a single stage-2 low pressure (LP) turbine blade. The ensuing rotor imbalance caused the LP turbine bearing to fail, which ultimately resulted in the uncontained release of debris.

As a result of this occurrence, the engine manufacturer released non-modification service bulletins NMSB72-AG729 and NMSB72-AG800, instructing operators of RB211-524 engine variants to fit a more robust LP turbine bearing, so as to reduce the likelihood of catastrophic engine failure resulting from rotor imbalance.

Abstract

At about 0830 on 8 July 2010, a crew member on board the multipurpose ship Cape Darnley was fatally injured following an explosion that occurred while he was attempting to cut the top off a 200 litre steel drum. When the oiler touched an angle grinder's spinning cutting disk onto the top of the drum, the heat generated ignited the vapours inside the drum. Once ignited, the rapid expansion of the vapour/air mixture resulted in the drum exploding.

The ATSB investigation found that an appropriate risk analysis was not undertaken and a hot work permit was not completed for the task.

The investigation also found that the oiler was not aware of the ship's work permit requirements or the risks associated with using an angle grinder to cut the top off a closed drum.

The ATSB acknowledges the safety actions taken by the ship's managers to address the two safety issues identified during the investigation.

Abstract

At 1845 Singapore Time on 27 May 2010, an Airbus A321-231, registered VH-VWW and operating as Jetstar flight JQ57, was undertaking a landing at Singapore Changi International Airport. The aircraft was not in the correct landing configuration by 500 ft height above the aerodrome and, as required by the operator's procedures in the case of an unstable approach, the crew carried out a missed approach.

The investigation identified several events on the flight deck during the approach that distracted the crew to the point where their situation awareness was lost, decision making was affected and inter‑crew communication degraded. In addition, it was established that the first officer's performance was probably adversely affected by fatigue.

The investigation did not identify any organisational or systemic issues that might adversely impact the future safety of aviation operations. However, following this occurrence, the aircraft operator proactively reviewed its procedures and made a number of amendments to its training regime and other enhancements to its operation.

The ATSB has completed its technical analysis report of the flight recorder data from an Avions de Transport Régional ATR-42-300F aircraft, registered PK-YRP, on behalf of the Indonesian National Transportation Safety Committee (NTSC). The aircraft carried out a forced landing in a rice field, approximately 33 km (18 NM) north-east of Balikpapan-Sepinggan Airport, Indonesia, after reportedly losing power from both engines.  The aircraft was operating a scheduled passenger service from Berau-Kalimaru Airport to Temindung Airport, Indonesia. Two of the 51 passengers on-board sustained serious injuries.

The NTSC is responsible for investigating this occurrence. The NTSC requested assistance from the Australian Transport Safety Bureau (ATSB) in the recovery and analysis of information from the aircraft's flight data recorder and cockpit voice recorder.

To protect the information supplied by the NTSC to the ATSB and investigative work undertaken to assist the NTSC, the ATSB initiated an investigation under the Transport Safety Investigation Act 2003.

The ATSB's technical analysis report has now been provided to the NTSC, who is responsible for releasing a final investigation report on this occurrence.

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 31 March 2009, the pilot of a Fairchild Metro SA227-AC aircraft, registered ZK-NSS, experienced control difficulties during landing at New Plymouth Aerodrome, New Zealand, with the aircraft subsequently departing the runway. The New Zealand Transport Accident Investigation Commission (TAIC) commenced an investigation into the occurrence on 1 April 2009 (investigation number 09-003).

On 1 February 2010, the TAIC requested assistance from the Australian Transport Safety Bureau (ATSB) in the review and analysis of data recovered from the aircraft's flight data recorder (FDR). To protect the information supplied to the ATSB and the investigative analysis carried out to assist the TAIC, the ATSB initiated an investigation under the Transport Safety Investigation Act 2003 (TSI Act), and appointed an accredited representative to the TAIC investigation, in accordance with clause 5.23 of Annex 13 to the Convention on Civil Aviation (Chicago Convention).

The ATSB has completed its review and analysis of the FDR information from ZK-NSS and has provided feedback to the TAIC.

