International

The ATSB has completed its technical analysis report of the flight recorder data from Fairchild Dornier 328-110, registered PK-TXN, on behalf of the Indonesian National Transportation Safety Committee. The aircraft was operating a flight from Jayapura to Tanah Merah, Indonesia when it was involved in a runway excursion on landing.

The National Transportation Safety Committee (NTSC) of Indonesia 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 flight data recorder. 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 Transport Safety Investigation Act 2003.

The ATSB's Technical Analysis Report has been sent to the NTSC to assist its ongoing investigation. The NTSC is responsible for releasing a final investigation report regarding 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.

At Indonesia's request, the Australian Transport Safety Bureau (ATSB) appointed an accredited representative in accordance with Clause 5.23 of Annex 13 to the Convention on International Civil Aviation, to participate in the NTSC's investigation into the fatal accident in the Makassar Strait, Indonesia, involving a Boeing 737 operated by AdamAir.

The aircraft disappeared off radar and crashed into the ocean. The aircraft was destroyed and the two pilots, four flight attendants and 96 passengers on board were fatally injured.

Australia's accredited representative to the investigation worked closely with the NTSC throughout the investigation.

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

On 25 March 2008, the NTSC published its final report into the accident on its website.

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 Papua New Guinea Accident Investigation Commission (AIC) has released its Final Report into the controlled flight into terrain that occurred near Kokoda, Papua New Guinea on 11 August 2009, involving a De Havilland DH-6 Twin Otter aircraft, registration P2-MCB. The AIC investigated this accident, together with support from the Papua New Guinea Department of Transport, in accordance with its obligations under Annex 13 to the Convention on International Civil Aviation. The AIC requested the Australian Transport Safety Bureau (ATSB) to assist their investigation by providing investigator support, information and technical advice and facilities support.

In accordance with paragraph 5.23 of Annex 13, the ATSB appointed an Accredited Representative and a number of advisors to the Accredited Representative (ATSB investigators) to assist the AIC during the on-site phase, in the technical examination of a number of recovered aircraft items and components, and as requested by the AIC during the remainder of the investigation.

The ATSB is reproducing the AIC report titled Controlled flight into terrain, 11 km south-east of Kokoda Airstrip, Papua New Guinea, 11 August 2009, P2-MCB, de Havilland Canada DHC-6-300 on its web site with the permission, and on behalf of the Commission. An abstract drawn from that report follows:

On 11 August 2009, a de Havilland Canada DHC-6 Twin Otter aircraft, registered P2-MCB, with two pilots and 11 passengers, was being operated on a scheduled regular public transport service from Port Moresby to Kokoda Airstrip, Papua New Guinea (PNG)

At about 1113, the aircraft impacted terrain on the eastern slope of the Kokoda Gap at about 5,780 ft above mean sea level in heavily-timbered jungle about 11 km south-east of Kokoda Airstrip. The aircraft was destroyed by impact forces. There were no survivors.

Prior to the accident the crew were manoeuvring the aircraft within the Kokoda Gap, probably in an attempt to maintain visual flight in reported cloudy conditions. The investigation concluded that the accident was probably the result of controlled flight into terrain: that is, an otherwise airworthy aircraft was unintentionally flown into terrain, with little or no awareness by the crew of the impending collision.

The investigation identified a number of factors that led to increased safety risk. Those related to the crew of the aircraft, the weather conditions affecting the flight, crew training and the conduct of the flight. A number of the safety factors had the potential to adversely affect the safety of future aviation operations.

As a result of the investigation, the Accident Investigation Commission of PNG (AIC PNG) issued a safety recommendation in respect of the installation of cockpit voice recorders (CVR) in PNG aircraft with a seating capacity of 18 or more passengers. In response, the Civil Aviation Safety Authority of PNG (CASA PNG) intends legislating to require the installation of CVRs in turbine-powered aircraft with seating for more than nine passengers. As a result of the investigation, CASA PNG has also established a principal medical officer position and has advised of action to move responsibility for the administration of the PNG mandatory occurrence notification system to the AIC PNG. Extensive proactive safety action has been taken by the aircraft operator in response to the risk of inadvertent flight into cloud while employing visual flight procedures and in regard to operations into Kokoda Airstrip an effort to prevent a recurrence.

A full copy of the Papua New Guinea AIC report titled Controlled flight into terrain, 11 km south-east of Kokoda Airstrip, Papua New Guinea, 11 August 2009, P2-MCB, de Havilland Canada DHC-6-300 (File ref AS 09 1005) is available from the 'Download Final Report' link titled on the right, immediately above the 'Feedback' tab.

Any media enquiries in respect of the AIC report should be directed to:

Mr David Inau
CEO, Accident Investigation Commission
Telephone: +675 311 2406
Email: ceoaicpng@hotmail.com

Address:  
Accident Investigation Commission    
PO Box 1790, Boroko
National Capital District
Port Moresby, Papua New Guinea

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

The ATSB assisted the New Zealand Transport Accident Investigation Commission (TAIC) in their investigation into the loss of the vessel. TAIC is the lead agency in this investigation.

The inter-island ferry, the MV Princess Ashika, sank in Tongan waters 5 August 2009. There were many lives tragically lost. Pursuant to the Royal Commission Act (Cap 41) Laws of Tonga, a Royal Commission into the Sinking of the MV Princess Ashika was established.

