International

Dornier Do 228-202, ZK-VIR, was carrying out a positioning flight from Westport to Christchurch on the South Island of New Zealand. At about 50 NM north of Christchurch, while cruising at 10,000 feet, both pilots reported becoming 'giddy' and close to fainting. The pilots turned off the cockpit heating and directed external air into the cockpit. A PAN call was made and the aircraft descended to the area minimum safe altitude of 9,000 feet. The crew elected to continue to Christchurch where they were able to make a safe landing.

The Transport Accident Investigation Commission (TAIC) of New Zealand initiated an investigation into the incident, TAIC reference: 07-002. TAIC investigators obtained the cockpit voice recorder (CVR) from the aircraft and requested assistance from the Australian Transport Safety Bureau (ATSB) to recover any information that may have been recorded. In accordance with clause 5.23 of Annex 13 to the Convention on International Civil Aviation, the ATSB appointed an Accredited Representative to assist TAIC and initiated an investigation under the Transport Safety Investigation Act 2003.

The CVR was transported to the ATSB audio laboratory in Canberra for examination in the custody of a TAIC investigator. The CVR information was downloaded on the 11 April 2007. The CVR and copies of the recovered information were provided to the TAIC investigator to be transported back to New Zealand.

The TAIC is responsible for releasing a final investigation report regarding this occurrence. Once it has been completed, a copy of the TAIC investigation report (07-002) may be found at: www.taic.org.nz or by contacting:

TAIC
PO Box 10-323
Wellington 6036
New Zealand

At Indonesia's request on 7 March 2007, the Australian Transport Safety Bureau 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 at Yogyakarta, Indonesia, involving a Boeing 737 operated by Garuda Indonesia.

The aircraft overran the runway and crashed into a rice field 252 metres from the end of the runway. The aircraft was destroyed by impact forces and the post-impact fire.

There were two pilots, five flight attendants and 133 passengers on board. One flight attendant and 20 passengers, including five Australians were fatally injured. One flight attendant and 11 passengers, including 3 Australians were seriously injured, and two flight attendants and 98 passengers sustained minor injuries.

The ATSB dispatched a Deputy Director and two senior investigators to assist its Indonesian counterpart with the investigation. The ATSB also cooperated closely with the NTSC in the analysis of the aircraft black box recorders.

Australia's accredited representative to the investigation continued to work 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 and investigation under the Transport Safety Investigation Act 2003.

On 22 October 2007, 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.

Abstract

In the early hours of 22 June 2009, an Airbus Industrie A330 (A330), registered VH-QPI (QPI), encountered an area of severe turbulence associated with convective activity while en route from Hong Kong to Perth, Western Australia. As a result of the incident, a combined total of seven passengers and crew members received minor injuries. After consultation with medical and operational personnel, the pilot in command continued the flight to Perth. The aircraft suffered minor internal damage and, after a maintenance check, was returned to service.

The cloud associated with the convective activity consisted of ice crystals; a form of water that has minimal detectability by aircraft weather radar. Consequently, the convective activity itself was not detectable by QPI's radar. As the event occurred at night with no moon, there was little opportunity for the crew to see the weather.

The operator intends to upgrade the weather radar fitted to its A330 fleet, which will increase the fleet's capability to detect convective turbulence. Two other minor safety issues were identified during the investigation relating to the risks associated with the use of the pilot flight library when turbulent conditions are encountered, and the engagement of the manual latch to the cockpit door preventing timely access to the flight deck by other operational staff. The operator has taken, or is proposing, relevant safety action to address those issues.

What happened

On 10 June 2009, the flight crew of a Jetstar Airways Airbus A330 aircraft, registered VH-EBF, flying from Osaka, Japan to Gold Coast, Queensland, observed flames at the base of the right main windshield. The fire had initiated from an electrical connection to the windshield heating system. The fire was extinguished by the flight crew and the flight diverted to Guam.

The ATSB investigation concluded that the overheat failure of the right windshield was related to the use of a polysulfide sealant (PR1829) within the body of the electrical connector terminal block. Use of that sealant had created conditions within the block which led to unintended electrical heating effects during operation of the windshield heating system. Consequentially, this had developed into the thermal breakdown of the sealant and the initiation of a localised fire.

Subsequent to the occurrence involving VH-EBF, similar windshield overheating events in other Airbus A330 and A320 aircraft were reported. The aircraft manufacturer's technical examination of those windshields concluded that contact between the braided wires within the terminal block, as well as the unintended migration of the PR1829 sealant had probably combined to trigger the reported events.