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

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

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

What happened

On 28 October 2009, an Airbus A330-202 (A330) aircraft, registered VH-EBA (EBA), was being operated as Jetstar flight 12 on a scheduled passenger service from Narita, Japan to Coolangatta, Australia. Soon after entering cloud at 39,000 ft, there was a brief period of disagreement between the aircraft's three sources of airspeed information. The autopilot, autothrust and flight directors disconnected, a NAV ADR DISAGREE caution message occurred, and the flight control system reverted to alternate law, which meant that some flight envelope protections were no longer available. There was no effect on the aircraft's flight path, and the flight crew followed the operator's documented procedures. The airspeed disagreement was due to a temporary obstruction of the captain's and standby pitot probes, probably due to ice crystals. A similar event occurred on the same aircraft on 15 March 2009.

The rate of unreliable airspeed events involving the make of pitot probes fitted to EBA (Goodrich 0851HL) was substantially lower than for other probes previously approved for fitment to A330/A340 aircraft. However, both of the events involving EBA occurred in environmental conditions outside those specified in the certification requirements for the pitot probes. The French Bureau d'Enquêtes et d'Analyses pour la sécurité de l'aviation civile (BEA) has recommended the European Aviation Safety Agency (EASA) to review the certification criteria for pitot probes in icing environments.

At the time of the occurrence, most of the operator's A330 pilots had not received unreliable airspeed training. Most of these pilots had transferred from the operator's A320 fleet, and the third-party training provider had not included the topic in its A320 endorsement training program, even though it was included in the aircraft manufacturer's recommended program since 2004.

The operator identified the problem and included unreliable airspeed in its recurrent training program for the A320 from May 2009 and the A330 from October 2009. The training provider included the topic in its endorsement program from July 2010. The operator, training provider and the Civil Aviation Safety Authority all initiated safety action to minimise the likelihood of similar problems in the future.

On 2 April 2008, the UK Air Accidents Investigation Branch (AAIB) advised the Australian Transport Safety Bureau (ATSB) that the AAIB had commenced an investigation in response to a number of minor accidents involving aircraft fitted with Australian-manufactured Jabiru engines. In support of its investigation, the AAIB requested the appointment by the ATSB of an accredited representative in accordance with international protocols.

The ATSB appointed an accredited representative under the provisions of clause 5.18 of Annex 13 to the Convention on International Civil Aviation. To protect any work undertaken to assist the AAIB, and any information supplied to the ATSB by the AAIB, on 7 April 2008 the ATSB initiated an investigation under the Transport Safety Investigation Act 2003.

The UK AAIB is responsible for releasing a final investigation report. Once completed, a copy of the report can be requested from the AAIB at:

• www.aaib.gov.uk, or at
• Air Accidents Investigation Branch
  Berkshire Copse Road
  Aldershot
  Hampshire
  GU11 2HH
  Tel: 01252 510300
  Fax: 01252 376999
  Email: enquiries@aaib.gov.uk

For AAIB press enquiries: 020 7944 3387

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

On 25 September 2008, the pilot of a Bell 206L4 helicopter, registered P2-HBC, was conducting sling loading operations in the vicinity of Lake Murray, Papua New Guinea. While conducting a vertical lift, a witness reported hearing a 'different noise' from the helicopter's engine, before observing the pilot jettison the load. The witness then observed the helicopter oscillating from side to side, yawing to the left and then descending through the tree canopy to impact the ground. The pilot was fatally injured and the helicopter seriously damaged.

This accident is being investigated by the Papua New Guinea Accident Investigation Commission (AIC) in accordance with its obligations under Annex 13 to the Convention on International Civil Aviation. The AIC requested the Australian Transport Safety Bureau's (ATSB's) assistance with their investigation by providing forensic engineering examination of a small selection of instruments and some fuel system detritus recovered from the accident helicopter.

The ATSB subsequently received and examined a fuel quantity gauge, turbine outlet temperature (TOT) gauge and an annunciator panel from the helicopter's instrument cluster. Various marks and observations evident on the components were documented and analysed with respect to the possible relevance of those markings to the accident event. In addition, a small sample of dried material from the internal surfaces of the fuel filter check valve that was provided by the AIC was examined and found to be characteristic of the biopolymer films produced by microbial growth.

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