Abstract

After departing Port Moresby, Papua New Guinea, at 0406 Universal time, coordinated on 31 December 2007, the flight crew of a Boeing 737-229 aircraft, registered VH-OZX, operating a scheduled flight from Port Moresby to Brisbane, experienced severe vibration through the aircraft's airframe, resulting in the crew declaring a MAYDAY and returning to Port Moresby.

A subsequent examination found a section of the right elevator balance tab had detached and was missing. Examination of the remaining sections of the balance tab revealed that two attachment screws from one of the elevator balance tab hinge blocks had unwound, which led to the tab failure.

The investigation found that airframe vibration had been reported by the flight crew the day prior to the accident. On that occasion, a level I - General Inspection of the aircraft was conducted by a licensed aircraft maintenance engineer after the aircraft landed, with no defects found.

The aircraft manufacturer was aware that other operators had experienced in-flight vibration as a result of excessive wear in the elevator balance tab hinge and control linkages, and had issued a number of service bulletins (SBs) to address the issues. These SBs included SB737-55A1070, which directed operators to carry out detailed inspection of the elevator balance tabs, including checks for free-play, control rod wear and loose hinge screws.

As a result of this accident, the aircraft operator implemented a 'fleet campaign directive' requiring the immediate accomplishment of SB 737-55A1070 on all of its aircraft.

On 25 May 2007, an Indonesian registered Boeing 737-3YO, PK-AWP, touched down heavily while landing at Polonia Airport, Medan, Indonesia. The landing resulted in nosewheel vibration, a deflated left nosewheel tyre and overheated brakes.

The flight data recorder (FDR) was recovered from the aircraft. The Indonesian National Transportation Safety Committee (NTSC) was responsible for investigating this incident. The NTSC requested ATSB assistance in the recovery of data from the FDR tape on 12 December 2007. The Executive Director of the ATSB approved the request. To protect the information supplied by the ATSB to the NTSC and investigation work undertaken to assist this agency, the ATSB initiated an investigation under the Transport Safety Investigation Act 2003.

The FDR tape was provided to the ATSB on 17 December 2007. The tape was found to be damaged and the recovery of data was problematic, however, the ATSB successfully recovered the incident flight data from the damaged FDR tape. A data listing and graphical representation of data recorded during the incident flight and a report describing the recovery procedures, were finalised on the 10 January 2008. This information was provided to the NTSC.

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

Abstract

At 0715 Coordinated Universal Time on 20 October 2007, a Boeing Company 747-438 aircraft, registered VH-OJB, departed Los Angeles International Airport, USA, on a scheduled passenger flight to Brisbane, Australia. There were four flight crew, 14 cabin crew, and 406 passengers on board the aircraft.

The first officer was the handling pilot for the flight. As the aircraft became airborne, a tyre on the left body landing gear disintegrated and a section of tyre debris impacted a line of the number 1 hydraulics system in the left body landing gear well. That caused fluid and pressure loss from that system.

A short time later, the electronic indicating and crew alerting system (EICAS) screen in the cockpit advised that the number 1 hydraulics system had failed, and a report was received from the cabin crew that a 'bang' was heard in the vicinity of the left main landing gear shortly before the aircraft became airborne. The flight crew completed checklist items, and the flight continued uneventfully to Brisbane.

The operator found some inconsistencies in the aircraft manufacturer's documentation relating to hydraulics failures. The aircraft manufacturer has noted those and has advised that it will examine them as part of its ongoing standardisation program.

Abstract

At approximately 1944 Coordinated Universal Time on 23 July 2007, an Airbus Industrie A330- 202 aircraft, registered VH-EBE, was about 4 hours into its flight from Bangkok, Thailand to Melbourne, Australia, when the left (No-1) engine had an uncommanded shutdown.

The flight crew attempted unsuccessfully to restart the engine and subsequently diverted to Denpasar Airport, Indonesia. The operator's maintenance staff inspected the aircraft and performed a series of tests and examinations, which revealed that the engine electronic control unit (ECU) for the No-1 engine had malfunctioned.

The defective ECU was sent to the component manufacturer for a detailed inspection. That inspection found a short circuit in the input output module (IOM) circuit board that developed from a microscopic air void in the insulation compound of the circuit board layers.

As a result of this incident, the aircraft operator replaced the ECUs in a number of aircraft, and the board manufacturer amended its production standards and procedures.

Abstract

A Boeing Company 767-300 aircraft, registered VH-OGP, was being operated on an overnight international passenger flight from Nagoya, Japan to Cairns, Qld. On board the aircraft were a pilot in command (PIC), a copilot, seven cabin crew and 162 passengers. The copilot was the pilot flying for the sector and had just completed a period of crew rest. The PIC handed back the control of the aircraft to the copilot at about 1600 UTC and got up to go to the toilet. The copilot heard a bang and turned to see the PIC had collapsed on the cockpit floor. There was no response from the PIC to the copilot's questioning. The copilot switched on the cockpit lights and saw that the PIC appeared to be staring into space and remained unresponsive. The copilot then alerted the cabin service manager to come to the flight deck.

At approximately 1650 UTC, the PIC had recovered sufficiently to return to the cockpit, where he remained for the duration of the flight. A PAN call was transmitted by the PIC when the aircraft entered the Australian Flight Information Region and emergency services were placed on standby for the aircraft's arrival and landing at Cairns.

The PIC was subsequently examined and cleared to return to flight duties by a Designated Aviation Medical Examiners (DAME). The DAME determined that the PIC probably had been affected by a gastro-intestinal illness that had previously been experienced by members of the PIC's family. A Norovirus gastro-intestinal disorder was prevalent in the Queensland region at the time.