Safety action from the aircraft manufacturer included a program to identify and replace all windshields that had been produced using the PR1829 polysulfide sealant within the electrical connector terminal block assembly. That program was initiated in early 2010 and extended to the replacement of approximately 1,500 units within the world-wide Airbus fleet. The ATSB have been advised that due to limited fleet-wide completion of the windshield replacement program, the European Aviation Safety Authority (EASA) is considering the implementation of an Airworthiness Directive (AD) that will require all European operators of applicable Airbus aircraft to comply with the Airbus windshield replacement program. The ATSB were also advised that the windshield replacement program was completed across the Qantas Group of applicable aircraft in April 2011, and that windshields fitted to other Australian operated A330 aircraft are not affected by the replacement program.

The ATSB has completed its technical analysis report of the cockpit voice recorder download from Boeing 747-4U3 aircraft, registration PK-GSH, on behalf of the Indonesian National Transportation Safety Committee (NTSC). The aircraft was operating a scheduled international flight between Jeddah, Saudi Arabia and Jakarta, Indonesia. When the undercarriage was extended for landing at Jakarta, the left wing landing gear failed to extend. Following a number of flypasts, the crew landed the aircraft smoothly on runway 07R. The aircraft canted to the left during the landing and an emergency evacuation was carried out.

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 cockpit voice 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.

On 7 March 2009, an Indonesian registered Fokker 50 aircraft, PK-RAR, on a flight from Batam - Hang Nadim airport to Matak Island, Indonesia, overran the runway during landing. The weather was reportedly poor with heavy rain.

The National Transportation Safety Committee (NTSC) of Indonesia was 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 and cockpit voice 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.

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 provided information to the NTSC during the course of the investigation and the ATSB's Technical Analysis Report has now been provided to the NTSC. The NTSC 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

______________

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

The ATSB has completed its technical analysis report of the flight recorder data from a British Aerospace BAe146-300 aircraft, registered PK-BRD, on behalf of the Indonesian National Transportation Safety Committee (NTSC). The aircraft was operating a cargo transport flight from Jayapura to Wamena, West Papua, Indonesia when it collided with terrain following a rejected landing approach (go-around) at Wamena on 9 April 2009. All six people on board were fatally injured.

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 aircraft's flight data recorder and cockpit voice 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.

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 provided information to the NTSC during the course of the investigation and the ATSB's Technical Analysis Report has now been provided to the NTSC.

The NTSC 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

______________

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

On 22 Jan 2002, A Schweizer 333 helicopter, registered A2-HDB, crashed at Gaborone Airport in Botswana, killing the pilot, who was an Australian citizen. The Republic of Botswana Department of Civil Aviation (DCA) initiated an investigation into the accident.

The Australian Transport Safety Bureau (ATSB) was notified of the accident in 2005 and appointed an expert under the provisions of clause 5.27 of Annex 13 to the Convention on International Civil Aviation. To protect information supplied by the Botswana DCA to the ATSB and investigative work undertaken to assist the Botswana DCA, the ATSB initiated an investigation under the Transport Safety Investigation Act 2003. A copy of a draft report was sent to the ATSB for review and comment in February 2008. The ATSB provided comments to the Botswana DCA on 20 February 2008.

The Botswana DCA is responsible for releasing a final investigation report regarding this accident. Once completed, a copy of the report can be requested from the Botswana DCA at the following address:

Department of Civil Aviation
PO Box 250
Gaborone
Republic of Botswana

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

On 21 April 2008 a European Airwings Springbok aircraft suffered a loss of engine power which led to a forced landing being carried out near Levroux, France. There were no injuries to the occupant and the aircraft was slightly damaged. The aircraft was fitted with an Australian manufactured Jabiru aero engine.

The Bureau d'Enquêtes et d'Analyses (BEA) of France is responsible for investigating this occurrence. The BEA requested assistance from the Australian Transport Safety Bureau (ATSB) in establishing a line of communication with the Australian engine manufacturer. The ATSB appointed an accredited representative in accordance with protocols established by the International Civil Aviation Organisation, (ICAO), Annex 13 regarding accident and incident investigation.

Contact was made with Jabiru and copies of correspondence were provided to the BEA. On 24 November 2008 the BEA advised that their investigation had been completed.

Accident reports published by the BEA may be found on the Bureau d'Enquêtes et d'Analyses (BEA) website.

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

The ATSB has completed its technical analysis report of the flight recorder data from the Boeing Co. 737-2H6, registration PK-CJG on behalf of the Indonesian National Transportation Safety Committee. The aircraft was operating a flight from Jakarta to Jambi, Indonesia on 27 August 2008 when it overran runway 31 at Jambi airport. The aircraft impacted an occupied house near the end of the runway and came to rest in a field. A number of people on the ground were seriously injured and some aircraft occupants were injured during the subsequent evacuation. The aircraft was substantially damaged.

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 and cockpit voice 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.